Treating Bulimia Nervosa and Binge Eating: An Integrated Metacognitive and Cognitive Therapy Manual. Myra Cooper, Gillian Todd & Adrian Wells, Routledge, 2008, £22.99 pb, 264 pp. ISBN 9781583919453

Since 1979, when Gerald Russell described bulimia nervosa ¹ and Aaron Beck published Cognitive Therapy of Depression, ² cognitive–behavioural therapy (CBT) has been repeatedly applied in people with bulimia; Fairburn's CBT for bulimia nervosa demonstrated particular efficacy over the 1980s and 1990s. Fresh speculation and creativity are always crucial, though. As new features of the disorder and potential obstacles to treatment have been observed, CBT has expanded its repertoire – for instance, Ulrike Schmidt's BitE by BitE added motivational enhancement techniques. ³

Wells's ‘metacognitive’ stance is the new ingredient here. This has much in common with ‘mentalisation’ and ‘mindfulness’. In this state of mind we can take a step back from our knee-jerk responses to life, see ourselves more objectively and cultivate non-judgemental wisdom. It involves not only thinking, but thinking about thinking, not only learning, but learning about learning, in that striving towards maturity which characterises all effective therapies. It moves ahead of classical CBT by not asking ‘Is this thought correct?’ so much as ‘Is this the most helpful way to think about things?’ However, the excellent chapter which traces the development of structured evidence-based therapies for bulimia stops disappointingly short of integrating its claim for the use of metacognition into the discussion.

I have two important reservations. The first is that metacognitive therapy is so far unproven. Second, I would be reluctant to move directly into metacognitive work without at least trying to introduce regular, spaced eating patterns. For me, this is the single most crucial intervention in changing minds and brains, even where years of previous therapy have failed. I am supported in this view by two masters: Fairburn claims this intervention is ‘fundamental to successful treatment’, ⁴ highlighting the gratifying early success experiences that result; Waller's group, too, emphasises ‘the introduction of structure to dietary intake’. ⁵

It is brave to publish another textbook of CBT for eating disorders so soon after the appearance of two new classics (Cognitive Behavioral Therapy for Eating Disorders by Waller and colleagues ⁵ was followed in 2008 by Fairburn's acclaimed account Cognitive Behaviour Therapy and Eating Disorders ⁴ ). Readers seeking an education in both eating disorders and CBT should devour either or both of these. Should you invest too in Cooper's modestly-priced paperback? The authors are streetwise clinicians who know exactly what they are talking about. Sample stories – such as ‘Jasmine's’ – illustrate the plight of having bulimia tellingly. There is a particularly good set of evaluation scales, useful photocopiable handouts, and the directions for introducing detached mindfulness can be used across different diagnostic groups. So if you work regularly with individuals with bulimia nervosa, I recommend you add this book to your collection, but not that it be used as your main resource.