Enhanced Cognitive Behavioural Therapy (CBT-E)
What is CBT-E?
CBT-E stands for “enhanced cognitive behavoural therapy” and is a form of CBT designed specifically for the treatment of eating disorders. It is one of the most effective forms of treatment for eating disorders, so is often recommended as the first line of treatment. CBT-E can be used for people with bulimia nerovsa, binge eating disorder, anorexia, OSFED or similar difficulties.
CBT-E is based on the same principles as standard CBT - that the way in which we think and behave can affect how we feel. By changing what we do and how we think (by learning CBT techniques) we can make a significant change to how we feel. CBT-E builds on this by also taking into account the role of the body and the impact of eating disordered behaviours such as restricting, bingeing, exercising or purging.
How does CBT-E work?
Sometimes people see CBT as a “manualised approach”. However, CBT-E is designed to be a highly individualised treatment, with the clinician choosing relevant tools and techniques depending on the difficulties the person is experiencing. Although there are common threads, every course of CBT-E will look different.
CBT-E has four stages:
Creating an individual “formulation” or shared understanding of what is causing/maintaining the eating disorder and making intial changes to stabilise eating patterns. This includes psychoeducation and starting to reduce weight concern.
Reviewing the progress so far and making a brief treatment plan for the next phase of treatment
Addressing the factors that maintain the eating disorder e.g. reducing shape and weight concern, finding different ways to manage emotions, or addressing restriction and dietary rules.
Preparing for ending by thinking about how to deal with setbacks and how to maintain change.
People sometimes find it helpful to have review sessions following therapy to ensure they are maintinaing the progress made in therapy, although this is personal preference.
How long does CBT-E take?
When people are not significantly underweight, CBT-E is typically 20 sessions long. When people are significantly underweight, CBT-E is typically 40 sessions long, as time is needed to support people with weight gain in addition to the other therapeutic work.
Therapy can take longer if there are other “external” maintaining mechanisms. This means cases in which the eating disorder is being driven by other difficulties such as perfectionism, low self-esteem, or interpersonal difficulties, or cases in which the eating disorder is being used to try and protect the self from other difficulties, such as past traumatic experiences. In these situations it is important to address both the eating disoder and the underlying difficulty, so that the person is not left with the difficulties that contributed to the eating disorder in the first place. This can be done using broaded CBT, or by integrating other approaches, such as schema therapy, compassion-focussed therapy or EMDR.
CBT-E and weight
Most people with eating disorders will have a fear of weight gain, or a drive to lose weight. They may try and avoid weighing themselves, or find themselves weighing themselves constantly in an attempt to control or check weight. This can make addressing weight head on very scary. However, it is a crucial part of CBT-E, as addressing weight directly helps people start to reduce their anxiety around it.
In CBT-E we ask people people to do a weekly weigh in as part of their therapy session. This is very much used as a therapy tool - to help challenge unhelpful beliefs about weight and shape, to help make sense of the normal weight fluctuations everyone experiences, and to help weight become less important. If this concerns you, we can always talk about this during assessment or your early sessions.
For people who are underweight, CBT-E integrates weight gain into treatment. Again, this is challenging. This is not something the therapist imposes upon the person in therapy. Instead, early sessions are spent exploring the pros and cons of change and the risks of remaining underweight, with the goal of supporting the person who is underweight to decide to try weight gain. This might feel overwhelming. However, being low weight can have a significant impact on people physically, emotionally and cognitively. Whilst reaching a healthy weight will not “fix” things, people can experience a significant change in how they feel as a result of reaching a healthy weight for them.
During the final stages of therapy, attention is paid to helping people learn how to maintain their weight, a skill which it is important to master.