What Is CBT-E? Understanding Enhanced Cognitive Behavioral Therapy for Eating Disorders

If you or someone you love has ever sought treatment for a mental health condition like anxiety, depression, or an eating disorder, you’re likely familiar with cognitive behavioral therapy (CBT). But while CBT is widely applicable to many different mental health conditions, in recent years, a new variation meant specifically to treat eating disorders, known as CBT-E, has emerged. CBT-E stands for enhanced cognitive behavioral therapy, but is also sometimes referred to as cognitive behavioral therapy for eating disorders. It shares many similarities with CBT, with some key differences.

Read on to learn the details on CBT-E, how and why it’s used to treat eating disorders, and whether you or your loved one may want to explore its benefits.

What is CBT-E?

Specifically designed to treat eating disorders, CBT-E is rooted in the principles of CBT but considered an “enhanced” modality because of the innovative strategies and procedures implemented in its development. Rather than targeting a single diagnosis like anxiety or depression, CBT-E is designed to be flexible and individualized, so it can adapt to fit a variety of needs.

“Enhanced cognitive behavioral therapy is a modular approach to treating a wide range of eating disorders,” says Equip Director of Adult Programs, Lara Effland, LICSW, CEDS-S. “It’s a patient-focused treatment that includes psychoeducation about the mechanisms of a patient’s eating disorder, common triggers, and areas that prevent them from recovery.”

Initially developed for adults in outpatient treatment, CBT-E has more recently been used in adolescent populations as well, and is considered a viable treatment option alongside family-based treatment (FBT). CBT-E is notably a “transdiagnostic” model, which recognizes that people with the same diagnosis may present with very different symptoms, and it can be used to treat all types of eating disorders including anorexia, bulimia, BED, and others.

“CBT-E has an initial focus on building motivation and engagement in care,” Effland says. “The goal of therapy is to change disordered eating by changing patterns of behavior and problematic thoughts that contribute to disordered eating behavior. Namely, thoughts around the over-evaluation of shape and weight, how weight and shape are associated with self-worth, and the person’s desire to control them.”

Effland explains that CBT-E includes four specific stages:

  • Stage 1: “Starting Well”: During the initial stage, the focus is on providing personalized education and guidance to patients and helping them gain an understanding of their eating disorder. Sessions are generally twice a week.
  • Stage 2: “Taking Stock”: The goal in this stage is to establish some processes for monitoring and tracking goals, usually through twice weekly sessions.
  • Stage 3: Individualized modules based on each patient’s specific needs. Stage 3 is the most variable stage, and will look different from person to person. Topics addressed might include body image; weight restoration; mindset and setbacks; moods and eating; and dietary restraint and restriction. Weekly sessions are typically focused on helping the patient understand the processes that are maintaining the eating disorder and beginning to address the concerns and issues underlying the problematic behavior.
  • Stage 4: “Ending Well”: The focus in the final stage of CBT-E is planning ahead for the future and developing strategies for coping with changes and setbacks.

According to Effland, CBT-E uses a variety of different interventions depending on patients' unique needs and challenges. Some of those interventions include:

  • The self-monitoring tool, a formalized framework for tracking eating and drinking behaviors and how patients feel about them
  • Collaborative review of a patient’s weight to help dispute eating disorder thoughts about weight.
  • Behavioral experiments and cognitive restructuring to dispute eating disorder thoughts
  • Behavior chaining, or a sequence of behaviors in which one action triggers the next one
  • Education about the relationship between thoughts, mood, and behavior

“Unlike FBT, CBT-E has specific treatment recommendations for addressing things like dietary rules and restraint, body image, perfectionism, low self-esteem, and mood, among others,” Effland says.

How does CBT-E differ from traditional CBT?

CBT is a popular therapeutic approach designed to help patients become aware of negative or inaccurate thoughts and begin to challenge them. It’s a leading treatment for anxiety, depression, and a variety of other co-occurring issues. CBT-E, on the other hand, is a treatment modality that uses CBT as a basis but is specifically designed to adapt to the needs of different eating disorder diagnoses.

Effland explains that CBT is based on the foundational belief that thoughts can lead to emotions and behaviors that are either helpful or unhelpful, and when you intervene in one part of the thought-emotion-behavior cycle, you intervene in them all. “This theory is included in CBT-E as the basis for the treatment. However, CBT-E uses the psychoeducation of eating disorders as the basis for the remaining interventions. It’s CBT through the lens of an eating disorder,” she says.

CBT-E also differs from CBT in that it follows a structured, tailored pattern of treatment consisting of the four distinct stages outlined above. While the stages are designed to focus on particular areas, like education and self-monitoring, each one is customized to fit the patient’s unique needs and goals, and the third module in particular may focus on a variety of topics that are specific to the patient’s particular challenges, like body image or mood management.

What does the research say about CBT-E for eating disorder treatment?

The evidence for the effectiveness of CBT-E has been promising so far, according to researchers. “It’s the most empirically supported treatment for eating disorders, especially bulimia and binge eating, and can be successful for anorexia,” Effland says. “CBT-E is the leading evidence-based treatment for adults with an eating disorder.”

According to a 2017 paper on the evolution of CBT for eating disorders, studies have shown that CBT-E may be particularly effective for eating disorder patients having significant difficulty with issues like mood intolerance, perfectionism, interpersonal difficulties, and low self-esteem. When compared with interpersonal psychotherapy (IPT), significantly more people who underwent CBT-E (66%) met criteria for remission compared to 33% for IPT. A slightly older study examining the effectiveness of CBT-E in adults found that by the end of treatment, two thirds of the patients who completed treatment achieved full remission.

