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.
22 thoughts on “What Is… CBT-E (Enhanced CBT for Eating Disorders)”
It’s so overwhelming. I like to believe I have it under control by myself. I can’t bear the idea of anyone else involved in my food choices…
Yeah, I can see how that would be hard.
I’m aware of CBT but CBT-E was unknown to me. Thanks for the info
Many of the books I’ve read on binge eating disorder and bulimia speak of CBT. It seems to be the go to for helping people navigate their food phobias. It makes sense because the way we think and feel about ourselves and food is a major cause of eating disorders.
Yeah, it seems logical.
Really nice capture of this therapy! Thanks for writing this.
I’ve been through it and I must admit I’d forgotten a lot of what it involved/ blocked it out ha!
It was interesting to read about – thanks for the idea!
Looks like an effective, holistic approach. I really like the information on urge-surfing!
Yeah, it’s a cool concept.
I’m a yo-yo dieter. Starve and binge, repeat. Thanks for the link to Overcoming Binge Eating, I’ve downloaded a sample.
I hope it’s helpful!
I don’t have an ED but I notice acquaintances in my life who have EDs as a way to cope with complex trauma don’t do well with CBT-E or Maudsley Method Family Therapy
Oh that’s too bad.
Yeah, I’m not sure what other approaches are out there since quite a lot of trauma therapists don’t know how to work with EDs despite a significant clinical population with comorbidity.
You’ve written a great article on CBT-E for eating disorders. I avoided looking at it until today: even now, I want a heads up with the topic. I have a few thoughts on the treatment plan, and I’m sorry for the long comment.
The first thought is about a scene from “The Dead Poets Society.” Robin Williams’ character is talking about a textbook’s efforts to rank poetry using a chart, “I like Byron, I’d give him a 42 but I can’t dance to it.” This is the feeling I get when I read structured plans for amorphous problems (I’m not a huge fan of stage one).
The second thought is about SH’s comment: yup. The worst experience I had with the worst outcome was family therapy. You take someone with an eating disorder who almost always feels invisible and makes their therapy not about them. I’m definitely not still bitter.
I was surprised by the claim of 2/3 recovery. I don’t think I believe it. I’d like to know how long the average person had been suffering – length of eating disorder impacts possibility for recovery – and what things look like some time out. People with eating disorder are pleasers. Doing what’s asked of them is natural, but it doesn’t necessarily mean change will stick.
Additionally, stage one creates high focus on a behaviour that already consumes. Agreeing to do what most people with eating disorders already do isn’t hard. Getting us to stop is the issue.
In my opinion, weighing is a mistake. It’s like group therapy. It’s not great for people with eating disorders, at least in my experience. I’d be curious to see longitudinal studies regarding group participation outcome. Peer therapy might work. If the bodies and neuroses are similar. Turning off the comparative part of the brain is almost impossible.
“Urge surfing” is also something I disagree with. Anxiety is highly correlated with eating disorders and binges closely resemble panic attacks. Things got better for me when I learned to label what I was feeling and started focusing on that (I like the five step focus). I rarely binged when it wasn’t a panic. Sometimes it was a planned panic.
I like the mental focuses list, especially the “feeling fat” component. Dealing with what’s underneath is the only thing that can help. And practical instruction on what to do and not do re laxatives, diuretics, emetics, and water are important. That stuff can kill you.
The timeline is also short. Even forty weeks isn’t enough. And someone who says “my eating disorder started at eleven” is mistaken if they’re counting behaviour. Add at least a year of run up.
One thing that does help is an interrupter. I think it’s the same for addictions (and ED have many commonalities). Being pulled out of the environment you’re in breaks up patterns and goes a long way to putting people on the road to recovery. Good thing there’s no money.
Excellent points. I can see family therapy working well in some cases but being a shitshow most of the time.
This paper argues why patients should be weighed, but the line of reasoning sounds pretty weak to me. I can see it for medical reasons if someone is underweight, but otherwise, it seems like it would reinforce preoccupation with something that shouldn’t be reinforced.
It was an interesting paper. I believe that exposure and desensitizing to weight and scales is important, but that’s a very late stage recovery thing. I’m only just starting to do it (three years without vomiting in October, and it can still make me want to restrict).
One thing they miss, that most of the doctors I’ve been brutally honest with miss and now know about, is the lying. We can’t help it, really, it’s just what we do. That impacts what we say about what we think/believe/know and about eating and food and our weight, and also what we tell the people treating us. I think they’re likely mistaken about the degree to which “broken cognition” is a factor, especially once you move beyond the very young.
That makes sense.
This was scary to read…but great to learn about. A completely new concept for me but I think I had therapists who tried this.
Yeah, eating disorders are scary stuff.