“By correcting erroneous beliefs we can lower excessive reactions.” – Aaron Beck, M.D.
Cognitive behavioral therapy (CBT) is one of the most widely recognized and heavily researched treatment interventions to date. CBT is applied for an array of mental health disorders and symptoms. Through extensive research and empirical studies, CBT has demonstrated effective outcomes for people with various diagnoses including eating disorders, depression, anxiety, insomnia, trauma, among others. For many clinicians and practitioners, cognitive behavioral therapy is the therapeutic approach taken to assist clients and patients with their personal struggles.
History of CBT
Dr. Aaron Beck, a distinguished psychiatrist began his research in the 1960’s on how the conscious mind plays a significant role in determining how a person interacts in the world. At that time, therapeutic models like psychoanalysis and behaviorism often negated the conscious mind and focused instead on concepts like impulses, analysis of the unconscious, conditioning, and “uncontrollable” responses. These viewpoints concerned Dr. Beck since the conscious mind, specifically our thoughts, is the largest constituent of how we interpret our experiences.
For decades, Dr. Beck continued his research, co-founding the Beck Institute and coined the term cognitive therapy, also known as cognitive behavioral therapy. He repeated multiple research studies demonstrating the effectiveness of CBT interventions with a variety of mental health disorders. What he and his team of researchers discovered was that by identifying, monitoring, and effectively changing our thoughts, we can alter our maladaptive perceptions ultimately leading to significant and positive behavior change.
Fundamentals of CBT
The basic principle of cognitive behavioral therapy is actually quite simple: our thoughts have a direct relationship with our emotions and our behaviors. According to Beck (1979) “the cognitive approach is concerned with conscious meanings as well as external events”. A patient working within the cognitive behavioral model reports her/his beliefs, feelings, and behaviors to the CBT clinician as the foundation of the therapeutic work. A client’s thoughts, or schemas, underlie the way she/he understands and navigates experiences from day to day. These schemas are generally not obvious and often automatic. Automatic thoughts require direct awareness in order to untangle the maladaptive thoughts from healthy and effective thoughts. In a therapeutic setting, a patient’s schemas are identified, evaluated, and explored.
For example, if an individual believes the schema “I am not a good person”, their behaviors and emotions may result in isolation from others, sadness, depression, and low self-esteem. Moreover, this person would likely reject any messages that conflict with this negative notion. Consequently if they received a compliment from a friend or loved one, they would surely dismiss it and consider it untrue due to this underlying, maladaptive schema.
Cognitive distortions, or distorted thinking, is another concept in CBT. Distorted thinking presents in many forms and most of us have experienced moments of distorted thinking. Distortions in our beliefs can often alter a person’s rational perceptions and create irrational and inflexible schemas. These schemas tend to be extreme and frequently produce unforgiving self-criticisms and can lead to other forms of distorted thinking. An example of distorted thinking is evaluating things in absolute terms such as “always”, “never”, or “every.” This leads to All-or-Nothing Thinking and statements like “I am always so clumsy” or “I am never on time.” In this example, it is unlikely that the person is always so clumsy or never on time. An effective analysis of cognitive distortions can bring awareness and factual evidence to maladaptive ideologies.
Enhanced CBT for Eating Disorders
“Eating Disorders are essentially cognitive disorders.” – Christopher G. Fairburn, D.M.
“Enhanced” cognitive behavioral therapy for eating disorders, or CBT-E, is a well-known and empirically-supported treatment. Multiple research studies have demonstrated the effectiveness of CBT-E with eating disorders (Bowers & Ansher, 2008; Byrne, Rursland, Allen, & Watson, 2011; Fairburn, 2008). The root of eating disordered psychopathology lies in the over-evaluation of the body, perfectionistic standards, and the idea of control. According to Dr. Christopher Fairburn, psychiatrist and principal researcher of CBT-E, the concepts of cognitive behavioral therapy match perfectly with eating disorder treatment.
As a treatment, CBT-E is a structured, fixed-length intervention (e.g., 20 sessions) that begins with an evaluation and general clinical assessment. A case formulation is created and revised based on the patient’s progress throughout treatment. CBT-E uses “well-specified strategies and procedures to address the targeted psychopathology” (Fairburn, 2008). Fairburn (2008) categorizes eating disorders as “transdiagnostic” meaning that eating disorder diagnoses have symptoms that tend to overlap. CBT-E is considered a transdiagnostic treatment meant to address the underlying mechanisms that maintain all eating disorders.
CBT-E is not generally intended to be used in combination with other psychological treatments and requires delivery by one therapist. The primary goals of the CBT-E therapist are to keep the patient engaged and maintain an effective therapeutic relationship. Therefore, a strong therapeutic alliance, collaboration and active patient participation, and understanding the relationship between a patient’s eating disordered schemas, emotions, and behaviors are essential to treatment outcome.
A major component of CBT-E is identifying the processes that maintain the eating disorder psychopathology (Fairburn, 2008). For example, the vast majority of patients with an eating disorder tend to be extremely apprehensive about their weight, body image, and the notion of “being in control.” For these people, negative self-judgments and critical self-evaluations become routine when striving for a “perfect” and “never-good-enough” body ideal. If these negative body image schemas are repeated frequently, they can become automatic, maintaining the eating disorder, and lead to greater eating disorder symptoms and behaviors. These symptoms and behaviors can include:
- Restricting meals
- Binge eating
- Purging (vomiting)
- Laxative use
- Excessive exercise
- Excessive weighing or avoidance of weight
- Persistent and frequent comparison to others
- Dietary food rules (e.g., “good” versus “bad” foods)
- Calorie counting
- Other compensatory behaviors
CBT-E Treatment and the Next Steps
After recognizing and identifying the patient’s cognitive schemas (thoughts) maintaining the eating disorder, initiating treatment interventions that successfully produce behavior change is implemented. The initial stages of treatment will include a collaborative and joint effort to create a “formulation” or a visual diagram of the process that maintains the patient’s eating disorder (Fairburn, 2008). This process allows the patient to visually observe what is sustaining maladaptive and harmful behaviors and creates an illustration which separates the patient from their eating disorder problems.
