CBT-E resources

Handouts from cognitive behavior therapy and eating disorders.

F2.3 - CBT-E formulation of bulimia nervosa

F2.4 - CBT-E formulation of “restricting” anorexia nervosa

F2.5 - Transdiagnostic CBT-E formulation

T4.2 - Points to make when describing CBT-E

T5.1 - Topics to cover when assessing the eating problem

F5.2 - CBT-E formulation of eating disorder NOS in the patient's own words

T5.2 - Instructions for self-monitoring

F5.3 - Blank monitoring record

T6.1 - Topics to cover when educating patients about eating disorders

T6.2 - Patient handout on regular eating

F8.3 - Over-evaluation of control over shape and weight – an extended formulation

F8.5 - Feelings of fatness

F9.3 - Over-evaluation of control over eating – an extended formulation

F10.2 - Binge analysis

F11.2 - CBT-E formulation of binge eating / purging anorexia nervosa

T11.2 - Patient handout on the effects of being underweight

T12.1 - Short-term maintenance plan

T12.2 - Long-term maintenance plan

F13.1 - Transdiagnostic CBT-E formulation with clinical perfectionism added

F13.2 - Over-evaluation of achieving and achievement – an extended formulation

F13.3 - CBT-E formulation of bulimia nervosa with core low self-esteem added

Melissa Gerson LCSW

Cognitive Behavioral Therapy

Learn more about cbt-e, enhanced cognitive behavioral therapy (cbt-e) is cbt to treat eating disorders..

Posted October 20, 2022 | Reviewed by Vanessa Lancaster

  • A form of CBT called enhanced cognitive behavioral therapy (CBT-E) is an adaptation of CBT designed to treat eating disorders.
  • CBT-E moves through four distinct stages of treatment over the course of 20 to 40 weeks via regular outpatient therapy sessions.
  • Enhanced CBT is different from CBT. It’s important to ask providers about their training and ensure their training is in CBT-E.

Photo by Johannes Plenio on Unsplash

Cognitive behavioral therapy (CBT) is a popular therapy modality with adaptations to treat a wide range of mental health conditions, including depression , anxiety , OCD , and more. Broadly, CBT focuses on identifying patterns of thoughts, emotions, and/or behaviors that negatively influence our lives. A form of CBT called enhanced cognitive behavioral therapy (“CBT-E”) is an adaptation of CBT designed to treat eating disorders.

An Overview of CBT-E

CBT-E is considered the first-line, evidence-based treatment for people with eating disorders, including anorexia nervosa (AN), bulimia nervosa (BN), or binge eating disorder (BED). Even though these conditions present different problematic behaviors, they share many of the same foundational features at their core. For example, people with AN, BN, and BED often experience extreme concern with weight and shape and/or difficulty coping with negative emotions.

These factors–“overvaluation” of shape and weight and mood intolerance–are common triggers to problematic eating behaviors like food restriction, binge eating, or purging.

While CBT-E is a manualized and structured treatment, it’s intended to fit the client “like a glove” with a focus on creating a personalized “formulation” or map of the client’s eating disorder and a customized plan for addressing their unique patterns and challenges.

The Four Stages of CBT-E

CBT-E moves through four distinct stages of treatment over the course of 20 to 40 weeks via regular outpatient therapy sessions. The longer treatment length is generally for those who need to restore weight (as with anorexia nervosa). CBT-E highlights the importance of “starting well” and building momentum at the start, so sessions are generally twice weekly for the first four to eight weeks, then once weekly for roughly eight weeks, and bi-weekly thereafter.

The focus of Stage One is understanding and then systematically addressing the factors keeping the individual locked in their eating problem. The therapist guides the client in establishing a pattern of regular and consistent eating. The client learns how to effectively plan ahead, anticipate challenges and maintain a predictable routine of eating every few hours.

This initial treatment stage involves education , building self-awareness, and problem-solving to avoid known triggers. We expect significant change during this brief initial period of about four to eight weeks.

Stage Two of CBT-E is just a session or two during which the therapist and client review progress, identify ongoing challenges and collaborate around building the plan for Stage Three.

Stage Three

Stage Three involves once-weekly sessions that focus on factors that may be fueling remaining problematic eating behaviors. Typically, concerns with body weight and shape are addressed in this phase of treatment. There’s also a lot of attention focused on forms of over-control of food–like continued avoidance of certain foods, restriction of overall food quantity, etc.

Stage Three also focuses on event and mood-related triggers to disordered eating .

During the fourth and final stage of CBT-E, the client and therapist begin to look ahead to the future and life post-CBT-E. The tasks of Stage Four are consistency, mindfulness , and engaging strategies to reduce vulnerability to relapse in the future.

Get Connected With CBT-E

If you’re interested in finding a CBT-E therapist for yourself or a loved one, here are a few tips:

  • Enhanced CBT is different from standard CBT. It’s important to ask potential providers about their training and to be sure that their training is in CBT-E, specifically. There’s not a CBT-E “certification” per se; most CBT-E providers have been trained in practice, research, or academic settings. The Centre for Research on Dissemination at Oxford (CREDO) provides online training for professionals, which is an excellent way to learn CBT-E.
  • Adherence to the CBT-E treatment as it’s intended increases the potential for a good outcome. Integrating “some CBT-E techniques” is generally not enough and may result in a diluted treatment. It’s like taking a medication that’s been watered down; it just won’t work as well.
  • A CBT-E practitioner will explain at the start of treatment that the work will be time-limited (about 20 weeks for bulimia and binge eating; 40 weeks for anorexia). There will be four distinct stages and a clear agenda for each and every session. Issues unrelated to eating will not be the focus of treatment and should be tabled until after CBT-E is completed. If the provider is inclined to approach the treatment as open-ended or with a loose structure and time frame, then it’s not CBT-E.
  • Involved treatments “programs” with lots of groups and additional services are not always necessary. CBT-E is intended to be the intervention.

cbt e resources

Of note, CBT-E is not typically the first-line approach for children and teens with AN or BN. Most often, treatment for kids/teens with eating disorders needs to incorporate caregivers either as central to the treatment or closely integrated. family-based treatment is a more common recommendation for younger people presenting with disordered eating.

Barriers to Accessing CBT-E for Eating Disorders

Unfortunately, therapy can be very expensive and thus not accessible to most people who need it. It may be difficult to find adherent CBT-E providers who accept commercial insurance or Medicaid. Of note is a self-guided ( self-help ) version of CBT-E: Overcoming Binge Eating by Christopher Fairburn. This self-help guide can be an effective course for BED and some cases of BN. It may be more effective if there is external support available as a supplement.

Some specialized eating disorder research and training centers offer CBT-E for reduced fees or even free of charge in exchange for participation in research studies. It may take some searching online to identify local facilities or institutions with research protocols and the opportunity for free treatment.

To find a therapist near you, visit the Psychology Today Therapy Directory .

Atwood, M.E., Friedman, A. (2019). A systematic review of enhanced cognitive behavioral therapy (CBT-E) for eating disorders. International Journal of Eating Disorders , 53(3), 311-330.

“A Description of CBT-E.” (n.d.) CBT-E.

Murphy R, Straebler S, Cooper Z, Fairburn CG. Cognitive behavioral therapy for eating disorders. Psychiatr Clin North Am. 2010 Sep;33(3):611-27. doi: 10.1016/j.psc.2010.04.004. PMID: 20599136; PMCID: PMC2928448.

Melissa Gerson LCSW

Melissa Gerson, LCSW, is founder and Clinical Director of Columbus Park Center for Eating Disorders, an outpatient facility providing treatment to individuals of all ages and genders.

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Cognitive-behavioral therapy- enhanced (cbt-e) for eating disorders.

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Eating disorders are complicated physical and mental illnesses that can have devastating effects. Due to the severity of these disorders, treatment requires highly specialized care in order to work toward decreased symptomatology. Cognitive-behavioral therapy- enhanced (CBT-E) is the current evidence-based treatment for adults struggling with eating disorders. This presentation will provide an overview of the CBT-E protocol, which is important as a review for clinicians who are more familiar with CBT-E and as a crucial learning experience for clinicians who are not yet implementing this protocol. Following this presentation, attendees should have a basic understanding of the CBT-E protocol and how to access additional resources and training opportunities, in the hopes that this will improve treatment for patients with eating disorders.

Due to the ongoing effort to improve and hone skills as clinicians, this presentation will allow clinicians the opportunity to increase knowledge about an evidence-based treatment for patients with eating disorders. An ongoing effort to educate about evidence-based protocols seems to be necessary to improve clinical care.

Clinicians will learn more about CBT-E theory, as well as specific clinical skills and procedures used in CBT-E. The hope is that clinicians will then use such skills and interventions with their patients in the future, as well as will seek additional resources and training opportunities related to CBT-E.

Target Audience

Physican, Pyschologist, Social Worker, Counselor

Learning Objectives

  • Describe how cognitive-behavioral theory explains how a patient’s eating disorder behaviors and cognitions are maintained and difficult to change.
  • In CBT-E, creating a personal formulation with a patient is given as homework to complete after the second session.
  • In each CBT-E case, phase three focuses solely on body image and cognitive restructuring.
  • 1.00 ACEP NBCC clock hours
  • 1.00 AMA PRA Category 1 Credit™
  • 1.00 Category I credits for Social Workers
  • 1.00 Psychologists
  • 1.00 Participation

North Pavillion, 3rd Floor Conference Room

Sheppard Pratt holds the standard that its continuing medical education programs should be free of commercial bias and conflict of interest. In accord with Sheppard Pratt's Disclosure Policy, as well as standards of the Accreditation Council for Continuing Medical Education (ACCME) and the American Medical Association (AMA), all planners, reviewers and speakers have been asked to disclose any relationship he/she or a partner/spouse has with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, during the past 12 months. All planners, reviewers and speakers have also been asked to disclose any payments accepted for this lecture form any entity besides Sheppard Pratt Health System, and if there will be discussion of any products, services or off-label uses of product(s) during this presentation.

Laura Sproch, Ph.D. reports having no financial relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients , during the past 12 months. She will not be discussing any patient products, services or off-label uses in this presentation.

Event Planners/Reviewers Disclosures: The following event planners and/or reviewers are reported as having no financial interest, arrangement or affiliation with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients , during the past 12 months.: Victoria Crandell, LCPC, Kate Clemmer, LCSW-C, Tom Flis, LCPC, Ellen Mongan, M.D., Caroline Cahn, LCSW-C, Faith Dickerson, Ph.D., Robert Roca, M.D., Drew Pate, M.D., Meena Vimalananda, M.D., Briana Riemer, M.D, Jennifer Tornabene and Bonnie Katz.

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Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders

About this program.

Target Population: Adolescents (12-19) with eating disorders

For children/adolescents ages: 12 – 19

Program Overview

Enhanced Cognitive Behaviour Therapy (CBT-E) for Adolescents with Eating Disorders has a transdiagnostic scope of the treatment which allows it to be used to treat the full range of disorders that occur in adolescent patients including anorexia nervosa (AN) and bulimia nervosa (BN). It can be used as an alternative to Family-Based Treatment.

Program Goals

The goals of Enhanced Cognitive Behaviour Therapy (CBT-E) for Adolescents with Eating Disorders are:

  • Engage in the treatment and be actively involved in the process of change.
  • Eliminate the eating disorder psychopathology (i.e., the dietary restraint and restriction, and low weight if present; extreme weight control behaviors; and preoccupation with shape, weight, and eating).
  • Learn how to recognize and counteract the mechanisms maintaining the eating disorder psychopathology.
  • Experience lasting change.

Logic Model

The program representative did not provide information about a Logic Model for Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders .

Essential Components

The essential components of Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders include:

  • Step One - Starting well and deciding to change
  • The aims are to engage the patient in treatment and change, including addressing weight regain.
  • The appointments are twice weekly for 4 weeks and involve the following:
  • Jointly creating a formulation of the processes maintaining the eating disorder
  • Establishing real-time self-monitoring of eating and other relevant thoughts and behaviors
  • Educating about:
  • Body weight regulation and fluctuations
  • The adverse effects of dieting
  • The ineffectiveness and physical complications of self-induced vomiting and laxative misuse as a means of weight control, if applicable
  • Introducing and establishing weekly in-session weighing, and becoming proficient in interpreting and coping with weight fluctuations
  • Introducing and adhering to a pattern of regular eating, with planned meals and snacks
  • Thinking about addressing weight regain (if indicated)
  • Involving parents to facilitate treatment
  • Step Two - Addressing the change
  • The aim is to address weight regain (if indicated) and the key mechanisms that are maintaining the patient’s eating disorder.
  • The appointments are twice a week until the rate of weight regain stabilizes, at which time they are held once a week. This Step involves the following CBT-E modules:
  • Underweight and Undereating:
  • Creating a daily positive energy balance of about 500 kcal to achieve a mean weekly weight regain of about 0.5 kg
  • Overvaluation of Shape and Weight:
  • Providing education on overvaluation and its consequences
  • Nurturing previously marginalized domains of self-evaluation
  • Reducing unhelpful body checking and avoidance
  • Re-labelling unhelpful thoughts or feelings such as “feeling fat”
  • Exploring the origins of the overvaluation
  • Learning to identify and control the eating disorder mindset
  • Dietary Restraint:
  • Changing inflexible dietary rules into flexible guidelines
  • Introducing previously avoided foods
  • Events and Mood-related Changes in Eating:
  • Developing proactive problem-solving skills to tackle such triggering events
  • Developing skills to accept and modulate intense moods
  • Setbacks and Mindsets:
  • Providing education about setbacks and mindsets
  • Identifying eating‐disorder mindset reactivation triggers
  • Spotting setbacks early on
  • Displacing the mindset
  • Exploring the origins of the overvaluation.
  • Review sessions
  • These are held one week after Step One and then every four weeks, for the purposes of:
  • Identifying barriers to change, both general (e.g., school pressures) and features of the eating disorder itself (e.g., difficulties in weight regain, presence of dietary restraint)
  • Adjusting the initial formulation in light of progress and/or emerging issues
  • Deciding to continue with the focused form of CBT-E rather than the broad form
  • The broad form of CBT-E includes four additional modules (i.e., clinical perfectionism, low self-esteem, interpersonal difficulties, or mood intolerance), one of which may be added to the focused modules in Step Two. This form of treatment is indicated if clinical perfectionism, low self-esteem, interpersonal difficulties, or mood intolerance are marked, and appear to be maintaining the disorder and obstructing change.
  • Step Three – Ending well
  • The aims are to ensure that progress made during treatment is maintained, and that the risk of relapse is minimized. There are three appointments, 2 weeks apart, covering the following:
  • Addressing concerns about ending treatment
  • Devising a short-term plan for continuing to implement changes made during treatment (e.g., reducing body checking, introducing further avoided foods, eating more flexibly, maintaining involvement in new activities) until the post-treatment review session
  • Phasing out treatment procedures, in particular self-monitoring and in-session weighing
  • Education about realistic expectations and identifying and addressing setbacks
  • Devising a long-term plan for maintaining body weight, and averting and coping with setbacks
  • Posttreatment review session
  • Reviewing the long-term maintenance plan around 4, 12, and 20 weeks after treatment has finished

Program Delivery

Child/adolescent services.

Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders directly provides services to children/adolescents and addresses the following:

  • Eating disorder psychopathology such as over-evaluation of shape, weight and eating control, strict dieting, binge eating, self-induced vomiting, laxative misuse, diuretic misuse, excessive exercising, food checking, body checking, body avoidance, feeling fat, low weight and starvation syndrome; and/or co-existing psychopathology (in a subgroup of patients) such as clinical perfectionism, core low self-esteem, marked interpersonal difficulties, and/or mood intolerance

Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: The role of parents is to support the implementation of the one-to-one treatment. Parental involvement includes two short joint sessions with the adolescent during the assessment and preparation phase, one parent-alone session in the first week of treatment, and then several joint sessions with the adolescent and the therapist at the end of the individual patient’s session. The joint sessions typically last about 15 minutes. Additional joint sessions can be scheduled under unusual circumstances, such as family crises, extreme difficulties during meals, or parental criticism towards the adolescent. The main goals of these joint sessions are to keep parents informed and involved in the treatment process and up to date on the progress of their child. These sessions are also used to discuss how parents might help their child in creating an optimal family environment which is supportive of change and help them to implement some key procedures of the treatment.

Recommended Intensity:

Not underweight patients have 20 sessions of 50 minutes (twice a week in the first four weeks, then once a week; in the last 6 weeks there are three appointments, 2 weeks apart) with Posttreatment review at 4-, 12-, and 20-week follow-up. Underweight patients (BMI < 18.5) have 40 sessions (duration depends by the amount of weight that has to be regained). The appointments are twice a week until the rate of weight regain stabilizes, at which time they are held once a week. in the last 6 weeks there are three appointments, 2 weeks apart) with posttreatment review at 4-, 12-, and 20-week follow-up. Events and circumstances may influence the duration of treatment (e.g., life crisis, development of clinical depression).

Recommended Duration:

Non-underweight patients: 20 weeks; Underweight patients: 40 weeks

Delivery Settings

This program is typically conducted in a(n):

  • Outpatient Clinic
  • Group or Residential Care

Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders includes a homework component:

In common with other forms of CBT, monitoring and success in completing strategically planned homework tasks are of paramount importance. Therapist and patient agree on specific homework tasks to do between sessions. These are of fundamental importance and must be given absolute priority, as it is what patients do between the sessions that will determine the benefits or limitations of the treatment. Examples include real-time self-monitoring, regular eating, evaluating the pros and cons of weight regain, etc.

Enhanced Cognitive Behavior Therapy (CBT-E) for Adolescents with Eating Disorders has materials available in a language other than English :

For information on which materials are available in this language, please check on the program's website or contact the program representative ( contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

Typical psychotherapy office

Manuals and Training

Prerequisite/minimum provider qualifications.

The minimum qualification to deliver the training depend on the rules to deliver psychological treatments, which varies from one country to another.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Dalle Grave, R., & Calugi, S. (2020). Cognitive behavior therapy for adolescents with eating disorders . Guilford Press. https://www.guilford.com/books/Cognitive-Behavior-Therapy-for-Adolescents-with-Eating-Disorders/Grave-Calugi/9781462542734

Dalle Grave , R., & el Khazen, C. (2022). Cognitive Behaviour Therapy for Eating disorders in young people: Parents' guide. Routledge. https://www.routledge.com/Cognitive-Behaviour-Therapy-for-Eating-Disorders-in-Young-People-A-Parents/Grave-Khazen/p/book/9780367775049

Training Information

There is training available for this program.

Training Contact:

Training Type/Location:

The online training program in CBT-E is now available to any eligible therapist who wants to receive training at no cost. Access to the training is funded by Health Education England in partnership with Oxford Health NHS Foundation Trust.

https://www.cbte.co/for-professionals/training-in-cbt-e/

It is also recommended that they receive expert clinical supervision that may be available via videoconferencing (or face-to-face, if local) by a member of the CBT-E Training Group. For further information please contact: [email protected]

Number of days/hours:

Varies dependent on personal pace through the training

Relevant Published, Peer-Reviewed Research

Dalle Grave, R., Calugi, S., Doll, H. A., & Fairburn, C. G. (2013). Enhanced cognitive behaviour therapy for adolescents with anorexia nervosa: An alternative to family therapy? Behaviour Research and Therapy, 51 (1), R9-R12. https://doi.org/10.1016/j.brat.2012.09.008

Type of Study: One-group pretest–posttest study Number of Participants: 49

Population:

  • Age — Adolescents: 13-17 years (Mean=15.5 years); Parents: Not specified
  • Race/Ethnicity — Adolescents: 100% White; Parents: Not specified
  • Gender — Adolescents: 100% Female; Parents: Not specified
  • Status — Participants included adolescents with marked anorexia nervosa.

Location/Institution: A community-based eating disorder clinic

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to establish the immediate and longer-term outcome following Enhanced Cognitive Behavior Therapy (CBT-E) . Measures utilized include the Eating Disorder Examination Questionnaire (EDE-Q6.0) and the Symptom Checklist-90 . Results indicate there was a substantial increase in weight together with a marked decrease in eating disorder psychopathology. Over the 60-week posttreatment follow-up period, there was little change despite minimal subsequent treatment. Limitations include lack of a control group, generalizability due to gender and ethnicity, and small sample size.

Length of controlled postintervention follow-up: 60 weeks.

Calugi, S., Dalle Grave, R., Sartirana, M., & Fairburn, C. G. (2015). Time to restore body weight in adults and adolescents receiving cognitive behaviour therapy for anorexia nervosa. Journal of Eating Disorders, 3 , Article 21. https://doi.org/10.1186/s40337-015-0057-z

Type of Study: One-group pretest–posttest study Number of Participants: 46 Adolescents and 49 Adults

  • Age — Adolescents: Mean=15.5 years; Adults: Mean=24.6 years
  • Race/Ethnicity — Adolescents: Not specified; Adults: Not specified
  • Gender — Adolescents: 100% Female; Adults: 98% Female
  • Status — Participants included adolescents and adults recruited from consecutive referrals to a specialist eating disorder clinic.

Location/Institution: Verona area of Italy

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to provide benchmark data on the duration of treatment required to restore body weight in adolescents and adults with anorexia nervosa treated with outpatient Enhanced Cognitive Behaviour Therapy (CBT-E) . Measures utilized include the Eating Disorder Examination Questionnaire (EDE-Q6.0) . Results indicate 29 (63.1%) of the adolescents and 32 (65.3%) of the adults completed all 40 sessions of treatment. Significantly more adolescents reached the goal BMI than adults (65.3% vs. 36.5%). The mean time required by the adolescents to restore body weight was about 15 weeks less than that for the adults (Mean=14.8 weeks vs. Mean=28.3 weeks). Limitations include lack of control group, lack of follow-up, small sample size, and generalizability due to gender.

Length of controlled postintervention follow-up: None.

Dalle Grave, R., Calugi, S., Sartirana, M., & Fairburn, C. G. (2015). Transdiagnostic cognitive behaviour therapy for adolescents with an eating disorder who are not underweight. Behaviour Research and Therapy, 73 , 79-82. https://doi.org/10.1016/j.brat.2015.07.014

Type of Study: One-group pretest–posttest study Number of Participants: 68

  • Age — Adolescents: 13-19 years (Mean=16.5 years); Parents: Not specified
  • Race/Ethnicity — Adolescents: Not specified; Parents: Not specified
  • Gender — Adolescents: 13-19 years (Mean=16.5 years); Parents: Not specified
  • Status — Participants were adolescent patients with an eating disorder and body mass index centile corresponding to an adult BMI >/= 18.5.

Location/Institution: A community-based eating disorder clinic in Verona area of Italy

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to evaluate the effects of Enhanced Cognitive Behavioral Therapy (CBT-E ) on non-underweight adolescents with an eating disorder. Measures utilized include the Eating Disorder Examination Questionnaire (EDE-Q6. 0) and the Symptom Checklist-9 0. Results indicate three-quarters completed the full 20 sessions. There was a marked treatment response with two-thirds having minimal residual eating disorder psychopathology by the end of treatment. Limitations include lack of follow-up, lack of control group, and generalizability due to gender.

Dalle Grave, R., Sartirana, M., & Calugi, S. (2019). Enhanced cognitive behavioral therapy for adolescents with anorexia nervosa: Outcomes and predictors of change in a real‐world setting. International Journal of Eating Disorders, 52 (9), 1042-1046. https://doi.org/10.1002/eat.23122

  • Age — Adolescents: 11-18 years (Mean=15.5 years), Parents: Not specified
  • Status — Participants were adolescents with anorexia nervosa.

Location/Institution: An outpatient eating-disorder service located in Verona, Italy

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to establish the outcomes and predictors of change in a cohort of adolescents with anorexia nervosa treated via Enhanced Cognitive Behavioral Therapy (CBT-E) in a real-world clinical setting. Measures utilized include the Eating Disorder Examination Questionnaire , the Brief Symptom Inventory , and the Clinical Impairment Assessment . Results indicate 35 patients (71.4%) who finished the program showed both considerable weight gain and reduced scores for clinical impairment and eating disorder and general psychopathology. Changes remained stable at 20 weeks. No baseline predictors of drop-out or treatment outcomes were detected. Limitations include small sample size, generalizability due to gender and ethnicity, and lack of control group.

Length of controlled postintervention follow-up: 20 weeks.

Le Grange, D., Eckhardt, S., Dalle Grave, R., Crosby, R. D., Peterson, C. B., Keery, H., Leser, J., & Martell, C. (2020). Enhanced cognitive-behavior therapy and family-based treatment for adolescents with an eating disorder: a non-randomized effectiveness trial . Psychological Medicine. Advance online publication. https://doi.org/10.1017/S0033291720004407

Type of Study: Pretest-posttest study with a nonequivalent control group (Quasi-experimental) Number of Participants: 97

  • Age — Adolescents: 12–18 years (Mean=14.6 years), Parents: Not specified
  • Race/Ethnicity — Adolescents: 89% Caucasian, 4% Multiracial/Other, 3% Asian, 3% Not reported, and 1% African American; Parents: Not specified
  • Gender — Adolescents: 83% Female; Parents: Not specified
  • Status — Participants were adolescents with a with a DSM-5 eating disorder diagnosis and their parents.

Location/Institution: The Center for the Treatment of Eating Disorders (CTED) at Children’s Minnesota, MN, a pediatric specialty clinic in the USA.

Summary: (To include basic study design, measures, results, and notable limitations) The purpose of the study was to compare the relative effectiveness of family-based treatment (FBT) and Enhanced Cognitive-Behavior Therapy (CBT-E). Participants and their parents chose between FBT and CBT-E treatments. Measures utilized include the Eating Disorder Examination (EDE) or the Eating Disorder Examination Questionnaire (EDE-Q), the Clinical Impairment Assessment (CIA), the Beck Anxiety Inventory (BAI) , the Child Depression Inventory (CDI- 2), the Rosenberg Self-Esteem Scale (RSE) , the Child Behavior Checklist (CBCL), the Brief Symptom Inventory (BSI), the McMaster Family Assessment Device (FAD ) and the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-Kid) . Results indicate slope of weight gain at end of treatment was significantly higher for FBT than for CBT-E , but not at follow-up. There were no differences in the EDE Global Score or most secondary outcome measures at any time-point. Several baseline variables emerged as potential treatment effect moderators at end of treatment. Choosing between FBT and CBT-E resulted in older and less-well participants opting for CBT-E. Limitations include an a priori power calculation to guide recruitment efforts was not conducted, participants were not randomly allocated to either FBT or CBT-E, compliance with postbaseline assessment s was less than optimal, and diversity was limited.

Length of controlled postintervention follow-up: 6 months and 1 year.

Additional References

Dalle Grave, R., Eckhardt, S., Calugi, S., & Le Grange, D. (2019). A conceptual comparison of family-based treatment and enhanced cognitive behavior therapy in the treatment of adolescents with eating disorders. Journal of Eating Disorders, 7, Article 42. https://doi.org/10.1186/s40337-019-0275-x

Dalle Grave, R., Sartirana, M., Sermattei, S., & Calugi, S. (2021). Treatment of eating disorders in adults versus adolescents: Similarities and differences. Clinical Therapeutics, 43 (1), 70-84. https://doi.org/10.1016/j.clinthera.2020.10.015

Dalle Grave, R. (2019). Cognitive-behavioral therapy in adolescent eating disorders. In J. Hebebrand & B. Herpertz-Dahlmann (Eds.), Eating disorders and obesity in children and adolescents (pp. 111-116). Elsevier.

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Date Program Content Last Reviewed by Program Staff: December 2021

Date Program Originally Loaded onto CEBC: December 2021

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Treatment model training workshop: Cognitive Behaviour Therapy for Eating Disorders (CBT-E)

Presented by tanya gilmartin and annette honigman ceed senior clinicians and amy woods ceed senior eating disorder lived experience advisor, monday 18 march and tuesday 19 march 2024 royal park campus parkville 9.00am – 5.00pm.

This 2-day workshop modules provides a comprehensive introduction to Enhanced Cognitive Behaviour Therapy (CBT-E), the latest version of the leading empirically supported, outpatient psychological treatment for eating disorders. The workshop draws on the work of Prof Christopher Fairburn, Director of the Centre for Research on Eating Disorders at Oxford University (CREDO), internationally recognised researcher and author, and Dr Anthea Fursland, researcher & principal psychologist of the Eating Disorders Program at the Centre for Clinical Investigations WA (CCI).

Participants will gain:

  • A comprehensive introduction & overview of Enhanced Cognitive Behaviour Therapy (CBT-E)
  • Understanding of the importance of client engagement, early behaviour change & addressing obstacles to change
  • Understanding of how the trans-diagnostic approach of CBT-E can be used with the full range of eating disorders seen in clinical practice
  • Modification of behaviours & beliefs associated with over-evaluation of control of weight, shape & eating (eg food & physical activity related safety & avoidance behaviours; body checking / avoidance)
  • weight regain in underweight individuals

The training provides didactic, interactive & experiential practise opportunities. Prior knowledge of understanding and assessment of eating disorders, and basic CBT principles is assumed.