As for the effectiveness of CBT-E in adolescents, the research is somewhat limited but also encouraging. A 2013 study found that two-thirds of the 49 participants who received 40 sessions of CBT-E over 40 weeks completed the full treatment with no additional input. These patients demonstrated a substantial increase in weight and a marked decrease in eating disorder psychopathology, leading researchers to consider it a viable form of treatment for adolescents.

While CBT-E has been shown to effectively treat a range of diagnoses, Effland does point out that patients may also require additional forms of treatment to address all symptoms and ongoing issues. “CBT-E doesn’t treat all conditions or disorders related to an eating disorder and you might need to incorporate other treatments to support co-occurring conditions and disorders,” she says.

What should patients and families expect from CBT-E?

While the exact format of CBT-E will vary depending on the patient and their needs, the core principles revolve around tackling the underlying mechanisms of the eating disorder, and learning ways to work through the root issues. “Your treatment is individualized and tailored to your specific eating problem and needs,” Effland says. “You, your treatment team, and your support system will become experts on your eating problem and what keeps it going.”

In addition to following the four-stage modular format, CBT-E is also conducted in a particular, but personalized way. CBT-E is a one-to-one talking-type of treatment that focuses primarily on what is keeping the eating problem going,” Effland says. “If needed, we will address things that have happened in the past if they will be helpful on your journey to recovery.” According to Effland, eating disorder treatment with CBT-E can take between 20-40 weeks, depending on various factors including whether or not a patient needs to gain weight.

At Equip, our providers pull from a variety of the leading evidence-based modalities to personalize treatment to each patient, and this often includes CBT-E. Whether your treatment plan includes CBT-E or not, here are the general pieces of the treatment puzzle that you can expect from eating disorder treatment at Equip:

  • You will meet with your therapist and dietitian weekly for at least the first ten weeks.
  • You will meet with your peer mentor as often as is helpful.
  • You will meet with your medical provider in the first week of treatment and as often as recommended after that.
  • Your family or supports will meet with their family mentor as often as needed. They can also join you for sessions with your therapist as frequently as is needed.

To learn more about CBT-E at Equip, our team is here to answer any questions you might have. Reach out today to schedule a consultation.

References
  1. Agras, W. Stewart, Ellen E. Fitzsimmons-Craft, and Denise E. Wilfley. 2017. “Evolution of Cognitive-Behavioral Therapy for Eating Disorders.” Behaviour Research and Therapy 88 (January): 26–36. https://doi.org/10.1016/j.brat.2016.09.004.
  2. Byrne, Susan M, Anthea Fursland, Karina L Allen, and Hunna Watson. 2011. “The Effectiveness of Enhanced Cognitive Behavioural Therapy for Eating Disorders: An Open Trial.” Behaviour Research and Therapy 49 (4): 219–26. https://doi.org/10.1016/j.brat.2011.01.006.
  3. Dalle Grave, Riccardo, Simona Calugi, Helen A. Doll, and Christopher G. Fairburn. 2013. “Enhanced Cognitive Behaviour Therapy for Adolescents with Anorexia Nervosa: An Alternative to Family Therapy?” Behaviour Research and Therapy 51 (1): R9–12. https://doi.org/10.1016/j.brat.2012.09.008.
  4. Dalle Grave, Riccardo. 2022. “Enhanced Cognitive Behavior Therapy for Eating Disorders.” Eating Disorders, 1–21. https://doi.org/10.1007/978-3-030-67929-3_1-1.
  5. Le Grange, Daniel, Sarah Eckhardt, Riccardo Dalle Grave, Ross D. Crosby, Carol B. Peterson, Helene Keery, Julie Lesser, and Carolyn Martell. 2020. “Enhanced Cognitive-Behavior Therapy and Family-Based Treatment for Adolescents with an Eating Disorder: A Non-Randomized Effectiveness Trial.” Psychological Medicine 52 (13): 1–11. https://doi.org/10.1017/s0033291720004407.
  6. “Instructions for Self-Monitoring.” n.d. Accessed May 24, 2024. https://www.cbte.co/site/download/t5-2-instructions-for-self-monitoring/?wpdmdl=656&masterkey=5c6fc2bbccc43.
  7. ​​Mayo Clinic. 2019. “Cognitive Behavioral Therapy.” Mayoclinic.org. Mayo Clinic. March 16, 2019. https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610.
  8. Murphy, Rebecca, Suzanne Straebler, Zafra Cooper, and Christopher G. Fairburn. 2010. “Cognitive Behavioral Therapy for Eating Disorders.” Psychiatric Clinics of North America 33 (3): 611–27. https://doi.org/10.1016/j.psc.2010.04.004.
  9. Oxford Health. 2018. “Child and Adolescent Eating Disorder Service Cognitive Behaviour Therapy for Eating Disorders (CBT-E).” https://www.oxfordhealth.nhs.uk/camhs/wp-content/uploads/sites/13/2019/05/Eating-Disorders-CBTE-0718.pdf.
Michelle Konstantinovsky
Equip Contributing Editor
Clinically reviewed by:
Lara Effland, LICSW, CEDS-S
Director of Adult Services
Our Editorial Policy
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