KEY POINTS
- A form of CBT called enhanced cognitive behavioral therapy (CBT-E) is an adaptation of CBT designed to treat eating disorders.
- CBT-E moves through four distinct stages of treatment over the course of 20 to 40 weeks via regular outpatient therapy sessions.
- Enhanced CBT is different from CBT. It’s important to ask providers about their training and ensure their training is in CBT-E.
Cognitive behavioral therapy(CBT) is a popular therapy modality with adaptations to treat a wide range of mental health conditions, including depression, anxiety, OCD, and more. Broadly, CBT focuses on identifying patterns of thoughts, emotions, and/or behaviors that negatively influence our lives. A form of CBT called enhanced cognitive behavioral therapy (“CBT-E”) is an adaptation of CBT designed to treat eating disorders.
An Overview of CBT-E
CBT-E is considered the first-line, evidence-based treatment for people with eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN), or binge eating disorder (BED). Even though these conditions present different problematic behaviors, they share many of the same foundational features at their core. For example, people with AN, BN, and BED often experience extreme concern with weight and shape and/or difficulty coping with negative emotions.
These factors–“overvaluation” of shape and weight and mood intolerance–are common triggers to problematic eating behaviors like food restriction, binge eating, or purging.
While CBT-E is a manualized and structured treatment, it’s intended to fit the client “like a glove” with a focus on creating a personalized “formulation” or map of the client’s eating disorder and a customized plan for addressing their unique patterns and challenges.
The Four Stages of CBT-E
CBT-E moves through four distinct stages of treatment over the course of 20 to 40 weeks via regular outpatient therapy sessions. The longer treatment length is generally for those who need to restore weight (as with anorexia nervosa). CBT-E highlights the importance of “starting well” and building momentum at the start, so sessions are generally twice weekly for the first four to eight weeks, then once weekly for roughly eight weeks, and bi-weekly thereafter.
Stage One
The focus of Stage One is understanding and then systematically addressing the factors keeping the individual locked in their eating problem. The therapist guides the client in establishing a pattern of regular and consistent eating. The client learns how to effectively plan ahead, anticipate challenges and maintain a predictable routine of eating every few hours.
This initial treatment stage involves education, building self-awareness, and problem-solving to avoid known triggers. We expect significant change during this brief initial period of about four to eight weeks.
Stage Two
Stage Two of CBT-E is just a session or two during which the therapist and client review progress, identify ongoing challenges and collaborate around building the plan for Stage Three.
Stage Three
Stage Three involves once-weekly sessions that focus on factors that may be fueling remaining problematic eating behaviors. Typically, concerns with body weight and shape are addressed in this phase of treatment. There’s also a lot of attention focused on forms of over-control of food–like continued avoidance of certain foods, restriction of overall food quantity, etc.
Stage Three also focuses on event and mood-related triggers to disordered eating.
Stage Four
During the fourth and final stage of CBT-E, the client and therapist begin to look ahead to the future and life post-CBT-E. The tasks of Stage Four are consistency, mindfulness, and engaging strategies to reduce vulnerability to relapse in the future.
Get Connected With CBT-E
If you’re interested in finding a CBT-E therapist for yourself or a loved one, here are a few tips:
- Enhanced CBT is different from standard CBT. It’s important to ask potential providers about their training and to be sure that their training is in CBT-E, specifically. There’s not a CBT-E “certification” per se; most CBT-E providers have been trained in practice, research, or academic settings. The Centre for Research on Dissemination at Oxford (CREDO)provides online training for professionals, which is an excellent way to learn CBT-E.
- Adherence to the CBT-E treatment as it’s intended increases the potential for a good outcome. Integrating “some CBT-E techniques” is generally not enough and may result in a diluted treatment. It’s like taking a medication that’s been watered down; it just won’t work as well.
- A CBT-E practitioner will explain at the start of treatment that the work will be time-limited (about 20 weeks for bulimia and binge eating; 40 weeks for anorexia). There will be four distinct stages and a clear agenda for each and every session. Issues unrelated to eating will not be the focus of treatment and should be tabled until after CBT-E is completed. If the provider is inclined to approach the treatment as open-ended or with a loose structure and time frame, then it’s not CBT-E.
- Involved treatments “programs” with lots of groups and additional services are not always necessary. CBT-E is intended to be the intervention.
Of note, CBT-E is not typically the first-line approach for children and teens with AN or BN. Most often, treatment for kids/teens with eating disorders needs to incorporate caregivers either as central to the treatment or closely integrated. family-based treatment is a more common recommendation for younger people presenting with disordered eating.
Barriers to Accessing CBT-E for Eating Disorders
Unfortunately, therapy can be very expensive and thus not accessible to most people who need it. It may be difficult to find adherent CBT-E providers who accept commercial insurance or Medicaid. Of note is a self-guided (self-help) version of CBT-E: Overcoming Binge Eating by Christopher Fairburn. This self-help guide can be an effective course for BED and some cases of BN. It may be more effective if there is external support available as a supplement.
Some specialized eating disorder research and training centers offer CBT-E for reduced fees or even free of charge in exchange for participation in research studies. It may take some searching online to identify local facilities or institutions with research protocols and the opportunity for free treatment.
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