Cognitive behavioural therapy (CBT-E) for eating disorders

What place is there for CBT?

For children and adolescents, most professional organisations recommend a family-based approach for anorexia and for bulimia, rather than CBT.

But CBT is still a valid option if a family-based approach doesn't work for you. It's likely to be slower, especially if there is a lot of weight to regain, or if your child's brain is too affected to engage with a therapist, or to do 'homework' and access any sense of motivation. If your child is howling over every bite on their plate, they need a lot more help than a weekly CBT session.

CBT, like other modes of individual psychotherapy (I describe some here), could be useful after a family-based approach has run its course.

Indeed there is now an interesting variation on CBT for eating disorders, called CBT-T. The 'T' stands for Ten sessions.  The clinician manual for this approach is 'Brief Cognitive Behavioural Therapy for Non-Underweight Patients'. Glenn Waller wrote to me in 2023 that 'it was designed for adults, but we are finding that a lot of children and young people's services are adopting it, especially if a patient has had FBT, has regained weight, but the eating and body concerns are not shifting. It has also been tried successfully with adolescents in a study in Australia, with more to come.'

As CBT is often offered to our children, I'm going to tell you more about what it is, how well it works and doesn't work, what the risks are and how to manage them. I hope it will help you decide if you want to go down this path at any stage. Note that I won't comment on CBT-T as I don't know enough about it.

Make sure it's CBT specialised for eating disorders

Cognitive behavioural therapy (CBT) is a widely available treatment for depression or anxiety. Many therapists list it as one of their approaches to treating eating disorders, and it is essential that you satisfy yourself that they’re not offering general CBT, but are trained[i] in evidence-based CBT for eating disorders – in other words, CBT that is specially adapted and tested for eating disorders (in the UK it’s called CBT-ED). From here on, when I talk of CBT, I will be referring to one of these specialised, evidence-based forms.

It's mostly about behaviours

Rather than talking about change, this form of CBT seeks to improve behaviours (such as regular eating) to get physiological benefits. People have to keep an ongoing record of their eating or purging behaviours, they must be willing to talk and must be capable of rational thinking to take in information, to recognise the downsides of the illness, and to gain the motivation to experiment with new behaviours.

Does CBT work for adults with an eating disorder?

The most recent thorough review of all treatments comes from England’s NICE guidance. The outcome is that CBT is recommended for adults but is not the first choice for young people. It has been well researched on adults with bulimia and binge-eating disorder, and to a lesser extent, on adults with anorexia, and works better than most other individual therapies[ii]. According to Christopher Fairburn, who developed CBT ‘enhanced’ for eating disorders (CBT-E), ‘two-thirds of adult patients who complete treatment make an excellent response’, though the ‘outcome is less good’ in adults with a BMI under 17.5.[iii] CBT-E has been designed for adults with a BMI between 15 and 40. It can be delivered via self-help and in groups but it is more effective in individual therapy.

Does it work for teens?

For children and adolescents with anorexia or bulimia, the best evidence indicates that a family-based approach is superior and should be the first port of call. After a thorough review of the research, the NICE guidance clarified that CBT may be used only if a family approach is ‘unacceptable, contraindicated or ineffective’.[iv] The only valid reason to start off with CBT is when parents are unable or unwilling to give their child the level of support, supervision and uncritical acceptance that family therapy requires.

CBT has only been tested on a small number of younger patients with anorexia. After 40 sessions, only one-third of participants reached a weight close to their ideal body weight. One study compared FBT (family-based treatment) with CBT-E in adolescents with a range of eating disorders. Overall, it indicates that CBT-E has a place in some situations, but for youngsters needing rapid weight recovery, FBT is the first-line treatment [v] My own view, from hearing parents’ accounts, is that the progress of youngsters with anorexia treated with CBT seems to be unnecessarily slow and shaky.

For adolescents with bulimia, there is only one randomised controlled study comparing FBT with CBT. Both produce similar outcomes 12 months post-treatment but FBT produces improvements sooner,[vi] which may be why FBT is NICE’s top recommendation.

Glenn Waller and Christopher Fairburn, who have each developed and researched CBT, advise caution on the use of CBT on adolescents. Waller says that:

“CBT should be considered as an alternative that can be used only where FBT is not possible or indicated or where FBT has failed to be effective.”