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  • Letter to the Editor
  • Open access
  • Published: 29 May 2018

Implementation of enhanced cognitive behaviour therapy (CBT-E) for adults with anorexia nervosa in an outpatient eating-disorder unit at a public hospital

  • Stein Frostad   ORCID: orcid.org/0000-0001-5327-8418 1 ,
  • Yngvild S. Danielsen 1 , 2 ,
  • Guro Å. Rekkedal 1 ,
  • Charlotte Jevne 1 ,
  • Riccardo Dalle Grave 3 ,
  • Øyvind Rø 4 , 5 &
  • Ute Kessler 6 , 7  

Journal of Eating Disorders volume  6 , Article number:  12 ( 2018 ) Cite this article

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Anorexia nervosa (AN) in adults is difficult to treat, and no current treatment is supported by robust evidence. A few studies, most of which were performed by highly specialized research units, have indicated that enhanced cognitive behaviour therapy (CBT-E) for eating disorders can be effective. However, the dropout rate is high and the evidence from non-research clinical units is sparse.

This quality assessment project implemented CBT-E in an outpatient setting at a public hospital. Forty-four patients with AN started therapy. Each patient received at least 40 sessions of CBT-E over a 12-month period. Their body mass index (BMI) was recorded at baseline and after 3, 6 and 12 months. Reasons for not starting therapy or for leaving therapy prematurely were recorded.

Half ( n  = 22) of the 44 patients who started outpatient CBT-E did not complete the treatment. In the remaining sample there was a large (and statistically significant) weight gain after 12 months. The percentage of patients achieving the target BMI of > 18.5 kg/m 2 was 36.4, 50.0 and 77.3% after 3, 6 and 12 months, respectively.

Conclusions

This quality assessment project shows that it is possible to establish effective CBT-E in an outpatient eating-disorder unit at a public hospital. Although half of the patients did not complete CBT-E, the remaining patients achieved a significant increase in BMI at 1 year after the start of therapy.

Plain English summary

Anorexia nervosa (AN) in adults is difficult to treat. Enhanced cognitive behaviour therapy (CBT-E) for eating disorders has shown promising effects in some studies. This outpatient method was implemented at a public hospital in Bergen, Western Norway. Half of the 44 patients who started CBT-E did not complete the treatment, but CBT-E was associated with significant and relatively large increases in body mass index in the remaining patients. This quality assessment project shows that CBT-E for AN can be implemented successfully in an outpatient setting at a public hospital.

Introduction

Anorexia nervosa (AN) is a serious mental disorder with negative effects on physical, psychological and social functioning. The disorder is associated with high risks of severe medical complications and mortality [ 1 ]. While there has been some progress in treatments for children and adolescents with AN [ 2 , 3 ], AN in adults still has a relatively poor prognosis [ 4 , 5 ] and has been described as “one of the most difficult psychiatric disorders to treat” [ 6 ]. However, in recent years specific psychological interventions have shown promising results in some cohorts and randomized controlled trials.

Fairburn and colleagues studied 99 adults with AN from the UK and Italy who were treated with enhanced cognitive behaviour therapy (CBT-E) for eating disorders [ 7 ]. Their outpatient intervention was completed by 64% of the patients, who exhibited substantial improvements in weight and eating-disorder psychopathology. A variant of CBT-E has been compared with focal psychodynamic therapy and “optimized treatment as usual” in a multicentre randomized control trial involving 242 adults with AN [ 8 ]. All three treatments produced statistically significant improvements in mean body mass index (BMI), with no differences among them. In the Strong Without Anorexia Nervosa (SWAN) study, 120 patients with AN were randomized to 3 psychological treatments for AN: Specialist Supportive Clinical Management (SSCM), Maudsley Model Anorexia Nervosa Treatment for Adults (MANTRA), and CBT-E [ 9 ]. The treatments were completed by 60% of patients who showed equivalent effects on psychopathology and impairment. However, CBT-E was superior in helping patients to achieve a physically healthy weight, which is regarded as a fundamental requirement for recovery. These studies led to the recently published NICE (National Institute for Health and Care Excellence) guideline for eating disorders to recommend eating-disorder-focused cognitive behavioural therapy, MANTRA or SSCM for adults with AN [ 10 ].

Evidence-based psychological treatments are rarely implemented in clinical services for eating disorders in spite of these recommendations [ 11 ]. Moreover, when they are implemented, therapists usually fail to adhere to the manual or may even adopt an eclectic approach [ 12 ]. Problems with adherence to the manual are common in a real-world setting than in randomized control trials, which could reduce the therapeutic effects [ 11 , 13 ].

Studies of the implementation of CBT-E as standard treatment for AN in non-research clinical settings are therefore needed to evaluate the utility of the treatment in normal clinical practice. The primary aim of this quality assessment project was to measure the pre-post changes in BMI in a sample of consecutive adult patients receiving outpatient CBT-E for AN.

Setting and design

This quality-improvement project was performed at the Department of Eating Disorders (DED) of the Psychiatric Clinic at Haukeland University Hospital, Bergen, Western Norway. The DED is a specialist eating-disorder unit that forms part of the public health-care system in Norway. The DED consists of a small inpatient unit and an outpatient unit. Referrals are accepted from specialist health-care institutions, but general practitioners in primary health care can also refer a patient suffering from AN directly to the unit if the severity of the eating disorder makes successful treatment in ordinary psychiatric care unlikely. The referrals are evaluated by all members of the treatment team in a weekly meeting. The criteria for acceptance to treatment at the DED are the presence of an eating disorder of clinical severity, prior unsuccessful treatment attempt in other specialist health-care institution or a severity that makes successful treatment in ordinary psychiatric care unlikely. All patients aged ≥16 years who fulfil the referral criteria as specified by guidelines from the Norwegian Health Authorities have the right to publicly funded treatment (all annual costs above 2500 NOK [250 euros] are covered).

The treatment was chosen based on the symptom severity and patients’ age. CBT-E [ 14 ] was the standard treatment for all patients > 18 years who did not require inpatient treatment (supportive weight normalization or intensive CBT-E [ 15 ]). Patients younger than 18 years were offered family-based treatment for AN (FBT) if they fulfilled the inclusion criteria for this treatment [ 16 ]. CBT-E [ 14 ] was offered as a standard psychotherapy intervention for adolescents who were unable to benefit from FBT.

Patients with severe psychiatric co-morbidity (e.g. substance misuse or active psychosis) that precludes them receiving focused eating-disorder treatment were referred to receive another treatment before the eating disorder is addressed at the DED. If the patient participated actively in outpatient CBT-E but was unable to gain weight, the patient was offered inpatient intensive CBT-E at the DED, as described elsewhere [ 15 ]. Patients who were unable to benefit from CBT-E and were developing a life-threatening condition could enter inpatient supportive weight-normalization treatment. In both such cases the outpatient CBT-E was regarded as not completed.

This quality assessment project performed a longitudinal evaluation of the implementation of outpatient CBT-E for AN in during 2013 and 2014. The patients did not receive any other eating-disorder psychotherapy while they were receiving CBT-E.

Therapist training

The treatment team consisted of six clinical psychologists, one physician, one physiotherapist and one psychiatric nurse. All of the team members were trained CBT-E therapists who had attended a 2-day CBT-E workshop taken by the treatment developer Christopher Fairburn, followed by regular supervision by an experienced CBT-E psychotherapist. The team members also received weekly individual supervision from an experienced CBT-E therapist on-site during their first year at the DED. The implementation of CBT-E in individual patients is discussed in weekly 2-h team meetings. One of the main topics at these meetings is ensuring that all of the therapists adhere to the manual.

The intervention

CBT-E is an individualized and flexible treatment specifically designed to address the eating-disorder psychopathology in the patient. The psychotherapy intervention has the following three main goals: (i) to remove the eating-disorder psychopathology (i.e. disturbed way of eating and low weight [if present]; extreme weight-control behaviours; and concerns about eating, shape and weight), (ii) to correct the mechanisms that have been maintaining the psychopathology specified in the patient’s formulation, and (iii) to ensure that the changes are long-lasting, by helping patients respond promptly to any setbacks [ 14 ]. The treatment is described in detail in the complete treatment guide [ 14 ].

The outpatient CBT-E for underweight patients is delivered individually by the same trained therapist over about 40 sessions, and it is organized into 3 main steps. In Step 1 the aim is to engage patients and help them arrive at the decision to regain weight as well as address the eating-disorder psychopathology. This step lasts up to 8 weeks and involves providing personalized education on the effects of being underweight, creating the formulation with emphasis on the role of low weight in maintaining the disorder and a focus on helping the patient to make the decision to change and regain weight. The patients participate in twice-weekly sessions until they consistently gain weight.

Step 2 focuses on achieving weight regain at the same time as addressing the key mechanisms that maintain the eating-disorder psychopathology. The goal is to help patients reach a body weight that can be maintained without dietary restriction and without symptoms of being underweight. This will allow a normal social life. For most patients these goals can be achieved with a BMI of 19.0–20.0 kg/m 2 . One session every 4 weeks is dedicated to reviewing the progress and the obstacles, and designing the subsequent 4 weeks of treatment.

Step 3 focuses on helping patients to maintain their weight. This step usually lasts for 8 weeks, with appointments towards the end of treatment occurring at intervals of 2–3 weeks. The aim is to ensure that progress is maintained and that the risk of relapse is minimized.

In addition to CBT-E, all underweight patients were advised to take standard dietary supplements: two omega-3 capsules, one 500-mg calcium tablets, and one multivitamin tablet daily. Patients with severe clinical depression were treated with fluoxetine or similar antidepressants.

Outcome measure

The primary outcome measure was the pre-post changes in BMI. Weight was measured using a balance beam scale while wearing normal clothing, and height was measured using a wall-mounted height board. Height and weight were measured by the individual therapists. If the BMI at the start of treatment was unknown, the BMI at referral was used as the baseline.

Demographic and illness characteristics

The following information was collected as part of the screening interview by the CBT-E therapists: age, gender, number of years with eating disorder before being referred to DED, other axis-I disorders and symptoms, previous treatments for eating disorders, living situation, marital status, occupation and whether the patient was on sick leave or receiving a disability pension.

Diagnostic evaluation

Eating disorders were diagnosed based on a clinical evaluation by an experienced psychologist or physician at the DED according to criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [ 17 ]. This study applied a BMI of < 18.5 kg/m 2 as an inclusion criterion. The Mini International Neuropsychiatric Interview (MINI, version 6.0) [ 18 ] was used to screen for co-morbid psychiatric disorders at baseline. Suicidality was defined as reporting any suicidal thoughts or behaviours on the MINI.

Medical evaluation

The patients were assessed by a physician before they received health care at the DED. If the patient had severe AN, complications or co-morbid diseases, a senior medical specialist (S.F.) performed the medical assessment.

Reasons for not starting or not continuing treatment

If the patient decided to not start treatment, the therapist documented the background of this choice. Similarly, the reasons for ending prematurely were assessed in detail with patients during the sessions. Patients remaining in therapy for 12 months were regarded as completers.

Analyses were conducted using the IBM SPSS Statistics program (version 24). Paired-samples t -tests were conducted to compare the BMI between at the start of treatment (baseline) and after 12 months among the completers, as well as among all patients who started CBT-E (intention to treat – last observation carried forward). Cohen’s d effect sizes for within-sample changes in BMI from baseline to 12 months were calculated. Cohen’s d values of 0.2, 0.5 and 0.8 are considered to indicate small, moderate and large effects, respectively [ 19 ], while a value of 1.2 is considered to indicate a very large effect [ 20 ].

Patient flow

During 2013 and 2014, 257 patients were referred to the DED, of which 108 referrals (42%) were not accepted. The main reason for not accepting a referral was that the patient had not received treatment at a general psychiatric outpatient unit (81% of all cases). Among the patients accepted for treatment, 78 (52%) were referred from primary health care and 71 (48%) were referred from specialized health care.

A flowchart for the patients seeking treatment at the DED is shown in Fig.  1 . Among the 149 patients 44 patients started CBT-E (the intention-to-treat sample); their sociodemographic background and illness characteristics are presented in Table  1 . A considerable proportion of the patients struggled with suicidality thoughts or behaviours and depressive as well as anxiety disorders, as determined by the MINI (version 6.0) and clinical assessments.

figure 1

Flow chart over the patients referred to the Department of Eating Disorders during 2013 and 2014

Intention-to-treat findings

The BMI increased from 16.3±1.6 kg/m 2 (mean±SD) at baseline to 18.3±2.2 kg/m 2 (last observation carried forward) among all the patients who started treatment ( p  < 0.001). Cohen’s d for this change was 1.0 and thus it was classified as a large effect. The percentage of patients presenting with BMI ≥ 18.5 kg/m 2 at the last observation was 54.5% (24 of 44 patients).

Proportion of patients who completed CBT-E

Half of the patients ( n  = 22) completed the treatment, while 22 patients (50%) ended the treatment prematurely for reasons listed in Fig. 1 . Completers were significantly older than non-completers, while their BMI, number of years with eating disorder, rate of psychiatric co-morbidity, number of previous eating-disorder treatment attempts and living situation were all similar (as listed in Table 1 ).

Outcomes among completers

The BMI over the course of treatment for the 22 completers is shown in Fig.  2 : it was 16.4±1.9, 17.7±1.7, 18.7±1.6 and 19.3±1.4 kg/m 2 at baseline and after 3, 6 and 12 months, respectively. There was a significant weight gain after 12 months (BMI difference of 2.9±2.3 kg/m 2 , range 0.0–9.8 kg/m 2 , p  < 0.001). The effect size for this change was very large (Cohen’s d =  1.7) and the percentage of patients achieving the target BMI of ≥18.5 kg/m 2 was 36.4, 50.0 and 77.3% after 3, 6 and 12 months, respectively.

figure 2

BMI over the course of treatment for 22 patients who completed CBT-E

Outcomes among non-completers

The BMI over the course of treatment for the 22 non-completers was 16.2±1.3, 17.2±1.9, 18.0±1.5 and 18.3±2.2 kg/m 2 at baseline and after 3, 6 and 12 months, respectively. There were missing data from several patients at 3, 6 and 12 months, and the weight gain and effect size of this change was therefore not computed. The percentage of patients presenting with BMI ≥ 18.5 kg/m 2 at the last observation was 31.8% ( n  = 7).

Outcome among patients with severe AN

Seventeen of the 44 patients who started CBT-E presented with severe AN (BMI < 16 kg/m 2 according to DSM-5), of which 7 were completers. Five of these seven patients had a BMI of ≥18.5 kg/m 2 at 12 months after starting CBT-E: the BMI in this group of patients was 14.0±1.1 kg/m 2 at baseline and 18.9±2.1 kg/m 2 after 12 months.