Next, the treatment process incorporates behavioral strategies to effectively monitor eating disorder actions, urges, and emotions. This “self-monitoring” is central to treatment and is as significant to treatment outcomes as the patient’s participation itself (Fairburn, 2008). A monitoring record is used in real-time to assess food intake, thought patterns, behaviors, emotions, and the context of the situation. The action of self-monitoring alone can provide direct awareness to patient’s eating disordered patterns and behaviors. The therapist and patient then review and discuss the monitoring logs. These logs are viewed as homework assignments and homework is a critical part in both cognitive behavioral therapy and CBT-E. Homework provides the idiosyncratic details (behavioral characteristics) that are unique to the patient and allows for in-depth analysis of the individual’s eating disorder process.
In general terms, CBT-E treatment will include in-session weighing, reviewing homework assignments, reviewing the case formulation, meal monitoring, recording behavioral and weight trends, and joint collaboration to identify barriers and overall treatment progress. These interventions are designed to assess healthy and new adaptive behavioral changes and account for any eating disorder concerns interfering with treatment. Ongoing discussions between the therapist and patient are also very important for treatment outcomes. For example, the therapist will clarify schemas and behaviors in order to fully understand the patient’s perspective. Additionally, it is encouraged for patients to ask questions and process any uncomfortable moments during treatment.
Lastly, CBT-E termination sessions will include relapse prevention planning, review of patient’s treatment progress, identification of eating disorder concerns and obstacles to recovery, and support planning after completion of treatment. To recap, the paramount goal of CBT-E treatment sessions is joint collaboration for ongoing assessment and positive treatment outcomes.
In summation, enhanced cognitive behavioral therapy has been shown to help people suffering from an eating disorder. It is important to seek professional help and treatment if you or a loved one is experiencing eating disordered symptoms. Eating disorders are considered very grave and are among the highest in mortality rates across all mental health disorders (Arcelus, Mitchell, Wales, & Nielsen, 2011). Compassion, growth, and collaboration between a therapist and the patient are elemental in eating disorder treatment.
Many clinicians are trained in cognitive behavioral therapy and some offer expertise in CBT-E for eating disorders. Searching for a professional trained in both eating disorder treatment and cognitive behavioral therapy can assist in alleviating presenting symptoms. If you have any concerns regarding CBT treatment for eating disorders, please be sure to discuss this with your provider at the onset of treatment so you may feel more comfortable in getting your questions answered.
About The Author
Dr. Michelle Carcel is a clinical psychologist in private practice in La Jolla, California. She has extensive training and experience in eating disorder treatment including two years training and working as a practicum trainee and postdoctoral fellow at University of California, San Diego (UCSD) Eating Disorder Center for Treatment and Research. She is a member of the National Association of Cognitive Behavioral Therapists and works as a CBT-focused therapist.
Arcelus, J., Mitchell, A.J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: A meta-analysis of 36 studies. Archives General Psychiatry, 68(7), 724-731. doi: 10.1001/archgenpsychiatry.2011.74.
Beck, A. (1979). Cognitive therapy and emotional disorders. New York, NY: Penguin Books.
Beck, J.S. (2011). Cognitive therapy: Basics and beyond 2nd Edition. New York, NY: Guilford Press.
Bowers, W.A. & Ansher, L.S. (2008). The effectiveness of cognitive behavioral therapy on changing eating disorder symptoms and psychopathology of 32 anorexia nervosa patients at hospital discharge and one year follow-up. Annals of clinical psychiatry, 20(2), 79-86.
Byrne, S.M., Rursland, A., Allen, K.L., & Watson, H. (2011). The effectiveness of enhanced cognitive behavioural therapy for eating disorders: An open trial. Behaviour Research and Therapy, 49, 219-226.
Dalle Grave, R. (2012). Intensive cognitive behavioral therapy for eating disorders. New York, NY: Nova Publishers.
Fairburn, C.G. (2008). Cognitive behavioral therapy and eating disorders. New York, NY: The Guilford Press.
Faiburn, C.G., Cooper, Z., & Shafran, R. (2003). Cognitive behavior therapy for eating disorders: A transdiagnostic theory and treatment. Behaviour Research and Therapy, 41, 509-528.
Fairburn, C.G., et al. (2015). A transdiagnostic comparison of enhanced cognitive behavior therapy (CBT-E) and interpersonal psychotherapy in the treatment of eating disorders. Behavior Research and Therapy, 70: 64 – 71, doi: 10.1016/j.brat.2015.04.010.
Onslow, L., Woodward, D., Hoefkens, T., & Waddington, L. (2016). Experiences of enhanced cognitive behavioural therapy for bulimia nervosa. Behavioural and Cognitive Psychotherapy, 44(2), 168-178. doi: 10.1017/S135246581400068X
Poulsen, S., et al. (2014). A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for Bulmia Nervosa. The American Journal of Psychiatry, 171 (1), 109-116.
Wonderlich, S.A., et al. (2014). A randomized controlled comparison of integrative cognitive-affective therapy (ICAT) and enhanced cognitive-behavioral therapy (CBT-E) for bulimia nervosa. Psychological Medicine, 44(3), 543-553.
Written – 2016