[vii]

Glenn Waller explains CBT for eating disorders in this excellent webinar:

When is CBT indicated… or to be ruled out?

Fairburn indicates that CBT-E may not be suitable for those below the age of 15 and is rarely appropriate for children under 14 years old.

The CBT-E manual indicates a number of criteria that rule out the approach. If your youngster has lost a lot of weight (more than 20 per cent or so), or presents a health risk or a suicide risk, or has co-existing psychiatric problems, or refuses to engage in individual treatment, you cannot use CBT-E outpatient treatment right away. The manual recommends a preliminary intervention such as family therapy. If your child has clinical depression as well as an eating disorder, the therapist might want that to be treated first.

Above: manuals aimed at therapists, by Waller, then Fairburn, followed by self-help books by Waller, then Fairburn

My experience with CBT

If there are no major obstacles to your child having CBT and if you’ve already completed a course of family therapy, CBT might help your child deal with any eating disorder beliefs or habits that haven’t successfully been addressed in family therapy. It might help him learn more about relapse prevention and take responsibility for maintaining behaviours that will keep him safe.

I convinced my daughter to do precisely that when she was still suffering from an internal tension to keep her weight low. I came to regret it. The therapist, whom I had chosen with care and briefed, nevertheless believed everything my daughter told her. Four sessions in, without consulting us, she approved my girl’s pleas to join a gym and to stop any weight gain. At this stage we ended the therapy and slowly worked on undoing the damage.

That’s only my experience, but if you’re considering CBT, I recommend you first read the books written for therapists so as to know what to expect, and what to check when you interview them.[viii] (I did all that but sadly, in my case, it was not enough.) What follows is my summary of the main aspects of CBT treatment. As you will see, CBT shares some principles with family therapy and with approaches I describe in this book, but there are large differences, some of which I find alarming.

What is CBT like?

CBT therapists care very much about engagement with patients and nurturing their motivation for change. In his CBT-E manual, Fairburn suggests that a younger patient’s refusal to engage in treatment may be a way of asserting identity and independence and that girls may turn to controlling their eating, shape and weight as a way of boosting their self-esteem and enhancing peer approval. (I’m guessing these interpretations would make my daughter rather cross. I note that Glenn Waller’s book does not go down this road. It’s an example of how you can sound out therapists in order to find the best match for your child.)

What is the parents' involvement?

Young people, according to Fairburn, need to develop autonomy and will be helped to make choices and take appropriate control. With all this in mind, Fairburn wants therapists to be clear that they work exclusively on the youngster’s behalf and not on behalf of the parents. Parents are involved at the outset and there are regular joint meetings, but the bulk of the CBT-E therapy is between the young person and the therapist.

On the other hand, Waller gives examples of greater parent involvement and an intelligent approach to confidentiality. He emphasises that a therapist only spends an hour a week with a patient, and that the real therapy happens in the young person’s real world, where they are part of a family and benefit from their parents’ support.

If you're considering CBT for your child I would recommend you look at Ricardo Grave's books as they have been written with teens in mind. I have not read them myself.

What beliefs and behaviours are maintaining the eating disorder?

CBT treats disorders as ‘cognitive disorders’ (i.e. disorders related to how we think, perceive, remember, judge or learn). It focuses on the behaviours that maintain the disorder in the present rather than look for causes, though it may look at the past to help the person avoid sliding back into a problem once they have recovered. The theory is that all eating disorders share a core psychopathology: the over-evaluation of shape and weight and their control. Therapists help patients understand the factors that maintain their eating disorder, such as over-evaluating their shape and weight, calorie-counting and following strict dietary rules, being underweight, and reacting in certain ways to events and emotions.

The patient must self-monitor throughout the day by noting their behaviour around food, purging, body-checking, their mood and any triggering event. In sessions, patients get to see the mechanisms that maintain the eating disorder, they become conscious of the effect the eating disorder has on their life, and the therapist works on their motivation to make steps towards recovery. There is work to do on interpretations (what you see in the mirror, for instance, is not you; when you ‘feel’ fat, it does not mean you are fat) and there are instructions to follow each week (for example, no more eating between meals; no more weighing at home).