This quality assessment study aimed to describe the pre- post changes in BMI in a sample of consecutive patients treated with CBT-E for AN at a specialized outpatient eating-disorder unit at a public hospital. There were two main findings: (i) more than two-thirds of the patients who completed the treatment achieved a normal weight after 12 months, and (ii) half of the patients ended the treatment prematurely and did not recover to the same level as those who completed the treatment. In addition, there was a relatively large effect on BMI in this outpatient setting among a substantial subgroup of the patients with severe AN. These are typical patients who usually are referred to inpatient care or other intensive medical stabilization treatments, and not to outpatient psychological treatment. The implementation of CBT-E for AN allowed patients who previously would have been treated as inpatients to live their ordinary lives while they were receiving treatment.

CBT-E for AN was relatively easy to implement in our hospital outpatient unit. Moreover, the results of the present quality-assessment study are promising and are in line with those reported for clinical trials that have assessed the efficacy of CBT-E [ 9 , 14 ].

The main problem to address in the future is to reduce the proportion of non-completers. Indeed, the percentage of non-completers was higher than both that for CBT-E in the study in UK and Italy (36.4% were non-completers) and in the CBT-E arm of the SWAN study (33.3% were non-completers), while it was identical to that reported for an Australian effectiveness study on CBT-E in patients with AN [ 21 ]. While 77% of the patients who completed the treatment achieved the target BMI, the high dropout-rate implies that this represents only 39% of all the patients starting CBT-E. However, it should be stated that the rate of non-mutual premature termination of treatment was only 34% in the current sample, which is similar to reported rates for research clinical trials; seven of our patients were referred by our team to intensive treatments or to address other co-morbid conditions. It is also possible that some elements of randomized clinical trials missing in our clinical settings—such as excluding patients with severe AN and actively recalling patients who missed some sessions—might explain the non-completer rate being higher for our treatment than for CBT-E research trials.

Several studies have indicated that it is difficult to identify reliable predictors of attrition [ 22 , 23 ]. In our sample non-completers were younger than completers (25.6 versus 21.1 years p  = 0.03), suggesting that CBT-E might be more suitable for older patients. However, there were adolescents in both groups, and CBT-E has shown to be a promising treatment also for adolescents with AN [ 3 ]. Although we have no data indicating how to reduce attrition when implementing CBT-E in a real world clinical setting, the clinical experience that we gained by this quality improvement project leads us to suggest the following strategies on how to reduce treatment attrition. First, more time and effort should be dedicated to prepare the patients for CBT-E, stressing the importance of giving treatment priority, playing an active role and completing the treatment. Second, a great store should be placed on establishing and maintaining therapeutic momentum, stressing the importance to avoid breaks in treatment. Third, since patients with AN come to treatment with varying degrees of reluctance and ambivalence engaging the patient should be the top priority for the entire course of the treatment. Further, factors related to the treatment process itself (such as therapeutic alliance and early patient engagement in the treatment) warrant attention, and should be investigated in future studies [ 24 ].

This study was subject to the following limitations: there were missing data, especially from patients dropping out from treatment; no systematic data were obtained on pre-post changes in eating-disorder symptomatology or on a possible diagnostic switch to bulimia nervosa; and we obtained no long-term data describing the clinical situations of the patients after the 12-month assessment. We also did not assess therapist competence and treatment fidelity. However, since treatment fidelity was regarded as crucial for treatment success and essential for the feasibility of setting up this treatment, during the weekly 2-h team meetings adherence to the manual was regularly addressed. However, the main strength of the study is that it demonstrated the possibility of effectively implementing an evidence-based outpatient treatment for AN in a real-world clinical setting.

CBT-E can be implemented relatively easily in an outpatient setting at a public hospital. Patients who remain in therapy are likely to exhibit a substantial increase in BMI and thereby avoid costly and life-disruptive inpatient treatments. However, a large subgroup of patients does not complete the treatment, and the most challenging problem for future research to address is decreasing the non-completion rate.

Abbreviations

  • Anorexia nervosa
  • Body mass index

Enhanced cognitive behaviour therapy

Department of Eating Disorders

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Family based treatment

International Business Machines Statistical Package for the Social Sciences

Maudsley Model Anorexia Nervosa Treatment for Adults

Mini International Neuropsychiatric Interview

National Institute for Health and Care Excellence

Norwegian Krone

Regional Ethical Committee

Specialist Supportive Clinical Management

Strong Without Anorexia Nervosa Study

United Kingdom

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Acknowledgements

We thank Asle Halvorsen, Cecilie Nordenson, Hilde Lomundal, Inghild Nygård, Renate Hope, Vivi Braar Christensen, Signe Haugen and Marit Albertsen for implementing CBT-E.

The data collection of this project was supported by a quality improvement grant from Western Norway Regional Health Authority.

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Department of Eating Disorders, Psychiatric Clinic, Haukeland University Hospital, Bergen, Norway

Stein Frostad, Yngvild S. Danielsen, Guro Å. Rekkedal & Charlotte Jevne

Department of Clinical Psychology, University of Bergen, Bergen, Norway

Yngvild S. Danielsen

Department of Eating and Weight Disorders, Villa Garda Hospital, Garda, VR, Italy

Riccardo Dalle Grave

Regional Department for Eating Disorders, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway

Institute of Clinical Medicine, University of Oslo, Oslo, Norway

Department of Clinical Psychiatry, University of Bergen, Bergen, Norway

Ute Kessler

Psychiatric Department, Haukeland University Hospital, Bergen, Norway

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Contributions

YSD, GÅR and CJ contributed to data collection and analysis. UK and YSD analysed the data. OR and RDG contributed to the research questions, the data interpretation and discussion. YSD, UK and SF drafted the first version of the manuscript. SF, YSD, RDG, OR and UK prepared the final version of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Stein Frostad .

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Ethics approval and consent to participate.

This project is a part of the quality-improvement work at the DED at Haukeland University Hospital and was approved by the data protection officer at that hospital (approval no. 2015/12991). The project protocol was submitted for consideration to the Regional Ethical Committee and deemed exempt from review as it was classified as quality improvement (2018/275/REK vest). Consent to participate is not required for quality improvement projects.

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Frostad, S., Danielsen, Y.S., Rekkedal, G.Å. et al. Implementation of enhanced cognitive behaviour therapy (CBT-E) for adults with anorexia nervosa in an outpatient eating-disorder unit at a public hospital. J Eat Disord 6 , 12 (2018). https://doi.org/10.1186/s40337-018-0198-y

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  • Cognitive behaviour therapy

Journal of Eating Disorders

ISSN: 2050-2974

cbt e resources

CBT Techniques: 25 Cognitive Behavioral Therapy Worksheets

Cognitive behavioral therapy techniques worksheets

It’s an extremely common type of talk therapy practiced around the world.

If you’ve ever interacted with a mental health therapist, a counselor, or a psychiatry clinician in a professional setting, it’s likely you’ve participated in CBT.

If you’ve ever heard friends or loved ones talk about how a mental health professional helped them identify unhelpful thoughts and patterns and behavior and alter them to more effectively work towards their goals, you’ve heard about the impacts of CBT.

CBT is one of the most frequently used tools in the psychologist’s toolbox. Though it’s based on simple principles, it can have wildly positive outcomes when put into practice.

In this article, we’ll explore what CBT is, how it works, and how you can apply its principles to improve your own life or the lives of your clients.

Before you read on, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with a comprehensive insight into Positive CBT and will give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is cbt, cognitive distortions, 9 essential cbt techniques and tools.

  • Cognitive Behavioral Therapy Worksheets (PDFs) To Print and Use

Some More CBT Interventions and Exercises

A cbt manual and workbook for your own practice and for your client, 5 final cognitive behavioral activities, a take-home message.

What Is Cognitive Behavioral Therapy

“This simple idea is that our unique patterns of thinking, feeling, and behaving are significant factors in our experiences, both good and bad. Since these patterns have such a significant impact on our experiences, it follows that altering these patterns can change our experiences” (Martin, 2016).

Cognitive-behavioral therapy aims to change our thought patterns, our conscious and unconscious beliefs, our attitudes, and, ultimately, our behavior, in order to help us face difficulties and achieve our goals.

Psychiatrist Aaron Beck was the first to practice cognitive behavioral therapy. Like most mental health professionals at the time, Beck was a  psychoanalysis  practitioner.

While practicing psychoanalysis, Beck noticed the prevalence of internal dialogue in his clients and realized how strong the link between thoughts and feelings can be. He altered the therapy he practiced in order to help his clients identify, understand, and deal with the automatic, emotion-filled thoughts  that regularly arose in his clients.

Beck found that a combination of cognitive therapy and behavioral techniques produced the best results for his clients. In describing and honing this new therapy, Beck laid the foundations of the most popular and influential form of therapy of the last 50 years.

This form of therapy is not designed for lifelong participation and aims to help clients meet their goals in the near future. Most CBT treatment regimens last from five to ten months, with clients participating in one 50- to 60-minute session per week.

CBT is a hands-on approach that requires both the therapist and the client to be invested in the process and willing to actively participate. The therapist and client work together as a team to identify the problems the client is facing, come up with strategies for addressing them, and creating positive solutions (Martin, 2016).

Cognitive Distortions

Many of the most popular and effective cognitive-behavioral therapy techniques are applied to what psychologists call “ cognitive distortions ,” inaccurate thoughts that reinforce negative thought patterns or emotions (Grohol, 2016).

There are 15 main cognitive distortions that can plague even the most balanced thinkers.

1. Filtering

Filtering refers to the way a person can ignore all of the positive and good things in life to focus solely on the negative. It’s the trap of dwelling on a single negative aspect of a situation, even when surrounded by an abundance of good things.

2. Polarized thinking / Black-and-white thinking

This cognitive distortion is all-or-nothing thinking, with no room for complexity or nuance—everything’s either black or white, never shades of gray.

If you don’t perform perfectly in some area, then you may see yourself as a total failure instead of simply recognizing that you may be unskilled in one area.

3. Overgeneralization

Overgeneralization is taking a single incident or point in time and using it as the sole piece of evidence for a broad conclusion.

For example, someone who overgeneralizes could bomb an important job interview and instead of brushing it off as one bad experience and trying again, they conclude that they are terrible at interviewing and will never get a job offer.

4. Jumping to conclusions

Similar to overgeneralization, this distortion involves faulty reasoning in how one makes conclusions. Unlike overgeneralizing one incident, jumping to conclusions refers to the tendency to be sure of something without any evidence at all.

For example, we might be convinced that someone dislikes us without having any real evidence, or we might believe that our fears will come true before we have a chance to really find out.

5. Catastrophizing / Magnifying or Minimizing

This distortion involves expecting that the worst will happen or has happened, based on an incident that is nowhere near as catastrophic as it is made out to be. For example, you may make a small mistake at work and be convinced that it will ruin the project you are working on, that your boss will be furious, and that you’ll lose your job.

Alternatively, one might minimize the importance of positive things, such as an accomplishment at work or a desirable personal characteristic.

6. Personalization

This is a distortion where an individual believes that everything they do has an impact on external events or other people, no matter how irrational that may be. A person with this distortion will feel that he or she has an exaggerated role in the bad things that happen around them.

For instance, a person may believe that arriving a few minutes late to a meeting led to it being derailed and that everything would have been fine if they were on time.

7. Control fallacies

This distortion involves feeling like everything that happens to you is either a result of purely external forces or entirely due to your own actions. Sometimes what happens to us is due to forces we can’t control, and sometimes what it’s due to our own actions, but the distortion is assuming that it is always one or the other.

We might assume that difficult coworkers are to blame for our own less-than-stellar work, or alternatively assume that every mistake another person makes is because of something we did.

8. Fallacy of fairness

We are often concerned about fairness, but this concern can be taken to extremes. As we all know, life is not always fair. The person who goes through life looking for fairness in all their experiences will end up resentful and unhappy.

Sometimes things will go our way, and sometimes they will not, regardless of how fair it may seem.

When things don’t go our way, there are many ways we can explain or assign responsibility for the outcome. One method of assigning responsibility is blaming others for what goes wrong.

Sometimes we may blame others for making us feel or act a certain way, but this is a cognitive distortion. Only you are responsible for the way you feel or act.

10. “Shoulds”

“Shoulds” refer to the implicit or explicit rules we have about how we and others should behave. When others break our rules, we are upset. When we break our own rules, we feel guilty. For example, we may have an unofficial rule that customer service representatives should always be accommodating to the customer.

When we interact with a customer service representative that is not immediately accommodating, we might get angry. If we have an implicit rule that we are irresponsible if we spend money on unnecessary things, we may feel exceedingly guilty when we spend even a small amount of money on something we don’t need.

11. Emotional reasoning

This distortion involves thinking that if we feel a certain way, it must be true. For example, if we feel unattractive or uninteresting in the current moment, we think we  are unattractive or uninteresting. This cognitive distortion boils down to:

“I feel it, therefore it must be true.”

Clearly, our emotions are not always indicative of the objective truth, but it can be difficult to look past how we feel.

12. Fallacy of change

The fallacy of change lies in expecting other people to change as it suits us. This ties into the feeling that our happiness depends on other people, and their unwillingness or inability to change, even if we demand it, keeps us from being happy.

This is a damaging way to think because no one is responsible for our own happiness except ourselves.

13. Global labeling / mislabeling

This cognitive distortion is an extreme form of generalizing, in which we generalize one or two instances or qualities into a global judgment. For example, if we fail at a specific task, we may conclude that we are a total failure in not only that area but all areas.

Alternatively, when a stranger says something a bit rude, we may conclude that he or she is an unfriendly person in general. Mislabeling is specific to using exaggerated and emotionally loaded language, such as saying a woman has abandoned her children when she leaves her children with a babysitter to enjoy a night out.

14. Always being right

While we all enjoy being right, this distortion makes us think we must be right, that being wrong is unacceptable.

We may believe that being right is more important than the feelings of others, being able to admit when we’ve made a mistake or being fair and objective.

15. Heaven’s Reward Fallacy

This distortion involves expecting that any sacrifice or self-denial will pay off. We may consider this karma, and expect that karma will always immediately reward us for our good deeds. This results in feelings of bitterness when we do not receive our reward (Grohol, 2016).

Many tools and techniques found in cognitive behavioral therapy are intended to address or reverse these cognitive distortions.

9 Essential CBT Tools

There are many tools and techniques used in cognitive behavioral therapy, many of which can be used in both a therapy context and in everyday life. The nine techniques and tools listed below are some of the most common and effective CBT practices.

