Enhanced CBT for Eating Disorders: What It Is
Cognitive Behavioral Therapy (CBT) helps people restructure or change the way they think about things so they feel and do better.
Enhanced Cognitive Behavioral Therapy (CBT-E) is CBT modified to address the needs of people with eating disorders. It helps people examine how they think about food and their body and focuses on modifying eating behaviors.
CBT-E is a transdiagnostic treatment approach, meaning it addresses each individual’s unique thoughts and behaviors instead of treating the eating disorder (ED) diagnosis.
Two Forms, Two Intensities
There are two forms of CBT-E:
- Focused CBT-E addresses eating disorder related thoughts and behaviors, known as the core ED issues. It is the primary treatment choice for most ED patients.
- Broad CBT-E addresses core ED issues in addition to other obstacles to change an individual might have.
There are two intensities of CBT-E:
- Individuals who are not significantly underweight receive 20 therapy sessions over 20 weeks; this works for most adult patients.
- Those who are significantly underweight receive 40 sessions over 40 weeks, giving patients time to work on motivation for change plus under-eating and underweight issues.
The primary goal of either form or intensity of CBT-E is identifying and removing key thoughts and behaviors that support the eating disorder.
Four Stages of Treatment
CBT-E has four basic stages of treatment, each personalized to suit the unique ED thoughts and behaviors of patients.
Stage One lays the foundation for following stages and develops momentum for change. The goals are:
- To engage the patient in the therapy process, educate them about the treatment and their disorder.
- To create with the patient a personalized plan of action, including a diagram of specific thoughts and behaviors supporting that person’s ED.
- To have the patient begin self-monitoring by keeping an in-the-moment ED record (e.g., thoughts, feelings, actions) to be reviewed at each session.
- To begin the routine of weighing in at each session.
- To establish a routine of regular eating habits for the patient to follow plus strategies for maintaining the routine.
Stage Two is transitional. While continuing the steps in stage one, patient and therapist identify problems still requiring attention and discuss barriers to change that might have arisen. If necessary, stage one strategies are revised and a plan for stage three is created.
Stage Three is the main part of CBT-E, where a patient and a therapist address key thoughts and behaviors the patient uses to maintain the ED, such as:
- Over evaluation (overemphasis) of body shape and weight, including its origins.
- Frequent body checking and “feeling” fat.
- Extreme or rigid dietary rules.
- Event triggered changes in eating.
- Perfectionism, low self-esteem and interpersonal problems.
This stage includes finding healthier ways to evaluate the self.
Stage Four is about developing strategies for maintaining patient progress after therapy ends and discussing ways to lower the risk of relapse. Sessions might involve looking at realistic expectations, learning to view setbacks as lapses instead of relapses, and addressing lapses with techniques the patient has learned.
CBT-E addresses the special concerns of patients who are significantly underweight, such as having them experiment with changes, developing a personalized plan for gradual weight gain, looking at the risks of living in a starvation state and what not changing means for their future.
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