Written by Oxford CBT therapist Paul Jenkins.
CBT Eating Disorders
Many people do not seek help for an eating disorder (ED) and, of those who do, some do not receive ‘evidence-based treatments’ – that is, a psychological therapy which has shown to be effective in several research studies. Issues such as stigma and previous experiences can get in the way of people getting the help they need.
It can sometimes be confusing knowing what the ‘best’ psychological therapy is and, indeed, no therapy has been proven to be 100% effective. However, knowing what to expect before seeking professional support can certainly help in being prepared and can also get you thinking about what kind of treatment might work.
What follows below is a guideline for the treatment of EDs in adults, with a particular focus on a treatment known as CBT (Cognitive Behaviour Therapy). This is a type of psychological therapy that focuses on changing thoughts and behaviours and, in its many forms, is used as a treatment for a variety of psychological problems. There are similar treatments available for young people, although they can vary in their approach due to the different needs of this population.
CBT has been adapted to work with eating disorders. The term “CBT-ED” is an umbrella term used to refer to all ‘evidence-based’ forms of CBT for EDs. There are different varieties (a bit like different varieties of apples, for example!), which all have slightly different formats but which share the approach of encouraging behavioural change to address the thoughts and emotions that underpin eating disorders.
CBT-ED has been widely researched and recommended in several national guidelines, including those in the UK. It is effective for all types of eating problems, including anorexia nervosa, binge-eating disorder, and bulimia nervosa. In general, around two-thirds of those who complete treatment will do well.
CBT-ED typically lasts 20 sessions (for those who are not underweight) and up to 40 sessions (for those who are underweight). There is also a 10-session course of treatment (known as CBT-T). You can therefore expect treatment to last several months and, if you are underweight, perhaps longer than this.
How Will I Know if I’m Getting CBT-ED?
As CBT-ED is a personalised treatment, it is likely to be delivered slightly differently from therapist to therapist and treatment recommendations within EDs vary (e.g., treatment duration for anorexia nervosa is typically longer due to the need to restore weight). However, there are several elements of CBT-ED that should, in the vast majority of cases, be delivered uniformly. Although not an exhaustive list, CBT-ED should include:
– Creation of a personalised treatment plan (usually referred to as a formulation) that shows the key factors maintaining the eating problem. These might include things like the perceived importance of weight and shape and the presence of low weight (if applicable);
– Regular self-monitoring of dietary intake and associated thoughts and feelings. Such diaries are usually completed by the patient daily and shared with the therapist;
– Advice to eat regular meals and snacks to avoid feeling hungry, particularly in the early stages of treatment;
– Completion of ‘homework’ (i.e., tasks carried out between sessions to help practice what is learned in sessions);
– Reference to useful self-help materials, such as books or worksheets – particularly those written from a CBT perspective;
– Regular weighing – typically once per week;
– A focus on making early change, typically achieved by changing eating behaviour soon in treatment;
– Discussion of related areas (e.g., low self-esteem), although this is usually postponed until a significant behavioural change has been observed (e.g., reduction in the frequency of binge eating, weight restoration);
– Spacing sessions further apart towards the end of treatment (e.g., fortnightly) and focusing on the maintenance of change and minimising the risk of relapse.
For those who are overweight, CBT generally advises treating the ‘eating disorder’ before addressing obesity or other weight-related issues. Although weight loss can be an appropriate goal for some people, this is best left until the eating disorder is addressed, by which point a decision about weight loss can be made. In any case, body acceptance is an important component of most psychological interventions for disordered eating.
As an ‘individual’ treatment, significant others are not routinely included but there is the facility for this to happen if doing so can help facilitate treatment (and is acceptable to the patient). This is rarely the case in every session but, rather, a few of these sessions (which take place straight after a one-to-one session) can be conducted throughout treatment. (Again, there are some notable differences here regarding the treatment of younger patients.)
Finally, some treatments advocate the provision of sessions twice per week in the initial phases. This is usually used to promote initial behavioural change and will become weekly after a change has been achieved.
Are There any Checklists I can Use to See if I’m Getting CBT?
An Australian team led by Tracey Wade designed a 15-item checklist to help patients identify evidence-based treatment for EDs. Although some items are unique to the Australian context, they included questions such as whether the therapist is registered with a professional body, whether the therapist receives regular supervision specific to EDs, whether treatment focuses on early (behavioural) change, how many sessions are planned, and how / whether other healthcare professionals (e.g., GPs, dietitians) are involved.
There is also a guide describing the core features of CBT-E, a particular form of CBT-ED, available here. This has some similarities with Wade and colleagues’ checklist, such as a focus on early change, but also notes some important features of CBT-E, such as the use of ‘self-monitoring’, ‘open’ weighing, and regular eating.
Are there Any Therapist Registers?
There are several professional bodies in the UK with which therapists might be registered. These include the British Association for Behavioural and Cognitive Psychotherapies (BABCP) and the British Association for Counselling and Psychotherapy (BACP). Registration and/or accreditation with a professional body does not guarantee experience with EDs but does mean that registrants will be asked to demonstrate that they meet certain standards of proficiency, training, and experience and to adhere to a code of ethics and conduct.
Supervision is a common practice of psychological therapists whereby they discuss elements of their work (including detail of what is covered in sessions) with another practitioner. This is typically ‘confidential’ (in the sense that patients’ full names are rarely used) and usually with a therapist with similar experience and training. However, supervision is important for the appropriate delivery of CBT and helps protect patients from harm. In EDs, therefore, it is typically an expectation that therapists will have ED-specific supervision to support them in their work.
What Should I Do if I Am (or Someone I Know is) Thinking of Starting Therapy for an Eating Disorder?
If you’re thinking about starting psychological treatment for an eating disorder, it might be worth considering some of the elements mentioned above and discussing these at your assessment. Most therapists will be open to discussing these. As mentioned above, CBT-ED can (and, perhaps, should) be delivered in different ways but it is important that you are satisfied with the responses your therapist gives.
Starting treatment is a difficult step and treatment itself can involve many challenges. Knowing what to expect will help you get the help you need to recover.
If you would like an idea of your present needs try our online self assessment quiz here.
All clinicians at Oxford CBT practice Cognitive Behavioural Therapy, or are Psychologists, providing evidence-based interventions and support for a range of issues for both young people and adults. If you would like to book an appointment you can do so on our online booking portal. If you have a question please get in touch via our online contact form or call us on 01865 920077.