1. Journaling

This technique is a way to gather about one’s moods and thoughts. A CBT journal can include the time of the mood or thought, the source of it, the extent or intensity, and how we reacted, among other factors.

This technique can help us to identify our thought patterns and emotional tendencies, describe them, and change, adapt, or cope with them (Utley & Garza, 2011).

Follow the link to find out more about using a thought diary for journaling.

2. Unraveling cognitive distortions

This is a primary goal of CBT and can be practiced with or without the help of a therapist. In order to unravel cognitive distortions, you must first become aware of the distortions from which you commonly suffer (Hamamci, 2002).

Part of this involves identifying and challenging harmful automatic thoughts, which frequently fall into one of the 15 categories listed earlier.

3. Cognitive restructuring

Once you identify the distortions you hold, you can begin to explore how those distortions took root and why you came to believe them. When you discover a belief that is destructive or harmful, you can begin to challenge it (Larsson, Hooper, Osborne, Bennett, & McHugh, 2015).

For example, if you believe that you must have a high-paying job to be a respectable person, but you’re then laid off from your high-paying job, you will begin to feel bad about yourself.

Instead of accepting this faulty belief that leads you to think negative thoughts about yourself, with cognitive restructuring you could take an opportunity to think about what really makes a person “respectable,” a belief you may not have explicitly considered before.

4. Exposure and response prevention

This technique is specifically effective for those who suffer from obsessive-compulsive disorder (OCD; Abramowitz, 1996). You can practice this technique by exposing yourself to whatever it is that normally elicits a compulsive behavior, but doing your best to refrain from the behavior.

You can combine journaling with this technique, or use journaling to understand how this technique makes you feel.

5. Interoceptive exposure

Interoceptive Exposure is intended to treat panic and anxiety. It involves exposure to feared bodily sensations in order to elicit the response (Arntz, 2002). Doing so activates any unhelpful beliefs associated with the sensations, maintains the sensations without distraction or avoidance, and allows new learning about the sensations to take place.

It is intended to help the sufferer see that symptoms of panic are not dangerous, although they may be uncomfortable.

6. Nightmare exposure and rescripting

Nightmare exposure and rescripting are intended specifically for those suffering from nightmares. This technique is similar to interoceptive exposure, in that the nightmare is elicited, which brings up the relevant emotion (Pruiksma, Cranston, Rhudy, Micol, & Davis, 2018).

Once the emotion has arisen, the client and therapist work together to identify the desired emotion and develop a new image to accompany the desired emotion.

7. Play the script until the end

This technique is especially useful for those suffering from fear and anxiety. In this technique, the individual who is vulnerable to crippling fear or anxiety conducts a sort of thought experiment in which they imagine the outcome of the worst-case scenario.

Letting this scenario play out can help the individual to recognize that even if everything he or she fears comes to pass, the outcome will still be manageable (Chankapa, 2018).

8. Progressive muscle relaxation

This is a familiar technique to those who practice mindfulness. Similar to the body scan, progressive muscle relaxation instructs you to relax one muscle group at a time until your whole body is in a state of relaxation (McCallie, Blum, & Hood, 2006).

You can use audio guidance, a YouTube video, or simply your own mind to practice this technique, and it can be especially helpful for calming nerves and soothing a busy and unfocused mind.

9. Relaxed breathing

This is another technique that will be familiar to practitioners of mindfulness . There are many ways to relax and bring regularity to your breath, including guided and unguided imagery, audio recordings, YouTube videos, and scripts. Bringing regularity and calm to your breath will allow you to approach your problems from a place of balance, facilitating more effective and rational decisions (Megan, 2016).

These techniques can help those suffering from a range of mental illnesses and afflictions, including anxiety, depression, OCD, and panic disorder, and they can be practiced with or without the guidance of a therapist. To try some of these techniques without the help of a therapist, see the next section for worksheets and handouts to assist with your practice.

How does cognitive behavioral therapy work – Psych Hub

Cognitive-Behavioral Therapy Worksheets (PDFs) To Print and Use

Essential CBT Techniques and Tools

1. Coping styles worksheet

This PDF Coping Styles Formulation Worksheet instructs you or your client to first list any current perceived problems or difficulties – “The Problem”. You or your client will work backward to list risk factors above (i.e., why you are more likely to experience these problems than someone else) and triggers or events (i.e., the stimulus or source of these problems).

Once you have defined the problems and understand why you are struggling with them, you then list coping strategies. These are not solutions to your problems, but ways to deal with the effects of those problems that can have a temporary impact. Next, you list the effectiveness of the coping strategies, such as how they make you feel in the short- and long-term, and the advantages and disadvantages of each strategy.

Finally, you move on to listing alternative actions. If your coping strategies are not totally effective against the problems and difficulties that are happening, you are instructed to list other strategies that may work better.

This worksheet gets you (or your client) thinking about what you are doing now and whether it is the best way forward.

2. ABC functional analysis

One popular technique in CBT is ABC functional analysis . Functional analysis helps you (or the client) learn about yourself, specifically, what leads to specific behaviors and what consequences result from those behaviors.

In the middle of the worksheet is a box labeled “Behaviors.” In this box, you write down any potentially problematic behaviors you want to analyze.

On the left side of the worksheet is a box labeled “Antecedents,” in which you or the client write down the factors that preceded a particular behavior. These are factors that led up to the behavior under consideration, either directly or indirectly.

On the right side is the final box, labeled “Consequences.” This is where you write down what happened as a result of the behavior under consideration. “Consequences” may sound inherently negative, but that’s not necessarily the case; some positive consequences can arise from many types of behaviors, even if the same behavior also leads to negative consequences.

This ABC Functional Analysis Worksheet can help you or your client to find out whether particular behaviors are adaptive and helpful in striving toward your goals, or destructive and self-defeating.

3. Case formulation worksheet

In CBT, there are 4 “P’s” in Case Formulation:

  • Predisposing factors;
  • Precipitating factors;
  • Perpetuating factors; and
  • Protective factors

They help us understand what might be leading a perceived problem to arise, and what might prevent them from being tackled effectively.

In this worksheet, a therapist will work with their client through 4 steps.

First, they identify predisposing factors, which are those external or internal and can add to the likelihood of someone developing a perceived problem (“The Problem”). Examples might include genetics, life events, or their temperament.

Together, they collaborate to identify precipitating factors, which provide insight into precise events or triggers that lead to “The Problem” presenting itself. Then they consider perpetuating factors, to discover what reinforcers may be maintaining the current problem.

Last, they identify protective factors, to understand the client’s strengths, social supports, and adaptive behavioral patterns.

cbt e resources

Download 3 Free Positive CBT Exercises (PDF)

These detailed, science-based exercises will equip you or your clients with tools to find new pathways to reduce suffering and more effectively cope with life stressors.

Download 3 Free Positive CBT Tools Pack (PDF)

By filling out your name and email address below.

4. Extended case formulation worksheet

This worksheet builds on the last. It helps you or your client address the “Four P Factors” described just above—predisposing, precipitating, perpetuating, and protective factors. This formulation process can help you or your client connect the dots between core beliefs, thought patterns, and present behavior.

This worksheet presents six boxes on the left of the page (Part A), which should be completed before moving on to the right-hand side of the worksheet (Part B).

  • The first box is labeled “The Problem,” and corresponds with the perceived difficulty that your client is experiencing. In this box, you are instructed to write down the events or stimuli that are linked to a certain behavior.
  • The next box is labeled “Early Experiences” and corresponds to the predisposing factor. This is where you list the experiences that you had early in life that may have contributed to the behavior.
  • The third box is “Core Beliefs,” which is also related to the predisposing factor. This is where you write down some relevant core beliefs you have regarding this behavior. These are beliefs that may not be explicit, but that you believe deep down, such as “I’m bad” or “I’m not good enough.”
  • The fourth box is “Conditional assumptions/rules/attitudes,” which is where you list the rules that you adhere to, whether consciously or subconsciously. These implicit or explicit rules can perpetuate the behavior, even if it is not helpful or adaptive. Rules are if-then statements that provide a judgment based on a set of circumstances. For instance, you may have the rule “If I do not do something perfectly, I’m a complete failure.”
  • The fifth box is labeled “Maladaptive Coping Strategies” This is where you write down how well these rules are working for you (or not). Are they helping you to be the best you can be? Are they helping you to effectively strive towards your goals?
  • Finally, the last box us titled “Positives.” This is where you list the factors that can help you deal with the problematic behavior or thought, and perhaps help you break the perpetuating cycle. These can be things that help you cope once the thought or behavior arises or things that can disrupt the pattern once it is in motion.

On the right, there is a flow chart that you can fill out based on how these behaviors and feelings are perpetuated. You are instructed to think of a situation that produces a negative automatic thought and record the emotion and behavior that this thought provokes, as well as the bodily sensations that can result. Filling out this flow chart can help you see what drives your behavior or thought and what results from it.

Download our PDF Extended Case Formulation Worksheet .

5. Dysfunctional thought record

This worksheet is especially helpful for people who struggle with negative thoughts and need to figure out when and why those thoughts are most likely to pop up. Learning more about what provokes certain automatic thoughts makes them easier to address and reverse.

The worksheet is divided into seven columns:

  • On the far left, there is space to write down the date and time a dysfunctional thought arose.
  • The second column is where the situation is listed. The user is instructed to describe the event that led up to the dysfunctional thought in detail.
  • The third column is for the automatic thought. This is where the dysfunctional automatic thought is recorded, along with a rating of belief in the thought on a scale from 0% to 100%.
  • The next column is where the emotion or emotions elicited by this thought are listed, also with a rating of intensity on a scale from 0% to 100%.
  • Use this fifth column to note the dysfunctional thought that will be addressed. Example maladaptive thoughts include distortions such as over-inflating the negative while dismissing the positive of a situation, or overgeneralizing.
  • The second-to-last column is for the user to write down alternative thoughts that are more positive and functional to replace the negative one.
  • Finally, the last column is for the user to write down the outcome of this exercise. Were you able to confront the dysfunctional thought? Did you write down a convincing alternative thought? Did your belief in the thought and/or the intensity of your emotion(s) decrease?

Download this Dysfunctional Thought Record as a PDF.

6. Fact-checking

One of my favorite CBT tools is this  Fact Checking Thoughts Worksheet because it can be extremely helpful in recognizing that your thoughts are not necessarily true.

At the top of this worksheet is an important lesson:

Thoughts are not facts.

Of course, it can be hard to accept this, especially when we are in the throes of a dysfunctional thought or intense emotion. Filling out this worksheet can help you come to this realization.

The worksheet includes 16 statements that the user must decide are either fact or opinion. These statements include:

  • I’m a bad person.
  • I failed the test.
  • I’m selfish.
  • I didn’t lend my friend money when they asked.

This is not a trick—there is a right answer for each of these statements. (In case you’re wondering, the correct answers for the statements above are as follows: opinion, fact, opinion, fact.)

This simple exercise can help the user to see that while we have lots of emotionally charged thoughts, they are not all objective truths. Recognizing the difference between fact and opinion can assist us in challenging the dysfunctional or harmful opinions we have about ourselves and others.

7. Cognitive restructuring

This worksheet employs the use of Socratic questioning, a technique that can help the user to challenge irrational or illogical thoughts.

The first page of the worksheet has a thought bubble for “What I’m Thinking”. You or your client can use this space to write down a specific thought, usually, one you suspect is destructive or irrational.

Next, you write down the facts supporting and contradicting this thought as a reality. What facts about this thought being accurate? What facts call it into question? Once you have identified the evidence, you can use the last box to make a judgment on this thought, specifically whether it is based on evidence or simply your opinion.

The next page is a mind map of Socratic Questions which can be used to further challenge the thought. You may wish to re-write “What I’m Thinking” in the center so it is easier to challenge the thought against these questions.

  • One question asks whether this thought is truly a black-and-white situation, or whether reality leaves room for shades of gray. This is where you think about (and write down) whether you are using all-or-nothing thinking, for example, or making things unreasonably simple when they are complex.
  • Another asks whether you could be misinterpreting the evidence or making any unverified assumptions. As with all the other bubbles, writing it down will make this exercise more effective.
  • A third bubble instructs you to think about whether other people might have different interpretations of the same situation, and what those interpretations might be.
  • Next, ask yourself whether you are looking at all the relevant evidence or just the evidence that backs up the belief you already hold. Try to be as objective as possible.
  • It also helps to ask yourself whether your thought may an over-inflation of a truth. Some negative thoughts are based in truth but extend past their logical boundaries.
  • You’re also instructed to consider whether you are entertaining this negative thought out of habit or because the facts truly support it.
  • Then, think about how this thought came to you. Was it passed on from someone else? If so, is that person a reliable source of truth?
  • Finally, you complete the worksheet by identifying how likely the scenario your thought brings up actually is, and whether it is the worst-case scenario.

These Socratic questions encourage a deep dive into the thoughts that plague you and offer opportunities to analyze and evaluate those thoughts. If you are having thoughts that do not come from a place of truth, this Cognitive Restructuring Worksheet can be an excellent tool for identifying and defusing them.

How is positive cognitive-behavioral therapy (CBT) different from traditional CBT?

Although both forms of CBT have the same goal of bringing about positive changes in a client’s life, the pathways used in traditional and positive CBT to actualize this goal differ considerably. Traditional CBT, as initially formulated by Beck (1967), focuses primarily on the following:

  • Analyzing problems
  • Lessening what causes suffering
  • Working on clients’ weaknesses
  • Getting away from problems

Instead, positive CBT, as formulated by Bannink (2012), focuses mainly on the following:

  • Finding solutions
  • Enhancing what causes flourishing
  • Working with client’s strengths
  • Getting closer to the preferred future

In other words, Positive CBT shifts the focus on what’s right with the person (rather than what’s wrong with them) and on what’s working (rather than what’s not working) to foster a more optimistic process that empowers clients to flourish and thrive.

In an initial study comparing the effects of traditional and Positive CBT in the treatment of depression, positive CBT resulted in a more substantial reduction of depression symptoms, a more significant increase in happiness, and it was associated with less dropout (Geschwind et al., 2019).

cbt e resources

Haven’t had enough CBT tools and techniques yet? Read on for additional useful and effective exercises.

1. Behavioral experiments

These are related to thought experiments, in that you engage in a “what if” consideration. Behavioral experiments differ from thought experiments in that you actually test out these “what ifs” outside of your thoughts (Boyes, 2012).

In order to test a thought, you can experiment with the outcomes that different thoughts produce. For example, you can test the thoughts:

“If I criticize myself, I will be motivated to work harder” versus “If I am kind to myself, I will be motivated to work harder.”

