Understanding CBT-E: Cognitive Behavioural Therapy-Enhanced

What is CBT-E (Cognitive Behavioural Therapy – Enhanced?

This is a form of cognitive behavioural therapy that has been devised, and enhanced in certain areas, and particular strategies to specifically address eating disorders and their core psychopathology (i.e. the core eating disorder symptoms e.g. distorted thinking about shape and weight, perfectionism). In plain English, this means that CBT-E is a form of CBT that has been designed to be used, specifically, to treat people with eating disorders. In particular CBT-E, is generally used to treat adults with eating disorders. CBT, is one form of talking therapy, that addresses the way our thoughts influence our behaviours, which in turn makes us feel certain ways. If our thinking is distorted, it drives us to behave in a disordered way, and this in turn makes us feel disrupted and disordered also.

CBT-E is a goal focused talking therapy. A ‘let’s think about the here and now’ talking therapy. It is conducted within a specific time period, so it has a beginning, a middle, and an end. The therapy is led by the therapist who sets goals and objectives for the person, giving the person ‘homework’ between sessions. The therapy is designed to specifically fit with each person’s particular psychopathology (eating disorder symptoms). The person is also tasked with conducting ‘real time self monitoring’ which is a journal or log of their days, noting their eating and thoughts / feelings, as they experience them. This is not a diary because it must happen as soon after eating as possible. The person brings their monitoring form and ‘homework’ to each session which is used by the therapist during the session to work through and process making changes, and constructing new goals and objectives.

What is the ethos behind CBT-E?

Those who have devised and practice CBT-E approaches with people with eating disorders, do so based on the idea that:

  1. All of the eating disorders are essentially ‘cognitive disorders’, meaning that they share a distinctive core psychopathology that is cognitive in nature. I.e. the distorted thinking that develops when a person has an eating disorder is essentially the root of the problem, and by helping the person to think in a less distorted way, their eating disorder symptoms will reduce and eventually disappear. A CBT-E approach aims to normalise the person’s distorted thinking, which will in turn normalise their eating behaviours and address the other core aspects of the eating disorder.
  2. The core psychopathology is a) distorted thinking style, b) over-evaluation of body weight or shape, c) control, and d) dieting.
  3. CBT-E therapists approach a person’s eating disorder as if it is constructed like a house of cards. A person will often have lots of cards (issues and different aspects) that form the entire house (the eating disorder). Addressing some key issues – removing some key cards – will bring the whole house of cards down. For example, very often the key issues relate to the core psychopathology, such as dieting and body image.

If your treatment team have selected you to start CBT-E, this means that they have concluded, based on your clinical needs, that starting CBT-E now, will give you the best chance of recovering from your eating disorder.

Basics you need to know:

  • There are various adaptations of CBT-E, depending on your age, the type of eating disorder you have been diagnosed with, and your history. If you are unsure which type of CBT-E you are doing then ask your therapist. There is a longer version of CBT-E for people with anorexia, or people who are physically very underweight. If you are an older teenager there is a different form of CBT-E for you.
  • Generally CBT-E has a fixed length, with 20 sessions, over 20 weeks. It is crucial that when you start CBT-E, that you do it at a time when you can commit to this time period without interruptions, e.g. holidays.
  • There are four stages of CBT-E treatment. It is necessary for you to complete all four stages for the treatment to be effective. CBT-E has a very low relapse rate when people fully complete the four stages.
  • The aim of the treatment is a recovery which means addressing your eating disorder symptoms – it is to bring all the aspects of the eating disorder within the ‘normal’ range, e.g. normal BMI, normal eating behaviours, normal thinking and non-eating disorder responses to emotions.
  • At the end of the treatment you may still have some eating disorder thoughts and behaviours. This is not unusual, and research has shown that these lingering aspects continue to improve post-treatment.
  • Your weight will be tracked during the treatment by your therapist to ensure that it is going in the right direction.
  • When you begin your treatment you will do an initial assessment session that will last approximately an hour and a half. After this all sessions will last just under an hour.
  • You and your therapist will be working to become experts at understanding your eating problem, so that you can overcome this problem.
  • You will decide, with your therapist, on specific tasks for you to try between sessions.

The Four Stages of CBT-E outlined:

Stage One.

  • Stage one will be an intensive stage for you, and appointments are usually twice weekly during this stage.
  • Stage one will introduce 2 key aspects of the treatment: in session weighing, and regular eating.
  • Stage one usually lasts for 4 weeks, and includes 8 sessions

Stage Two

  • This is a brief stage, lasting 2 weeks and 2 sessions
  • Stage two is a transitional stage where progress is reviewed, specific barriers to change are identified together with your therapist, and stage three will be planned.

Stage Three

  • This is the longest part of the treatment, taking approximately 8 weeks, and 8 sessions.
  • During these 8 weeks the main elements of your eating disorder will be addressed and worked through.

Stage Four

  • Stage four will last approximately 6 weeks, and appointments tend to be every two weeks.
  • During this final stage the focus of the treatment shifts to looking to the future and focuses on both how to maintain the changes you have made, and how to minimise the risk of relapse.

Note: If your BMI is between 15 -17.5, your treatment will be 40 sessions, over approximately 40 weeks. Approximately the first 20 sessions will be twice-weekly, thereafter sessions will be weekly, and eventually every fortnight.

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