Does CBT-E work for treating eating disorders?
I write and podcast about the psychology of eating disorders. I have personally recovered from bulimia and have worked as a therapist for 20 years. I hope to inspire, educate and improve understanding about eating disorders through my writing and audio. Names used are fictional and stories shared are a combined insight of many client experiences. I believe that full recovery is possible for everyone.
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CBT-E is one of the most favoured and researched therapies for eating disorders.
It means enhanced cognitive behaviour therapy.
If you access support via the NHS (assuming that you are based in the UK), you may well be offered this treatment, particularly if you meet diagnostic criteria for anorexia nervosa, bulimia nervosa or binge eating disorder.
The approach is described as transdiagnostic, as it’s relevant for several different eating disorder diagnoses.
CBT-E was developed by Professor Christopher Fairburn and his team in Oxford over two decades ago, initially as a treatment for bulimia nervosa but then it expanded out to treat other eating disorders too.
Lengths of treatment vary.
If you are underweight, you are likely to have 40 treatment sessions over 40 weeks.
Weight gain is an integral part of this process, culminating in a period of weight maintenance.
You are encouraged to engage with this weight-gain process from an empowered, choosing position, rather than this being imposed by the therapist.
If you are not significantly underweight, you’ll receive 20 sessions over 20 weeks.
Sessions can be twice weekly to begin with (for all CBT-E) to gain momentum and build motivation early on.
CBT-E prides itself on not being a ‘one-size-fits-all’ treatment. It is individualised to each client, flexing dynamically to incorporate each person’s specific situation.
It is made up for four stages: -
Stage One
This centres on psychological formulation. The therapist and client work together to establish a mutual understanding of the eating disorder as a coping strategy.
There is also focus on building a stable eating pattern, through regular eating and balancing blood sugar.
This stage also incorporates psychoeducation and addressing concerns about weight and body image.
Stage Two
This is a brief review stage where progress is evaluated, and plans are made for future treatment (moving into Stage Three).
Stage Three
This stage targets processes that perpetuate and maintain the eating problem.
This involves dissecting the overevaluation you might possess, in correlating weight and worth. It also involves problem solving around managing daily events and emotions.
It attempts to target and reduce various forms of dietary restraint. For example: missing meals, not eating enough and delaying eating.
Stage Four
Stage Four begins to shift to the future and coping. It explores managing inevitable relapses and working on maintaining changes made so far.
A review session is normally planned for around 3-6 months after treatment to check-in on progress and to target any additional issues remaining.
My experience of delivering CBT-E
I trained in CBT-E early on in my career (around 2003).
My foundational therapy approach prioritises the relationship and being client centred. Therefore, I have never been a purist CBT-E practitioner.
Instead, I integrate these skills into my overall framework, which involves person-centred therapy, motivational enhancement therapy and compassion focused therapy.
As much as I value and appreciate the CBT-E tools, I would personally struggle to follow a rigorous plan of sticking to the absolute specifications.
That’s just me. I am an intuitive, feelings led person and value the flexibility to lean into this, when working with clients.
Perhaps CBT-E purists would argue that I’m not actually delivering CBT-E after all!
But I stand for the middle ground, where you can utilise these highly effective tools, whilst also having the flexibility to shift and move depending on the client’s specific needs.
I tend to simultaneously work with clients on deeper issues, alongside behavioural change, which can be very effective.
5 reflections to consider if you are offered CBT-E
1. Motivation
CBT-E is an action focused therapy. To benefit, you need to engage wholeheartedly, showing a commitment to attending sessions and completing homework tasks.
You won’t miraculously recover by passively cruising in your passenger seat and gazing dreamily out of the window.
It can be challenging!
Your therapist will guide and support you, but you need to have your hands firmly on the steering wheel.
2. Directive
If you enjoy a directive therapy approach and appreciate your therapist initiating, questioning and educating you, then you will thrive in a CBT-E setting.
If you prefer to free associate through speaking aloud and working through your issues by personal reflection, whilst receiving gentle insights from your therapist, then CBT-E may not suit you.
In this case, you may be better suited to person-centred or psychodynamic therapy, or psychotherapy sessions.
3. The present and the future
CBT-E focuses on the present and the future, with little delving into your childhood history and possible adverse life events.
If you have experienced significant trauma, you may find that CBT-E falls short in helping you. You may wish to seek out psychotherapy, somatic healing practices or EMDR (Eye Movement Desensitisation and Reprocessing).
Not to say that you can’t benefit from CBT-E in these instances, but you may need to focus more on the trauma aspect first.
4. Creative tools, pictorial representations and psychoeducation
CBT-E can be a highly interactive and engaging therapy, which can arm you with a toolbox of skills.
This can feel empowering and equip you with a therapeutic chest of delights.
5. The need for a skilled practitioner
Anyone can train in CBT-E; however, it is a skill to deliver it effectively and to personally tailor the experience to the client.
If you have an eating disorder, you will understandably be hugely ambivalent about change and will need a skilled and flexible approach to navigate along the healing road.
CBT-E delivered in a dogmatic and prescriptive manner could potentially alienate you, the client and trigger a shame response, causing withdrawal from treatment.
How effective is CBT-E?
The research statistics seem to vary widely.
Focusing on studies in which CBT-E was delivered well, evidence suggests that 2/3 of clients who are not significantly underweight, starting this treatment will make a full recovery. But these are statistics reported by the Oxford team and likely a little optimistic.
The general consensus in the eating disorder therapy community is that CBT-E works for around 40% of people.
It’s beneficial but like most treatment options, it is no magic pill.
It’s not so great for clients who have experienced unresolved adverse childhood experiences.
It’s not always as effective for underweight clients.
Clients that struggle with clinical perfectionism also may struggle with CBT-E.
Anecdotally, I would say that the tools are excellent and a valuable addition to the therapy toolbox.
What do you think?
Have you experienced CBT-E?
Are you a therapist who has delivered CBT-E? How did you find it?
I’d love to know in the comments.
To find out more about my work:-
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ONLINE COURSES
Online 10 Steps to Intuitive Eating - a course to help you heal your relationship with food.
Online Breaking Free from Bulimia - a course to help you break free from bulimia nervsoa.
Eating Disorders Training for Professionals - training for therapists in working with clients with eating disorders.
Body Image Training for Professionals - training for therapists in working with clients with body image issues.
Podcast - The Eating Disorder Therapist. A podcast to help you overcome disordered eating and find peace with food.