First, you would try criticizing yourself when you need the motivation to work harder and record the results. Then you would try being kind to yourself and recording the results. Next, you would compare the results to see which thought was closer to the truth.

These Behavioral Experiments to Test Beliefs can help you learn how to achieve your therapeutic goals and how to be your best self.

2. Thought records

Thought records are useful in testing the validity of your thoughts (Boyes, 2012). They involve gathering and evaluating evidence for and against a particular thought, allowing for an evidence-based conclusion on whether the thought is valid or not.

For example, you may have the belief “My friend thinks I’m a bad friend.” You would think of all the evidence for this belief, such as “She didn’t answer the phone the last time I called,” or “She canceled our plans at the last minute,” and evidence against this belief, like “She called me back after not answering the phone,” and “She invited me to her barbecue next week. If she thought I was a bad friend, she probably wouldn’t have invited me.”

Once you have evidence for and against, the goal is to come up with more balanced thoughts, such as, “My friend is busy and has other friends, so she can’t always answer the phone when I call. If I am understanding of this, I will truly be a good friend.”

Thought records apply the use of logic to ward off unreasonable negative thoughts and replace them with more balanced, rational thoughts (Boyes, 2012).

Here’s a helpful Thought Record Worksheet to download.

3. Pleasant activity scheduling

This technique can be especially helpful for dealing with depression (Boyes, 2012). It involves scheduling activities in the near future that you can look forward to.

For example, you may write down one activity per day that you will engage in over the next week. This can be as simple as watching a movie you are excited to see or calling a friend to chat. It can be anything that is pleasant for you, as long as it is not unhealthy (i.e., eating a whole cake in one sitting or smoking).

You can also try scheduling an activity for each day that provides you with a sense of mastery or accomplishment (Boyes, 2012). It’s great to do something pleasant, but doing something small that can make you feel accomplished may have more long-lasting and far-reaching effects.

This simple technique can introduce more positivity into your life, and our Pleasant Activity Scheduling Worksheet is designed to help.

4. Imagery-based exposure

This exercise involves thinking about a recent memory that produced strong negative emotions and analyzing the situation.

For example, if you recently had a fight with your significant other and they said something hurtful, you can bring that situation to mind and try to remember it in detail. Next, you would try to label the emotions and thoughts you experienced during the situation and identify the urges you felt (e.g., to run away, to yell at your significant other, or to cry).

Visualizing this negative situation, especially for a prolonged period of time, can help you to take away its ability to trigger you and reduce avoidance coping (Boyes, 2012). When you expose yourself to all of the feelings and urges you felt in the situation and survive experiencing the memory, it takes some of its power away.

This Imagery Based Exposure Worksheet is a useful resource for this exercise.

5. Graded exposure worksheet

This technique may sound complicated, but it’s relatively simple.

Making a situation exposure hierarchy involves means listing situations that you would normally avoid (Boyes, 2012). For example, someone with severe social anxiety may typically avoid making a phone call or asking someone on a date.

Next, you rate each item on how distressed you think you would be, on a scale from 0 to 10, if you engaged in it. For the person suffering from severe social anxiety, asking someone on a date may be rated a 10 on the scale, while making a phone call might be rated closer to a 3 or 4.

Once you have rated the situations, you rank them according to their distress rating. This will help you recognize the biggest difficulties you face, which can help you decide which items to address and in what order. It’s often advised to start with the least distressing items and work your way up to the most distressing items.

Download our Graded Exposure Worksheet here.

Situation Exposure Hierarchies CBT Interventions and Exercises

Some of these books are for the therapist only, and some are to be navigated as a team or with guidance from the therapist.

There are many manuals out there for helping therapists apply cognitive behavioral therapy in their work, but these are some of the most popular:

  • A Therapist’s Guide to Brief Cognitive Behavioral Therapy by Jeffrey A. Cully and Andra L. Teten (PDF here );
  • Individual Therapy Manual for Cognitive-Behavioral Treatment of Depression by Ricardo F. Munoz and Jeanne Miranda (PDF here );
  • Provider’s Guidebook: “Activities and Your Mood” by Community Partners in Care (PDF here );
  • Treatment Manual for Cognitive Behavioral Therapy for Depression by Jeannette Rosselló, Guillermo Bernal, and the Institute for Psychological Research (PDF here ).

Here are some of the most popular workbooks and manuals for clients to use alone or with a therapist:

  • The CBT Toolbox: A Workbook for Clients and Clinicians by Jeff Riggenbach ( Amazon );
  • Client’s Guidebook: “Activities and Your Mood” by Community Partners in Care (PDF here );
  • The Cognitive Behavioral Workbook for Anxiety: A Step-by-Step Program by William J. Knaus and Jon Carlson ( Amazon );
  • The Cognitive Behavioral Workbook for Depression: A Step-by-Step Program by William J. Knaus and Albert Ellis ( Amazon );
  • Cognitive-Behavioral Therapy Skills Workbook by Barry Gregory ( Amazon );
  • A Course in CBT Techniques: A Free Online CBT Workbook  by Albert Bonfil and Suraji Wagage (online here ).

There are many other manuals and workbooks available that can help get you started with CBT, but the tools above are a good start. Peruse our article: 30 Best CBT Books to Master Cognitive Behavioral Therapy for an excellent list of these books.

Body Scan Meditation

1. Mindfulness meditation

Mindfulness can have a wide range of positive impacts, including helping with depression, anxiety, addiction, and many other mental illnesses or difficulties.

The practice can help those suffering from harmful automatic thoughts to disengage from rumination and obsession by helping them stay firmly grounded in the present (Jain et al., 2007).

Mindfulness meditations, in particular, can function as helpful tools for your clients in between therapy sessions, such as to help ground them in the present moment during times of stress.

If you are a therapist who uses mindfulness-based approaches, consider finding or pre-recording some short mindfulness meditation exercises for your clients.

You might then share these with your clients as part of a toolkit they can draw on at their convenience, such as using the blended care platform Quenza (pictured here), which allows clients to access meditations or other psychoeducational activities on-the-go via their portable devices.

2. Successive approximation

This is a fancy name for a simple idea that you have likely already heard of: breaking up large tasks into small steps.

It can be overwhelming to be faced with a huge goal, like opening a business or remodeling a house. This is true in mental health treatment as well, since the goal to overcome depression or anxiety and achieve mental wellness can seem like a monumental task.

By breaking the large goal into small, easy-to-accomplish steps, we can map out the path to success and make the journey seem a little less overwhelming (e.g., Emmelkamp & Ultee, 1974).

3. Writing self-statements to counteract negative thoughts

This technique can be difficult for someone who’s new to CBT treatment or suffering from severe symptoms, but it can also be extremely effective (Anderson, 2014).

When you (or your client) are being plagued by negative thoughts, it can be hard to confront them, especially if your belief in these thoughts is strong. To counteract these negative thoughts, it can be helpful to write down a positive, opposite thought.

For example, if the thought “I am worthless” keeps popping into your head, try writing down a statement like “I am a person with worth,” or “I am a person with potential.” In the beginning, it can be difficult to accept these replacement thoughts, but the more you bring out these positive thoughts to counteract the negative ones, the stronger the association will be.

4. Visualize the best parts of your day

When you are feeling depressed or negative, it is difficult to recognize that there are positive aspects of life. This simple technique of bringing to mind the good parts of your day can be a small step in the direction of recognizing the positive (Anderson, 2014).

All you need to do is write down the things in your life that you are thankful for or the most positive events that happen in a given day. The simple act of writing down these good things can forge new associations in your brain that make it easier to see the positive, even when you are experiencing negative emotions.

5. Reframe your negative thoughts

It can be easy to succumb to negative thoughts as a default setting. If you find yourself immediately thinking a negative thought when you see something new, such as entering an unfamiliar room and thinking “I hate the color of that wall,” give reframing a try (Anderson, 2014).

Reframing involves countering the negative thought(s) by noticing things you feel positive about as quickly as possible. For instance, in the example where you immediately think of how much you hate the color of that wall, you would push yourself to notice five things in the room that you feel positively about (e.g., the carpet looks comfortable, the lampshade is pretty, the windows let in a lot of sunshine).

You can set your phone to remind you throughout the day to stop what you are doing and think of the positive things around you. This can help you to push your thoughts back into the realm of the positive instead of the negative.

In this post, we offered many techniques, tools, and resources that can be effective in the battle against depression, anxiety, OCD, and a host of other problems or difficulties.

However, as is the case with many treatments, they depend on you (or your client) putting in a lot of effort. We encourage you to give these techniques a real try and allow yourself the luxury of thinking that they could actually work.

When we approach a potential solution with the assumption that it will not work, that assumption often becomes a self-fulfilling prophecy. When we approach a potential solution with an open mind and the belief that it just might work, it has a much better chance of succeeding.

So if you are struggling with negative automatic thoughts , please consider these tips and techniques and give them a shot. Likewise, if your client is struggling, encourage them to make the effort, because the payoff can be better than they can imagine.

If you are struggling with severe symptoms of depression or suicidal thoughts, please call the following number in your respective country:

  • USA: National Suicide Prevention Hotline at 988;
  • UK: Samaritans hotline at 116 123;
  • The Netherlands: Netherlands Suicide Hotline at 09000767;
  • France: Suicide écoute at 01 45 39 40 00;
  • Germany: Telefonseelsorge at 0800 111 0 111 or 0800 111 0 222

For a list of other suicide prevention websites, phone numbers, and resources, see this website .

Please know that there are people out there who care and that there are treatments that can help.

Please let us know about your experiences with CBT in the comments section. If you’ve tried it, how did it work for you? Are there any other helpful exercises or techniques that we did not touch on in this piece? We’d love to know your thoughts.

We hope you enjoyed this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

  • Abramowitz, J. S. (1996). Variants of exposure and response prevention in the treatment of obsessive-compulsive disorder: A meta-analysis. Behavior Therapy , 27 (4), 583-600.
  • Anderson, J. (2014, June 12). 5 Get-positive techniques from cognitive behavioral therapy. Retrieved from http://www.everydayhealth.com/hs/major-depression-living-well/cognitive-behavioral-therapy-techniques/
  • Arntz, A. (2002). Cognitive therapy versus interoceptive exposure as treatment of panic disorder without agoraphobia. Behaviour Research and Therapy , 40 (3), 325-341.
  • Bannink, F. (2012).  Practicing positive CBT: From reducing distress to building success . John Wiley & Sons.
  • Beck, A. T. (1967). Depression. Hoeber-Harper.
  • Boyes, A. (2012, December 6). Cognitive behavioral therapy techniques that work: Mix and match cognitive behavioral therapy techniques to fit your preferences. Retrieved from https://www.psychologytoday.com/blog/in-practice/201212/cognitive-behavioral-therapy-techniques-work
  • Chankapa, N. P. (2018). Effectiveness of cognitive behavioral therapy on depression and self-efficacy among out-patient female depressants in Sikkim  (Masters dissertation). Retrieved from http://14.139.206.50:8080/jspui/bitstream/1/6059/1/nancy%20chankpa.pdf
  • Davis, R. (2019, March 6). The complete list of cognitive behavioral therapy (CBT) techniques. Retrieved from https://www.infocounselling.com/list-of-cbt-techniques/
  • Emmelkamp, P. M., & Ultee, K. A. (1974). A comparison of “successive approximation” and “self-observation” in the treatment of agoraphobia. Behavior Therapy, 5 (5), 606–613.
  • Geschwind, N., Arntz, A., Bannink, F., & Peeters, F. (2019). Positive cognitive behavior therapy in the treatment of depression: A randomized order within-subject comparison with traditional cognitive behavior therapy.  Behaviour research and therapy, 116 , 119-130.
  • Grohol, J. (2016). 15 Common cognitive distortions. Retrieved from https://psychcentral.com/lib/15-common-cognitive-distortions/
  • Hamamci, Z. (2002). The effect of integrating psychodrama and cognitive behavioral therapy on reducing cognitive distortions in interpersonal relationships. Journal of Group Psychotherapy, Psychodrama & Sociometry ,  55 (1), 3–14.
  • Jain, S., Shapiro, S. L., Swanick, S., Roesch, S. C., Mills, P. J., Bell, I., & Schwartz, G. E. (2007). A randomized controlled trial of mindfulness meditation versus relaxation training: effects on distress, positive states of mind, rumination, and distraction. Annals of Behavioral Medicine , 33 (1), 11-21.
  • Larsson, A., Hooper, N., Osborne, L. A., Bennett, P., & McHugh, L. (2016). Using brief cognitive restructuring and cognitive defusion techniques to cope with negative thoughts. Behavior Modification , 40 (3), 452-482.
  • Martin, B. (2016). In-depth: Cognitive behavioral therapy.  Retrieved from https://psychcentral.com/lib/in-depth-cognitive-behavioral-therapy/
  • McCallie, M. S., Blum, C. M., & Hood, C. J. (2006). Progressive muscle relaxation. Journal of Human Behavior in the Social Environment , 13 (3), 51-66.
  • Pathak, N. (Ed.). (2018). Does cognitive behavioral therapy treat depression? Retrieved from https://www.webmd.com/g00/depression/guide/cognitive-behavioral-therapy-for-depression/
  • Pruiksma, K. E., Cranston, C. C., Rhudy, J. L., Micol, R. L., & Davis, J. L. (2018). Randomized controlled trial to dismantle exposure, relaxation, and rescripting therapy (ERRT) for trauma-related nightmares. Psychological trauma: theory, research, practice, and policy , 10 (1), 67-75.
  • Psychology Tools. (n.d.). Retrieved from https://www.psychologytools.com/
  • Therapist Aid. (n.d.). Retrieved from https://www.therapistaid.com/
  • Utley, A., & Garza, Y. (2011). The therapeutic use of journaling with adolescents. Journal of Creativity in Mental Health , 6 (1), 29-41.

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Thank you for the work put into this amazing article! It encompasses every bit of CBT that is so useful for clients increasing their understanding of how “this” works in a very well-written tone. Well done!

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Cognitive Behavioral Therapy for Eating Disorders

Cognitive behavioral therapy (CBT) is the leading evidence-based treatment for bulimia nervosa. A new “enhanced” version of the treatment appears to be more potent and has the added advantage of being suitable for all eating disorders, including anorexia nervosa and eating disorder not otherwise specified. This article reviews the evidence supporting CBT in the treatment of eating disorders and provides an account of the “transdiagnostic” theory that underpins the enhanced form of the treatment. It ends with an outline of the treatment's main strategies and procedures.

