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Eating Disorders: The Journalof Treatment & PreventionPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/uedi20

How I Practice: The Rope TrickRoberta Trattner Sherman & Ron A. ThompsonPublished online: 10 Nov 2010.

To cite this article: Roberta Trattner Sherman & Ron A. Thompson (2001) How IPractice: The Rope Trick, Eating Disorders: The Journal of Treatment & Prevention,9:2, 173-176, DOI: 10.1080/10640260127718

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Eating Disorders, 9:173–176, 2001Copyright ©2001 Brunner/Routledge1064-0266/00 $12.00 + .00

Address correspondence to R. Sherman, Bloomington Hospital Eating Disorders Program,P. O. Box 1149, Bloomington, IN 47402.

173

How I Practice

The Rope Trick

ROBERTA TRATTNER SHERMAN and RON A. THOMPSONBloomington Hospital

When we began working with eating disorder patients about 20 years ago,we quickly became aware that body image disturbance was not only aneating disorder symptom, but also an impediment to the patient’s treatmentprogress. Unfortunately, we did not have the excellent sources now avail-able on body image disturbance (e.g., Thompson, 1990) and specific treat-ment protocols (e.g., Cash, 1997) designed to correct the problem. We feltthat body image disturbance had to be dealt with effectively if the patientwere to recover. The patient needed to perceive her body (self) more accu-rately, but as therapists we needed to see what she saw. We felt that weneeded an effective, as well as simple and inexpensive, way to work withthis problem. Our goal was to find a body image measurement device thatcould be used both in the assessment phase as well as the treatment phaseof therapy. We wanted to assist the patient in being aware of this disturbancewithout actually measuring the patient’s “fat” body parts, assuming that mea-surements with numbers, sizes, or weights would be unhelpful, if not anti-therapeutic. Could we measure without numbers? Better still, could patientsmeasure themselves therapeutically when feeling fat?

We decided to experiment with a small (diameter) 48 inch rope with nomarkings. We placed the rope in front of the patient and asked her to esti-mate the size of her waist using the rope. The patient manipulated the ropeuntil she believed that she had adequately estimated the size of her waist.We then marked her estimate using a paper clip. We then asked the patientto stand while we placed the rope around her waist. We then marked themeasurement with another paper clip. We took the rope from her waist and

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How I Practice174

again placed it in front of her. We then compared her estimate with ourmeasurement. Invariably, the patient’s estimate was significantly larger thanour measurement. Patients often responded with disbelief and sometimesclaimed that we had tricked them. We would then repeat, or have the patientrepeat, the measurement of her waist for those who believed that it was atrick or that we had used a trick rope. Those happened so frequently that wecalled our procedure the rope trick.

With the emotional investment patients have in body image disturbance,many were not about to readily accept our rope trick as legitimate. Somepatients rationalized the procedure by saying that they wanted or needed tobe thinner (for whatever reason), regardless of what our rope indicated.With this in mind, we added another estimate to the procedure before takingher actual measurement. After the patient estimated the size of her waist, wethen asked her to indicate with the rope how thin she wanted or needed tobe in order to be thin enough. We again marked this measurement with apaper clip, and then put the rope around her waist for an actual measure-ment. We now had her estimate of what she saw (experienced), what shewanted/needed to be, and what she actually was. Invariably, the actual mea-surement was still smaller than what she desired.

Despite the addition of desired thinness to our procedure, many pa-tients still protested, saying that regardless of what our rope indicated, theywere “fine.” That is, they did not have a serious problem and did not needtreatment. In order to challenge their denial, we added another componentto our rope trick. After the patient estimated the size of her waist, and indi-cated how thin she needed or wanted to be, we asked her to indicate withthe rope how small her waist would have to be before she believed that shehad a serious problem. We again marked this with a paper clip before put-ting the rope around her waist. Again, the actual measurement was stillsmaller than what she had indicated to be a serious problem.

For some patients, their need to protect their symptoms still pushedthem to resist. Some told us that their waist was not their problem—that itwas their butt, their thighs, or some other body part. We then used the ropetrick with that particular body part with the same results.

Our goal in the initial assessment in using the rope trick is not to con-vince the patient that she is thinner than she fears that she is. As an assess-ment tool, it allows us to see what the patient sees. We have not put thisprocedure to an empirical test, but at least anecdotally, the magnitude of thepatient’s body image disturbance often appears to reflect the seriousness ofher disorder or the size of her need to protect (maintain) her symptoms. Thatis, if she could perceive her body size and shape accurately, she would haveless reason to diet or engage in pathogenic weight loss and maintenancemethods. She would then have to confront the real issues associated withher unhappiness, and these are usually more threatening than her(mis)perceived fatness.

