In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is enhanced cognitive behavioural therapy, or CBT-E.
I first heard of CBT-E recently in a post by Burnie of Quash Stigma Not Fat; it was a form of therapy she had done to treat her anorexia nervosa. I was curious to learn what that involved, and in this post I’ll share what I discovered.
CBT-E was developed at the Centre for Research on Eating Disorders at Oxford (CREDO) based on a transdiagnostic view of eating disorders. According to this transdiagnostic view, the processes that are involved in maintaining an eating disorder are very similar across eating disorder diagnoses.
Treatment is divided into four stages. Stage one, “starting well”, involves the therapist and client developing a mutual understanding of the client’s ED and stabilizing their pattern of eating. The brief second stage, “taking stock”, involves reviewing progress and planning for the main stage of treatment, which is stage three. Stage three addresses core eating disorder issues like body image, dietary restraint, and the connection between events, moods, and eating. The emphasis is on the issues that are contributing the most to the maintenance of the particular individual’s ED. Towards the end of stage three, the focus shifts to dealing with setbacks, and in stage four, the emphasis is on the future and maintaining positive changes.
Things addressed in treatment
In stage one, the therapist creates a case formulation collaboratively with the client, identifying processes that are serving to maintain the client’s eating disorder that will be addressed in treatment. The pie chart below represents an example formulation with the main section of the pie, over-evaluation of shape and weight and their control, further broken down into the different ways it manifests.
Throughout treatment, patients are supposed to do real-time self-monitoring, recording everything they eat or drink (descriptions, not calories), what was going on at the time, and any compensatory strategies used (like laxatives or vomiting). The idea is that identifying what’s happening in the moment can help with making changes to behaviours that feel automatic or out of control. Body-checking behaviours are also monitored.
A regular eating schedule is established, with 3 meals and 3 snacks each day, and not going more than four hours without eating. Patients are also encouraged to practice eating socially. Weighing is done weekly, and patients are encouraged not to weigh themselves outside of that.
For patients who binge, work is done on urge surfing, engaging in behaviours that aren’t compatible with binging and serve as a distraction (like going for a walk) or doing things that make binging less likely (like leaving the kitchen). Binges are analyzed to identify triggers, like breaking a dietary rule, being disinhibited, under-eating, or negative mood or events.
Treatment addresses issues like judging self-worth based on body shape, preoccupation with thoughts about shape/weight and food/eating, body weight and shape checking, body avoidance, labelling mood states as “feeling fat”, rigid rules and checking around eating, secondary shame and guilt related to binge/purge behaviours, triggers for binges, and compensatory strategies like laxative/diuretic use and over-exercise.
CBT-E can be delivered on an outpatient, intensive outpatient, or inpatient basis. The length of treatment varies, ranging from 20 sessions over 20 weeks to 40 sessions over 40 weeks. The early sessions are held twice weekly, and then the sessions in stage four are more spread out. For patients who are underweight, the aim is to get them to a place where they’re making the decision for themselves to regain weight rather than have the decision forced onto them.
Standard CBT-E is delivered in a focused form that addresses the eating disorder psychopathology, but there’s also a broad form that incorporates work on perfectionism, low self-esteem, and interpersonal relationship issues. This addresses topics like preoccupation with thoughts about performance, checking focused on deficiencies in performance, having a sense of repeated failure, overgeneralizations, and cognitive biases.
For people with binge eating disorder, one of the CREDO researchers has published a CBT-E self-help book called Overcoming Binge Eating.
In studies of adults who weren’t significantly underweight, about 2/3 of patients receiving CBT-E made a full recovery, and that recovery tended to be well-maintained. According to the cbte.co website, the response rate is “somewhat lower in patients who are substantially underweight.” CBT-E has also demonstrated effectiveness in adolescents.
So, that’s CBT-E in a nutshell. It sounds like the biggest difference between this and standard CBT is the transdiagnostic model that considers all eating disorders to share the same basic processes. For those of you who have eating disorders or are in recovery, is CBT-E something you’re familiar with? How does it compare to any forms of treatment that you’ve been through?
- Murphy, R., Straebler, S., Cooper, Z., & Fairburn, C. G. (2010). Cognitive behavioral therapy for eating disorders. Psychiatric Clinics, 33(3), 611-627.
The Psychology Corner has an overview of terms covered in the What Is… series, along with a collection of scientifically validated psychological tests.
Ashley L. Peterson
BScPharm BSN MPN
Ashley is a former mental health nurse and pharmacist and the author of four books.