The eating disorders provide one of the strongest indications for cognitive behavioral therapy (CBT). Two considerations support this claim. First, the core psychopathology of eating disorders, the overevaluation of shape and weight, is cognitive in nature. Second, it is widely accepted that CBT is the treatment of choice for bulimia nervosa 1 and there is evidence that it is as effective with cases of “eating disorder not otherwise specified” (eating disorder NOS), 2 the most common eating disorder diagnosis. This article starts with a description of the clinical features of eating disorders and then reviews the evidence supporting cognitive behavioral treatment. Next, the cognitive behavioral account of eating disorders is presented and, last, the new “transdiagnostic” form of CBT is described.

Eating disorders and their clinical features

Classification and diagnosis.

Eating disorders are characterized by a severe and persistent disturbance in eating behavior that causes psychosocial and, sometimes, physical impairment. The DSM-IV classification scheme for eating disorders recognizes 2 specific diagnoses, anorexia nervosa (AN) and bulimia nervosa (BN), and a residual category termed eating disorder NOS. 3

The diagnosis of anorexia nervosa is made in the presence of the following features:

  • 1. The overevaluation of shape and weight; that is, judging self-worth largely, or even exclusively, in terms of shape and weight. This has been described in various ways and is often expressed as strong desire to be thin combined with an intense fear of weight gain and fatness.
  • 2. The active maintenance of an unduly low body weight. This is commonly defined as maintaining a body weight less than 85% of that expected or a body mass index (BMI; weight kg/height m 2 or weight lb/[height in] 2 × 703) of 17.5 or less.
  • 3. Amenorrhea, in postpubertal females not taking an oral contraceptive.

The unduly low weight is pursued in a variety of ways with strict dieting and excessive exercise being particularly prominent. A subgroup also engages in episodes of binge eating and/or “purging” through self-induced vomiting or laxative misuse.

For a diagnosis of bulimia nervosa 3 features need to be present:

  • 1. Overevaluation of shape and weight, as in anorexia nervosa.
  • 2. Recurrent binge eating. A “binge” is an episode of eating during which an objectively large amount of food is eaten for the circumstances and there is an accompanying sense of loss of control.
  • 3. Extreme weight-control behavior, such as recurrent self-induced vomiting, regular laxative misuse, or marked dietary restriction.

In addition, the diagnostic criteria for anorexia nervosa should not be met. This “trumping rule” ensures that patients do not receive both diagnoses at one time.

There are no positive criteria for the diagnosis of eating disorder NOS. Instead, this diagnosis is reserved for eating disorders of clinical severity that do not meet the diagnostic criteria of AN or BN. Eating disorder NOS is the most common eating disorder encountered in clinical settings constituting about half of adult outpatient eating-disordered samples, with patients with bulimia nervosa constituting about a third, and the rest being cases of anorexia nervosa. 4 In inpatient settings the great majority of cases are either underweight forms of eating disorder NOS or anorexia nervosa. 5

In addition, DSM-IV recognizes “binge eating disorder” (BED) as a provisional diagnosis in need of further study. The criteria for BED are recurrent episodes of binge eating in the absence of extreme weight-control behavior. It is proposed that BED be recognized as a specific eating disorder in DSM-V. 6

Clinical Features

Anorexia nervosa, bulimia nervosa, and most cases of eating disorder NOS share a core psychopathology: the overevaluation of the importance of shape and weight and their control. Whereas most people judge themselves on the basis of their perceived performance in a variety of domains of life (such as the quality of their relationships, their work performance, their sporting prowess), for people with eating disorders self-worth is dependent largely, or even exclusively, on their shape and weight and their ability to control them. This psychopathology is peculiar to the eating disorders (and to body dysmorphic disorder).

In anorexia nervosa, patients become underweight largely as a result of persistent and severe restriction of both the amount and the type of food that they eat. In addition to strict dietary rules, some patients engage in a driven form of exercising, which further contributes to their low body weight. Patients with anorexia nervosa typically value the sense of control that they derive from undereating. Some practice self-induced vomiting, laxative and/or diuretic misuse, especially (but not exclusively) those who experience episodes of loss of control over eating. The amount of food eaten during these “binges” is often not objectively large; hence, they are described as “subjective binges.” Many other psychopathological features tend to be present, some as a result of the semistarvation. These include depressed and labile mood, anxiety features, irritability, impaired concentration, loss of libido, heightened obsessionality and sometimes frank obsessional features, and social withdrawal. There are also a multitude of physical features, most of which are secondary to being underweight. These include poor sleep, sensitivity to the cold, heightened fullness, and decreased energy.

Patients with bulimia nervosa resemble those with anorexia nervosa both in terms of their eating habits and methods of weight control. The main feature distinguishing these 2 groups is that in patients with bulimia nervosa attempts to restrict food intake are regularly disrupted by episodes of (objective) binge eating. These episodes are often followed by compensatory self-induced vomiting or laxative misuse, although there is also a subgroup of patients who do not purge (nonpurging bulimia nervosa). As a result of the combination of undereating and overeating the weight of most patients with bulimia nervosa tends to be unremarkable and is within the healthy range, BMI  =  20–25. Features of depression and anxiety are prominent in these patients. Certain of these patients engage in self-harm and/or substance and alcohol misuse and may attract the diagnosis of borderline personality disorder. Most have few physical complaints, although electrolyte disturbance may occur in those who vomit or take laxatives or diuretics frequently.

The clinical features of patients with eating disorder NOS closely resemble those seen in anorexia nervosa and bulimia nervosa and are of comparable duration and severity. 7 Within this diagnostic grouping 3 subgroups may be distinguished, although there are no sharp boundaries among them. The first group consists of cases that closely resemble anorexia nervosa or bulimia nervosa but just fail to meet the threshold set by the diagnostic criteria (eg, binge eating may not be frequent enough to meet criteria for BN or weight may be just above the threshold in AN); the second and largest subgroup comprises cases in which the features of AN and BN occur in different combinations from that seen in the prototypic disorders—these states may be best viewed as “mixed” in character—and the third subgroup comprises those with binge-eating disorder. Most patients with binge-eating disorder are overweight (BMI = 25–30) or meet criteria for obesity (BMI ≥ 30).

The empirical status of cognitive behavioral therapy for eating disorders

Consistent with the current way of classifying eating disorders, the research on their treatment has focused on the particular disorders in isolation. Wilson and colleagues 8 have provided a narrative review of the studies of the treatment of the 2 specific eating disorders as well as eating disorder NOS, and an authoritative meta-analysis has been conducted by the UK National Institute for Health and Clinical Excellence (NICE). 1 This systematic review is particularly rigorous and, as with all NICE reviews, it forms the basis for evidence-based guidelines for clinical management.

The conclusion from the NICE review, and 2 other recent systematic reviews, 9,10 is that cognitive behavioral therapy (CBT-BN) is the clear leading treatment for bulimia nervosa in adults. However, this is not to imply that CBT-BN is a panacea, as the original version of the treatment resulted in only fewer than half of the patients who completed treatment making a full and lasting recovery. 8 The new “enhanced” version of the treatment (CBT-E) appears to be more effective. 2

Interpersonal psychotherapy (IPT) is a potential evidence-based alternative to CBT-BN in patients with bulimia nervosa and it involves a similar amount of therapeutic contact, but there have been fewer studies of it. 11,12 IPT takes 8 to 12 months longer than CBT-BN to achieve a comparable effect. Antidepressant medication (eg, fluoxetine at a dose of 60 mg daily) has also been found to have a beneficial effect on binge eating in bulimia nervosa but not as great as that obtained with CBT-BN and the long-term effects remain largely untested. 13 Combining CBT-BN with antidepressant medication does not appear to offer any clear advantage over CBT-BN alone. 13 The treatment of adolescents with bulimia nervosa has received relatively little research attention to date.

There has been much less research on the treatment of anorexia nervosa. Most of the studies suffer from small sample sizes and some from high rates of attrition. As a result, there is little evidence to support any psychological treatment, at least in adults. In adolescents the research has focused mainly on family therapy, with the result that the status of CBT in younger patients is unclear.

Preliminary findings have been reported from a 3-site study of the use of the enhanced form of CBT (CBT-E) to treat outpatients with anorexia nervosa. 14 This is the largest study of the treatment of anorexia nervosa to date. In brief, it appears that the treatment can be used to treat about 60% of outpatients with the disorder (BMI 15.0 to 17.5) and that in these patients about 60% have a good outcome. Interestingly and importantly the relapse rate appears low.

There is a growing body of research on the treatment of binge-eating disorder. This research has been the subject of a recent narrative review 15 and several systematic reviews. 1,16,17 The strongest support is for a form of CBT similar to that used to treat BN (CBT-BED). This treatment has been found to have a sustained and marked effect on binge eating, but it has little effect on body weight, which is typically raised in these patients. Arguably the leading first-line treatment is a form of guided cognitive behavioral self-help as it is relatively simple to administer and reasonably effective. 18

Until recently, there had been almost no research on the treatment of forms of eating disorder NOS other than binge-eating disorder despite their severity and prevalence. 7 However, recently the first randomized controlled trial of the enhanced form of CBT found that CBT-E was as effective for patients with eating disorder NOS (who were not significantly underweight; BMI >17.5) as it was for patients with bulimia nervosa with two-thirds of those who completed treatment having a good outcome. 2

In summary, CBT is the treatment of choice for bulimia nervosa and for binge-eating disorder with the best results being obtained with the new “enhanced” form of the treatment. Recent research provides support for the use of this treatment with patients with eating disorder NOS and those with anorexia nervosa.

The remainder of this article provides a description of this transdiagnostic form of CBT.

The cognitive behavioral account of eating disorders

Although the DSM-IV classification of eating disorders encourages the view that they are distinct conditions, each requiring their own form of treatment, there are reasons to question this view. Indeed, it has recently been pointed out that what is most striking about the eating disorders is not what distinguishes them but how much they have in common. 19 As noted earlier, they share many clinical features, including the characteristic core psychopathology of eating disorders: the overevaluation of the importance of shape and weight. In addition, longitudinal studies indicate that most patients migrate among diagnoses over time. 20 This temporal movement among diagnostic categories, together with the shared psychopathology, has led to the proposal that there may be limited utility in distinguishing among the disorders 19 and furthermore that common “transdiagnostic” mechanisms may be involved in their maintenance.

The transdiagnostic cognitive behavioral account of the eating disorders 19 extends the original theory of bulimia nervosa 21 to all eating disorders. According to this theory, the overevaluation of shape and weight and their control is central to the maintenance of all eating disorders. Most of the other clinical features can be understood as resulting directly from this psychopathology. It results in dietary restraint and restriction; preoccupation with thoughts about food and eating, weight and shape; the repeated checking of body shape and weight or its avoidance; and the engaging in extreme methods of weight control. The one feature that is not a direct expression of the core psychopathology is binge eating. This occurs in all cases of bulimia nervosa, many cases of eating disorder NOS, and some cases of anorexia nervosa. The cognitive behavioral account proposes that such episodes are largely the result of attempts to adhere to multiple extreme, and highly specific, dietary rules. The repeated breaking of these rules is almost inevitable and patients tend to react negatively to such dietary slips, generally viewing them as evidence of their poor self-control. They typically respond by temporarily abandoning their efforts to restrict their eating with binge eating being the result. This in turn maintains the core psychopathology by intensifying patients' concerns about their ability to control their eating, shape, and weight. It also encourages more dietary restraint, thereby increasing the risk of further binge eating.

Three further processes may also maintain binge eating. First, difficulties in the patient's life and associated mood changes make it difficult to maintain dietary restraint. Second, as binge eating temporarily alleviates negative mood states and distracts patients from their difficulties, it can become a way of coping with such problems. Third, in patients who engage in compensatory purging, the mistaken belief in the effectiveness of vomiting and laxative misuse as a means of weight control results in a major deterrent against binge eating being removed.

In patients who are underweight, the physiological and psychological consequences may also contribute to the maintenance of the eating disorder. For example, delayed gastric emptying leads to feelings of fullness even after patients have eaten only modest amounts of food. In addition, the social withdrawal and loss of previous interests prevent patients from being exposed to experiences that might diminish the importance they place on shape and weight.

The composite “transdiagnostic” formulation is shown in Fig. 1 . This illustrates the core processes that are hypothesized to maintain the full range of eating disorders. When applied to individual patients, its precise form will depend on the psychopathology present. In some patients, most of the processes are in operation (for example, in cases of anorexia nervosa binge-purge subtype) but in others only a few are active (for example, in binge-eating disorder). Thus, for each patient the formulation is driven by their individual psychopathology rather than their DSM diagnosis. As such, the formulation provides a guide to those processes that need to be addressed in treatment.

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The composite “transdiagnostic” cognitive behavioral formulation.

Enhanced cognitive behavioral therapy

“Enhanced” cognitive behavioral therapy (CBT-E) is based on the transdiagnostic theory outlined earlier and was derived from CBT-BN. It is designed to treat eating disorder psychopathology rather than an eating disorder diagnosis, with its exact form in any particular case depending on an individualized formulation of the processes maintaining the disorder. CBT-E is designed to be delivered on an individual basis to adult patients with any eating disorder of clinical severity who are appropriate to treat on an outpatient basis. It is described as “enhanced” because it uses a variety of new strategies and procedures to improve outcome and because it includes modules to address certain obstacles to change that are “external” to the core eating disorder, namely clinical perfectionism, low self-esteem, and interpersonal difficulties.

There are 2 forms of CBT-E. The first is the “focused” form (CBT-Ef) that exclusively addresses eating disorder psychopathology. Current evidence suggests that this form should be viewed as the “default” version, as it is optimal for most patients with eating disorders. 2 The second, a broad form of the treatment (CBT-Eb), addresses external obstacles to change, in addition to the core eating disorder psychopathology. Preliminary evidence suggests that this more complex form of CBT-E should be reserved for patients in whom clinical perfectionism, core low self-esteem, or interpersonal difficulties are pronounced and maintaining the eating disorder. 2

There are also 2 intensities of CBT-E. With patients who are not significantly underweight (BMI above 17.5), it consists of 20 sessions over 20 weeks. This version is suitable for the great majority of adult outpatients. For patients who have a BMI below 17.5, a commonly used threshold for anorexia nervosa, treatment involves 40 sessions over 40 weeks. The additional sessions and treatment duration are designed to allow sufficient time for 3 additional clinical features to be addressed, namely, limited motivation to change, undereating, and being underweight.

