There’s been a great deal of research over the last twenty years as those in the medical community seek to isolate the most effective methods for treating eating disorders. Consistently, the research comes back to Cognitive Behavioral Therapy – and specifically the newest version of CBT for eating disorders called Enhanced CBT (or CBT-E) – as the frontrunner for outpatient treatment of eating disorders in adults.
CBT-E is a transdiagnostic model, which means that it’s designed to treat any eating disorder behaviors whether they occur as part of anorexia, bulimia or binge eating (or any disordered eating that might not fall into a specific category). It may sound strange that the same treatment might be used to treat all of these seemingly distinct and separate conditions. That said, these disorders at their core share many of the same features; in particular, an extreme concern with weight and shape and/or difficulty coping with strong emotion. These factors – overvaluation of shape and weight and mood intolerance (difficulty tolerating feelings) – are known to be triggers to behaviors like over-eating, restricting or purging.
CBT-E is a treatment that should “fit like a glove.” While it is highly structured and specific, it is designed to be customized to each individual and to address the factors that are most responsible for the persistence of the eating disorder.
CBT-E is a relatively short-term, time limited, individual outpatient therapy. CBT-E is offered in two doses: the standard structure for bulimia and binge eating disorder is 20-sessions over 20-weeks. For anorexia, the treatment duration is longer – more like 40-weeks – since weight restoration is necessary. For all conditions, the treatment sessions are more frequent at the start (2x per week for the first 4-6 weeks) and then gradually spread out over time.
Stage One CBT-E
CBT-E is structured in four stages. The first stage, is focused on helping the client establish a regular and consistent pattern of eating. We focus in on monitoring intake to increase awareness of one’s eating patterns, planning ahead and timing meals thoughtfully to support normalized nutrition throughout the day. In Stage One of CBT-E the client begins to understand the factors that keep him/her/them locked into an eating struggle. We call these factors “maintaining mechanisms.” These maintaining mechanisms include chronic or yo-yo dieting, rigid food-related rules, weight preoccupation, and negative mood states that impact one’s eating.
Typically in Stage One, we begin to see a pattern of regular eating emerge as we refine our understanding of the factors fueling the problem and learn and practice a host of strategies designed to support the normalization of eating. These first 8-10 session are critically important. We want to see a strong start with a great deal of movement towards regular eating.
Stage Two CBT-E
During Stage Two of CBT-E we review progress to date, identify obstacles and map out a plan for Stage 3. This is a relatively short stage, typically 2 sessions over 2 weeks. In this phase of treatment we want to articulate clearly exactly what is fueling theremaining disordered behaviors or thoughts and then outline how we’ll address these triggers in the next phase of treatment.
Stage Three CBT-E
Stage Three of CBT-E targets and defuses the maintaining factors. This stage is typically about 6 sessions over 6 weeks. Here is where we will explore things like over-concern with weight and shape, persistent restrictive or rigid eating styles, and event or mood-related eating behavior. These factors are challenged systematically. In some cases, extreme perfectionism, low self-esteem and/or interpersonal difficulties may be areas that also need further exploration and treatment.
Stage Four CBT-E
Stage Four is about ending well; this stage is generally 4 sessions spread out over 8 weeks. In ending well, we shift to a focus to the future and how to reduce one’s vulnerability to relapse. At this point, the client knows him/her/themself well and can recognize the triggers to ED behaviors. The therapist, of course, is available down the road if for any reason there’s a need to revisit. That said, after a complete CBT-E treatment, one should have all the tools needed to maintain a strong recovery for the long term.
If you like what you’ve heard about CBT-E and are interested in finding a CBT-E provider, here are some tips:
- Enhanced CBT is very different from standard CBT. There is no “certification” per se in CBT-E; any health care provider can use the manual. Ideally, though, the therapist can explain how they were trained in CBT-E. It’s best if they received consultation from an experienced CBT-E provider while implementing the treatment over time. Alternatively, The Centre for Research on Dissemination at Oxford (CREDO) provides an online training for professionals. This is an excellent way to learn CBT-E.
- Make sure that the therapist plans toadhere fully to the CBT-E treatment. “Using techniques” from CBT-E is not enough. Without a doubt, completing the treatment as it’s intended is how you will get the best result. In a therapist bio, you’d want to avoid eclectic or “integrated” therapist approaches (i.e.“integrating psychodynamic psychotherapy,” “insight-oriented therapy” etc). Again, for behavioral change, adherent CBT-E is the best course.
- You can get a sense of adherence if the therapist explains at the start that the treatment is time-limited (roughly 20 weeks for bulimia and binge eating; more like 40 weeks for anorexia). That it consists of three distinct stages. That there is a clear agenda for each and every session. That the focus is on the factors getting in the way of regular eating; issues unrelated to eating are important, of course, but should not occupy session time. The treatment is solely focused on helping you with your eating problem.
My3square Can Help
Once you’ve settled on a treatment provider, my3square is here to support your important work towards recovery. We can provide the structure and encouragement needed to practice regular, varied eating while learning new skills to help you through.