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How I Practice 175

From the standpoint of treatment, another goal in using our procedurein the initial session is to create a little doubt in the patient’s mind regardingher size and shape. After doing the procedure with a patient, we ask her tosimply entertain the notion that she might not be able to see (experience)herself accurately. We sometimes follow this with a story about buying adress for an important occasion (i.e., job interview, prom, wedding, etc.). Weask her if she would buy the dress knowing that she was looking at herselfin a mirror that distorts what she sees. Again, we are simply trying to createa little doubt in the patient’s defenses.

There are ways—other than in an initial assessment—that we utilize ourrope. We use the procedure periodically during treatment to assess the patient’sprogress in decreasing the magnitude of her body image disturbance inparticular, as well as her need for her symptoms, in general.

We also have used the rope in group therapy as part of a series of bodyimage exercises. In group, we often have patients use the rope with othergroup members. Having a patient experience the rope from the other side(as a therapist) has been particularly helpful to some patients.

Perhaps the most helpful use of the rope for the patient involves usingthe rope as a reality check when she feels fat or feels that she has gained toomuch weight. We ask some of our patients to get their own rope and carry itwith them. It is small enough that it can easily fit in a purse or backpack.When feeling fat, or anxious about being fat, they are instructed to use theirrope as a reality check that they are not fat and have not gained too muchweight. They are instructed to look at the rope and reassure themselves thatthe rope indicates that they are not fat but that they must be feeling some-thing that does not feel good. They are instructed then to ask themselveshow they are feeling and asked to try to focus away from their body size andshape. Many patients report that they have found this to be very helpful.

The rope has sometimes been helpful to patients who complain thattheir family and friends are overreacting to the seriousness of their eatingdisorder. That is, the patient does not believe that her difficulty is seriousenough to warrant such concern. With the actual measurement, we remindthe patient that it (small waist/body) is what her family and friends see whenthey look at her. They are anxious and afraid based on what they see.

Because we have not empirically looked at our procedure, we cannotsay with scientific assurance that the procedure is an effective, therapeutictool. However, our clinical experience and patient feedback suggests that itdoes get patients’ attention, and their responses are seldom lukewarm. Re-garding patient response, the therapist must recognize that this procedure isa very direct confrontation for the patient. Intuitively, one would think that apatient would be happy to see that she is thinner than she had believed.However, this is incongruent with her need to see herself as fat. If she is notfat, her symptoms are unnecessary. Most patients are not ready to acceptthis.

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How I Practice176

We have often been asked about the validity of our procedure. Again,we have not put the procedure to any type of empirical investigation. Whatwe have done, however, is use the procedure with individuals, both womenand men, who do not have eating disorders or engage in disordered eating.Generally, they do not show as much disparity between their waist estimatesand our actual measures. Men generally show much less disparity in thisregard than women. In fact, asymptomatic males have often been very accu-rate in their estimates.

Regarding reliability and validity, we have been asked about learningeffects. That is, doesn’t the patient make adjustments in her estimates afterexperiencing the procedure? Knowing that she overestimated her waist thefirst time, does she compensate in subsequent measures? This is difficult toanswer without empirical testing, but anecdotally, it does not appear to bethe case. We have often used the procedure in several therapy sessions witha particular patient and do not see much change. We also have seen thepatient’s estimate become more distorted after the initial use of the proce-dure. Typically, this occurs with patients who experience a crisis or increasedemotional instability. But, this is what we would expect if body image distur-bance is a defense against emotional difficulties.

In conclusion, what we think we have in our rope trick is a simple andinexpensive tool that is effective and adaptable. Our patients find it useful aswell. Despite this, we want to remind anyone who might consider using ourprocedure that a single technique is not a substitute for good clinical skillsand judgment. It can only be a useful adjunct to such skills and judgment. Aswe suggested many years ago (Thompson & Sherman, 1989), it is the rela-tionship between therapist and patient and the process that occurs withinthat relationship that is the crux of effective treatment.

REFERENCES

Cash, T. F. (1997). The body image workbook: An 8-step program for learning to likeyour looks. Oakland, CA: New Harbinger Publications.

Thompson, J. K. (1990). Body image disturbance: Assessment and treatment. NewYork: Pergamon Press.

Thompson, R. A., & Sherman, R. T. (1989). Therapist errors in treating eating disor-ders: Relationship and process. Psychotherapy, 26, 62–68.

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