Are you stuck in a cycle of dieting, bingeing, purging, or exercising and having trouble figuring out how to stop? Are you preoccupied with food? Ashamed about your eating? Hating your body? If you are an adult struggling with your eating and body, you may feel out of control. You can break the cycle, achieve peace with food and your body, and get your life back. Our therapists who are trained in Cognitive Behavioral Therapy (CBT) for eating disorders can help. We provide therapy in our office in Los Angeles and online to people throughout California and some other states.
Why CBT is Indicated for Eating Disorders
CBT is the leading evidence-based treatment for bulimia nervosa and other eating disorders in adults. The most recent version is an “enhanced” protocol, CBT-E (Fairburn, Christopher G., 2008). Our therapists provide cognitive behavioral therapy (CBT) for adults and some older adolescents in California with bulimia, binge eating disorder, other specified feeding and eating disorder (OSFED), and disordered eating. Our therapists also incorporate elements from other models consistent with CBT into our work, including intuitive eating, DBT, mindful eating, mindfulness, and appetite awareness training. And we also incorporate Health at Every Size®, a social-justice anti-diet approach.
CBT for eating disorders was first described by Christopher Fairburn, MD in 1981 and has been updated several times, including a revision in 1993 co-authored by Dr. Muhlheim’s mentor, Dr. Terence Wilson (Fairburn, C. G., Marcus, M.D., & Wilson, G. T. (1993). Dr. Muhlheim was trained in CBT for eating disorders by Dr. Wilson, one of its developers, and she has trained many other professionals to deliver this therapy.
How CBT Works
CBT itself is a short-term psychological treatment based on the idea that how one thinks (cognition), feels (emotion), and behaves (behavior) all interact together. Specifically, one’s thoughts determine one’s feelings and behavior. Therefore, negative – and unrealistic – thoughts can cause distress and result in problems. CBT involves a variety of techniques to help a person understand the connection between their thoughts, feelings, and behaviors, and to develop strategies to feel and function better. CBT is a well-researched and effective type of therapy for anxiety, depression, phobias, panic attacks, and eating disorders, among others.
Cognitive behavioral therapy is an interactive, directive style of therapy with a primary focus on current issues. CBT is not a quick fix. A therapist advises and encourages – but cannot ‘do’ it for you. Most clients are seen once per week. A course of CBT is typically 6 weeks to 6 months. The strength of CBT is that you can continue to practice and develop your skills even after the sessions have finished. This makes it less likely that your symptoms or problems will return. It is a misconception that CBT only results in superficial changes. Once clients have achieved some relief from acute symptoms it is customary to turn our attention to identifying and modifying core beliefs. Core beliefs are rigid persistent beliefs that influence us in many different situations. It is through core belief work that some of the deeper changes in CBT occur.
How CBT for Eating Disorders (CBT-E) Works
Although it is a manualized treatment, CBT for eating disorders is a highly individualized treatment designed to be delivered in the outpatient setting. The treatment is time-limited and relatively short-term—approximately 20 sessions—and sessions are usually held weekly. In CBT, your therapist conducts an assessment and works collaboratively with you to identify patterns of behavior and thinking that are maintaining the eating disorder or disordered eating.
In cognitive behavioral therapy, the treatment focuses primarily on factors in the present that are keeping your disordered eating going. You and your therapist will work together as a team to understand your problems with food and collaboratively develop strategies to overcome it.
According to the cognitive model for eating disorders, dietary restriction underlies most eating disorders: skipping meals, restricting the type of food consumed, or restricting the amount of food consumed. This, in turn, drives binge or unplanned eating. Episodes of binge eating often lead to shame, disgust, guilt, self-criticism, and distress. Some people may purge to try to undo the “damage” from the binge episode. The person then usually resolves to diet again and the cycle repeats.
Recognizing this, CBT always begins with a detailed assessment of your eating and works to identify patterns of undereating that can be modified. Because eating enough is so essential to recovery, the initial focus is CBT is on changing behaviors.
Some of the primary cognitive behavioral strategies employed for eating disorder therapy include:
- Psychoeducation to understand what maintains the eating disorder and medical consequences
- Self-monitoring (keeping food records)
- Implementation of regular sufficient meals (usually 3 meals per day plus 2 to 3 snacks)
- Meal planning
- Introduction of “forbidden” or feared foods (exposure)
- The use of delays and alternatives to prevent bingeing and purging
- Strategies to manage negative mood states
- Cognitive restructuring to challenge eating disorder thoughts
- Strategies to address negative body image, perfectionism, and self-esteem issues
- Relapse prevention
We usually suggest reading or homework outside of the sessions to augment our work. Since the balance of your life takes place outside of the session, it is important that you collect data, “run experiments,” and practice the new techniques and strategies we discuss in your “real” life. Self-monitoring and practice sessions give us important feedback on what strategies work for you and facilitate progress as well as a greater self-awareness. The success and pace of therapy are related to the amount of effort you put in outside of sessions.
Also, in the course of CBT, we typically address how to redefine a health relationship with movement. You also may examine your values and we can help you evaluate whether certain activities are compatible with recovery.
Research Support for CBT for Eating Disorders
Cognitive behavioral therapy for eating disorders has been tested in numerous clinical trials and proven successful. Research studies indicate that about two-thirds of the patients who complete treatment have an excellent response. It is more effective than medication and most other forms of therapy to which it has been directly compared. It can also be successfully employed with older adolescents with bulimia nervosa. Most people who respond well to CBT for eating disorders will respond well in the first month by eating more regularly.
The UK’s National Institute for Health and Care Excellence (NICE) guidelines recommend CBT as the first-line treatment for adults with bulimia nervosa and binge eating disorder and one of three potential treatments to consider for adults with anorexia nervosa.
One study randomly assigned seventy female patients with bulimia nervosa to either five months of CBT (20 sessions) or two years of weekly psychoanalytic psychotherapy. After five months of therapy (the end of the CBT treatment), 42 percent of patients in the CBT group and only 6 percent of the patients in the psychoanalytic therapy group had ceased binge-eating and purging. At the end of two years (completion of the psychoanalytic therapy), 44 percent of the CBT group and 15 percent of the psychoanalytic group were symptom-free.
Another study compared CBT-E with interpersonal therapy (IPT), an alternative leading treatment for adults with an eating disorder. In this study, 130 adult patients with an eating disorder were randomly assigned to receive either CBT-E or IPT. Both treatment groups received 20 sessions of psychotherapy over a period of 20 weeks, followed by a 60-week follow-up period. At post-treatment, 66 percent of the CBT-E participants met criteria for remission, compared with only 33 percent of the IPT participants. Over the follow-up period, the CBT-E remission rate remained higher (69 percent versus 49 percent).
We also provide a specific CBT treatment for ARFID to adults with ARFID.
If CBT is not working well, your therapist will refer you to another type of therapy or to a higher level of care such as a partial hospitalization program. Alternatively, if you have a parent or other support person, you could consider an FBT approach. Contact us for more information about eating disorder therapy for adults.