Regular eating and weight recovery

The process is collaborative. For instance, with underweight patients, the decision to regain weight will come from them rather than be imposed by the therapist. Yet there is also a clear structure for each session, and the CBT-E manual specifies one essential requirement right from the start: patients must eat five to six times a day.

Regular eating helps underweight patients regain weight, of course, but it also helps avoid binges and this, in turn helps put a stop to purging.

Patients are weighed at each session and educated about normal weight fluctuations. If they are obese, the agreement is usually to treat the eating disorder first, then consider weight change (please note that more and more eating disorder specialists work on acceptance of current weight rather than weight loss). If they are underweight, then with CBT-E they have a standard BMI or weight-for-height bracket to aim for or to maintain. Weight regain, if it is needed, is a priority and is top of the agenda at each session.

In the CBT-E manual, healthy exercise is encouraged even in underweight patients on the basis of its psychological and physical benefits. (This is controversial, given the compulsive element often present in exercise.)

How long does it take?

For people who are not significantly underweight, treatment consists of around 20 outpatient sessions over 20 weeks. For non-underweight people there is also evidence in favour of a 10-session intensive version (CBT-I).[ix] For those who are very underweight (adults with a BMI of 15 to 17.5), CBT normally requires 40 outpatient sessions over 40 weeks. The additional sessions address weight restoration as well as the problem that patients may have little motivation to change.

I see a hazard with determining 'underweight' according to your child's BMI. Your child may come up as 'normal' weight on a BMI chart, yet you know that they have lost a lot of weight. If so, it's most likely they need to recover all or most of it, so your child may need to 40-session course, which is twice as long as the standard FBT treatment. Make sure clinicians are aware of this, and treat your child as they would someone in the 'underweight' category. (I say more on BMI issues here).

More to do after end of treatment

Towards the end of treatment, people will not have fully recovered but their thinking and behaviours will have normalised and the risk of relapse will be lower. The therapist and patient draw up a maintenance plan and a plan for dealing with setbacks. The person is by then able to be their own therapist, and may involve their family as co-therapists. Once treatment ends, the person is expected to continue maintaining progress. There is a review session 20 weeks or so after the end of treatment to assess any further needs.

CBT in an inpatient setting

CBT can take place in conjunction with inpatient treatment if patients are unable to make necessary changes to their eating or purging without intensive support.

Where to next?

Read about many different psychotherapy approaches in this post.

Read about Adolescent-Focused Therapy in this post, as just like CBT, it may be useful after a family-based approach has run its course.

References

[i] Therapists offering CBT-E may go through certification with Christopher Fairburn but if they already know general CBT and are experienced in dealing with eating disorders, they may also learn the approach from his manual. Glenn Waller delivers training on demand.

[ii] Glenn Waller (2016) ‘Recent advances in psychological therapies for eating disorders’

[iii] This statistic comes from Christopher G. Fairburn’s book "Cognitive Behavior Therapy and Eating Disorders"

See also Hollon and Wilson (2014) 'Psychoanalyis of Cognitive-Behavioral Therapy for Bulimia Nervosa'

[iv] NICE guidance (2017): nice.org.uk/guidance/ng69 and I explain it here

[vii] Glenn Waller (2016) ‘Recent advances in psychological therapies for eating disorders’

[viii]

Fairburn's CBT-E manual for therapists is 'Cognitive Behavior Therapy and Eating Disorders' (brown and white cover above). It lays out the approach’s protocol, is easy for parents to read and has a chapter on patients in their late teens. Patients are normally asked to read Christopher Fairburn’s book Overcoming Binge Eating (the last book pictured above).

I found it very useful to contrast the CBT-E manual with Waller's highly readable book for therapists (blue cover), which presents detailed guidance rather than a strict protocol. Authors are Waller, G., Cordery, H., Costorphine, E., Hinrichsen, H., Lawson, R., Mountford, V., Russel, K. (2007) Cognitive Behavioral Therapy for Eating Disorders: Comprehensive Treatment Guide There is a chapter on children and adolescents.

[ix]

Glenn Waller and colleagues (2016): a new ten-session version of CBT (CBTi – for intensive) for non-underweight cases. ‘We have just completed and reported on a case series of about 100 patients, and we get results that are nearly as good as the 20 session evidence-based versions, like CBT-E and others.’ Update: the research is now published and the method is in use.