In addition CBT-E has been adapted for younger patients 22 and for inpatient and day patient settings treatment. 23,24 Limitations on space preclude a description of these other forms of CBT-E. Further details of these adaptations of CBT-E, together with a comprehensive account of the treatment and its implementation, can be found in the main treatment guide. 25

An overview of the core aspects of treatment

CBT-E is a form of cognitive behavioral therapy and in common with other empirically supported forms of CBT it focuses primarily on the maintaining processes, in this case those maintaining the eating disorder psychopathology. It uses specified strategies and a flexible series of sequenced therapeutic procedures to achieve both cognitive and behavioral changes. The style of treatment is similar to other forms of CBT, that of collaborative empiricism. Although CBT-E uses a variety of generic cognitive and behavioral interventions (such as addressing cognitive biases), unlike some forms of CBT, it favors the use of strategic changes in behavior to modify thinking rather than direct cognitive restructuring. The eating disorder psychopathology may be likened to a house of cards with the strategy being to identify and remove the key cards that are supporting the eating disorder, thereby bringing down the entire house. Following, we summarize the core features of the focused and broad versions of CBT-E, including adaptations that need to be made for patients who are underweight. The treatment has 4 defined stages.

Preparation for treatment and change

An evaluation interview assessing the nature and extent of the patient's psychiatric problems is conducted before starting treatment. 26 This interview usually takes place over 2 or more appointments. The assessment process is collaborative and designed to put the patient at ease and begin to engage the patient in treatment and in change. Information from the assessment informs how best to proceed and, in particular, whether CBT-E is appropriate. If CBT-E is deemed to be appropriate, the main aspects of the therapy are described and patients are encouraged to make the most of the opportunity to overcome their eating disorder.

It is important that from the outset of CBT-E the patient is in a position to make optimum use of treatment. For this reason any potential barriers to benefiting from CBT-E should be explored. Important contraindications to beginning treatment immediately are physical features of concern, the presence of severe clinical depression, significant substance abuse, major distracting life events or crises, and competing commitments. Such factors should be addressed first before embarking on treatment.

It is crucial that treatment starts well. This is consistent with evidence that the magnitude of change achieved early in treatment is a good predictor of treatment outcome. 27,28 This initial intensive stage, designed to achieve initial therapeutic momentum, involves approximately 8 sessions held twice weekly over 4 weeks. The aims of this first stage are to engage the patient in treatment and change, to derive a personalized formulation (case conceptualization) with the patient, to provide education about treatment and the disorder, and to introduce and implement 2 important procedures: collaborative “weekly weighing” and “regular eating.” The changes made in this first stage of treatment form the foundation on which other changes are built.

Engaging the Patient in Treatment and Change

Many patients with eating disorders are ambivalent about treatment and change. Getting patients “on board” with treatment is a necessary first step. Engagement can be enhanced by conducting the assessment of the eating disorder in a way that helps the patient to become involved in, and hopeful about, the possibility of change and encourages the patient to take “ownership” of treatment.

Jointly Creating the Formulation

This is usually done in the first treatment session and is a personalized visual representation of the processes that appear to be maintaining the eating problem. The therapist draws out the relevant sections of Fig. 1 in collaboration with the patient, incorporating the patient's own experiences and words. It is usually best to start with something the patient wishes to change (eg, binge eating). The formulation helps patients to realize both that their behavior is comprehensible and that it is maintained by a series of interacting self-perpetuating mechanisms that are open to change. It is explained that “the diagram” provides a guide to what needs to be targeted in treatment if patients are to achieve a full and lasting recovery. At this early stage in treatment the therapist should explain that it is provisional and may need to be modified as treatment progresses and understanding of the patient's eating problem increases.

Establishing Real-time Self-monitoring

This is the ongoing “in-the-moment” recording of eating and other relevant behavior, thoughts, feelings, and events ( Fig. 2 is an example of a monitoring record). Self-monitoring is introduced in the initial session and continues to occupy an essential and central role throughout most of treatment. Therapists should clearly explain the reasons for self-monitoring. First, that it enables further understanding of the eating problem and it identifies progress. Second, and more importantly, it helps patients to be more aware of what is happening in the moment so that they can begin to make changes to behavior that may have seemed automatic or beyond their control. Fundamental to establishing accurate recording is jointly reviewing the patient's records each session and discussing the process of recording and any difficulties with this. The records also help inform the agenda for the session: it is best to save any problems identified in the records for the main part of the session.

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An example monitoring record.

Establishing Collaborative “Weekly Weighing”

The patient and therapist check the patient's weight once a week and plot it on an individualized weight graph. Patients are strongly encouraged not to weigh themselves at other times. Weekly in-session weighing has several purposes. First, it provides an opportunity for the therapist to educate patients about body weight and help patients to interpret the numbers on the scale, which otherwise they are prone to misinterpret. Second, it provides patients with accurate data about their weight at a time when their eating habits are changing. Third, and most importantly, it addresses the maintaining processes of excessive body weight checking or its avoidance.

Providing Education

From session 1 onward, an important element of treatment is education about weight and eating, as many patients have misconceptions that maintain their eating disorder. Some of the main topics to cover are as follows:

  • • The characteristic features of eating disorders including their associated physical and psychosocial effects
  • • Body weight and its regulation: the body mass index and its interpretation; natural weight fluctuations; and the effects of treatment on weight
  • • Ineffectiveness of vomiting, laxatives, and diuretics as a means of weight control
  • • Adverse effects of dieting: the types of dieting that promote binge eating; dietary rules versus dietary guidelines.

To provide reliable information on these topics, patients are asked to read relevant sections from one of the authoritative books on eating disorders 29,30 and their reading is discussed in subsequent treatment sessions.

Establishing “Regular Eating”

Establishing a pattern of regular eating is fundamental to successful treatment whatever the form of the eating disorder. It addresses an important type of dieting (“delayed eating”); it displaces most episodes of binge eating; it structures people's days and, for underweight patients, it introduces meals and snacks that can be subsequently increased in size. Early in treatment (usually by the third session) patients are asked to eat 3 planned meals each day plus 2 or 3 planned snacks so that there is rarely more than a 4-hour interval between them. Patients are also asked to confine their eating to these meals and snacks. They should choose what they eat with the only condition being that the meals and snacks are not followed by any compensatory behavior (eg, self-induced vomiting or laxative misuse). The new eating pattern should take precedence over other activities but should not be so inflexible as to preclude the possibility of adjusting timings to suit the patients' commitments each day.

Patients should be helped to adhere to their regular eating plan and to resist eating between the planned meals and snacks. Two rather different strategies may be used to achieve the latter goals. The first involves helping patients to identify activities that are incompatible with eating and likely to distract them from the urge to binge eat (eg, taking a brisk walk) and strategies that make binge eating less likely (eg, leaving the kitchen). The second is to help patients to recognize that the urge to binge eat is a temporary phenomenon that can be “surfed.” Some “residual binges” are likely to persist, however, and these are addressed later.

Involving Significant Others

The treatment is primarily an individual treatment for adults. Despite this, “significant others” are seen if this is likely to facilitate treatment and the patient is willing for this to happen. There are 2 reasons for seeing others: if they could help the patient in making changes or if others are making it difficult for the patient to change, for example, by commenting adversely on eating or appearance.

Stage two is a brief, but essential, transitional stage that generally comprises 2 appointments, a week apart. While continuing with the procedures introduced in Stage one, the therapist and patient take stock and conduct a joint review of progress, the goal being to identify problems still to be addressed and any emerging barriers to change, to revise the formulation if necessary, and to design Stage three. The review serves several purposes. If patients are making good progress they should be praised for their efforts and helpful changes reinforced. If patients are not doing well, the explanation needs to be understood and addressed. If clinical perfectionism, core low self-esteem or relationship difficulties appear to be responsible, this would be an indication for implementing the broad version of the treatment.

Stage three

This is the main body of treatment. Its aim is to address the key processes that are maintaining the patient's eating disorder. The mechanisms addressed, and the order in which these are tackled, depend upon their role and relative importance in maintaining the patient's psychopathology. There are generally 8 weekly appointments.

Addressing the Overevaluation of Shape and Weight

Identifying the overevaluation and its consequences.

The first step involves explaining the concept of self-evaluation and helping patients identify how they evaluate themselves. The relative importance of the various domains that are relevant may be represented as a pie chart ( Fig. 3 is an example of a pie chart with extended formulation), which for most patients is dominated by a large slice representing shape and weight and controlling eating.

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The overevaluation of shape and weight and their control: an extended formulation.

The patient and therapist then identify the problems inherent in this scheme for self-evaluation. Briefly there are 3 related problems: first, self-evaluation is overly dependent on performance in one area of life with the result that domains other than shape and weight are marginalized; second, the area of controlling shape and weight is one in which success is elusive, thus undermining self-esteem; and third, the overevaluation is responsible for the behavior that characterizes the eating disorder (dieting, binge eating, and so forth). 31

The final step in the consideration of self-evaluation is the creation of an “extended formulation” depicting the main expressions of the overevaluation of shape and weight: dieting, body checking and body avoidance, feeling fat, and marginalization of other areas of life. The therapist uses this extended formulation to explain how these behaviors and experiences serve to maintain and magnify the patient's concerns about shape and weight and thus they need to be addressed in treatment.

Enhancing the importance of other domains for self-evaluation

An indirect, yet powerful, means of diminishing the overevaluation of shape and weight is helping patients increase the number and significance of other domains for self-evaluation. Engaging in other aspects of their life that may have been pushed aside by the eating disorder results in these other areas becoming more important in the patient's self-evaluation. Briefly, this involves identifying activities or areas of life that the patient would like to engage in and helping them do so.

A second, direct, strategy is to target the behavioral expressions of the overevaluation of shape and weight. This is done at the same time as enhancing the other domains for self-evaluation and it involves tackling body checking, body avoidance, and feeling fat.

Addressing body checking and avoidance

Patients are often not aware that they are engaging in body checking and that it is maintaining their body dissatisfaction. The first step is therefore to obtain detailed information about their checking behavior by asking patients to monitor it. Patients are then educated about the adverse effects of repeated body checking as the way in which they check tends to provide biased information that leads them to feel dissatisfied. For example, scrutinizing parts of one's body magnifies apparent defects, and only comparing oneself to thin and attractive people leads one to draw the conclusion that one is unattractive. Most patients need substantial and detailed help to curb their repeated body checking and invariably attention needs to be devoted to their mirror use.

Patients who avoid seeing their bodies also need considerable help. They should be encouraged to progressively get used to the sight and feel of their body. This may take many successive sessions.

Addressing “feeling fat”

“Feeling fat” is an experience reported by many women but the intensity and frequency of this feeling appears to be far greater among people with eating disorders. Feeling fat is a target for treatment because it tends to be equated with being fat (irrespective of the patient's actual shape and weight) and hence maintains body dissatisfaction. Although this topic has received little research attention, clinical observation suggests that feeling fat is a result of mislabeling certain emotions and bodily experiences. Consequently, patients are helped to identify the triggers of their feeling fat experiences and the accompanying feelings. These typically are negative mood states (eg, feeling bored or depressed) or physical sensations that heighten body awareness (eg, feeling full, bloated, or sweaty). Patients are then helped to view “feeling fat” as a cue to ask themselves what else they are feeling at the time and once recognized to address it directly.

Exploring the origins of overevaluation

Toward the end of Stage three it is often helpful to explore the origins of the patient's sensitivity to shape, weight, and eating. A historical review can help to make sense of how the problem developed and evolved, highlight how it might have served a useful function in its early stages, and the fact that it may no longer do so. If a specific event appears to have played a critical role in the development of the eating problem, the patient should be helped to reappraise this from the vantage point of the present. This review helps patients distance themselves further from the eating disorder frame of mind or “mindset.”

Addressing Dietary Rules

Patients are helped to recognize that their multiple extreme and rigid dietary rules impair their quality of life and are a central feature of the eating disorder. A major goal of treatment is therefore to reduce, if not eliminate altogether, dieting. The first step in doing so is to identify the patient's various dietary rules together with the beliefs that underlie them. The patient is then helped to break these rules to test the beliefs in question and to learn that the feared consequences that maintain the dietary rule (typically weight gain or binge eating) are not an inevitable result. With patients who binge eat, it is important to pay particular attention to “food avoidance” (the avoidance of specific foods) as this is a major contributory factor. These patients need to systematically re-introduce the avoided food into their diet.

Addressing Event-related Changes in Eating

Among many patients with eating disorders, eating habits change in response to outside events and changes in their mood. The change may involve eating less, stopping eating altogether, overeating, or binge eating. If these changes are prominent, patients need help to deal directly with the triggers. Generally this may be achieved by training them in “proactive” problem solving coupled with the use of functional means of modulating mood.

Addressing Clinical Perfectionism, Low Self-esteem, and Interpersonal Problems

As noted earlier, there are 2 main forms of CBT-E. The components of the focused version are described previously. The “broad” version also includes these strategies and procedures but, in addition, addresses one or more “external” (to the core eating disorder) processes that may be maintaining the eating disorder. It is designed for patients in whom clinical perfectionism, core low self-esteem, or marked interpersonal problems are pronounced and appear to be contributing to the eating disorder. If the therapist decides, in the review of progress (Stage two), to use one or more of these modules, they should become a major component of all subsequent sessions. In the original version of the broad form of CBT-E a fourth module, “mood intolerance,” was included but this has since been integrated in to the standard, focused, form of the treatment as part of addressing events and moods. A description of the main elements of the 3 modules follows. A more detailed account is available in the main treatment guide. 32

Addressing clinical perfectionism

The psychopathology of clinical perfectionism is similar to that of an eating disorder. 33 Its core is the overevaluation of striving to achieve and achievement itself. People with clinical perfectionism judge themselves largely, or exclusively, in terms of working hard toward, and meeting, personally demanding standards in areas of life that they value. If they have a coexisting eating disorder such extreme standards are applied to their eating, weight, and shape. This intensifies key aspects of the eating disorder including dietary restraint, exercise, and shape checking. It is usually evident from the patient's behavior and it can interfere with important aspects of treatment, leading to, for example, overly detailed recording and a strong resistance to relaxing dietary restraint.

The strategy for addressing clinical perfectionism mirrors that used to address the overevaluation of shape and weight and the two can be addressed more or less at the same time. The first step is to add perfectionism to the patient's formulation and to consider the consequences of this for the patient and his or her life, including the self-evaluation pie-chart. Patients are then encouraged to take steps to enhance the importance of other, nonperformance related, domains for self-evaluation.

It is helpful to consider collaboratively patients' goals in areas of life that they value, which are usually multiple, rigid, and extreme, and whether these goals are in fact counterproductive and impairing their actual performance. Performance checking is addressed similarly to shape checking, beginning by first asking patients to record times when they are checking their performance. Then the therapist helps them appreciate that the data they obtain is likely to be skewed as a result of using biased assessment processes, such as selective attention to failure. Avoidance and procrastination also need to be addressed, as they interfere with patients being able to assess their true ability with the result that their fears of failure are maintained.

Addressing core low self-esteem

People with core low self-esteem (CLSE) have a longstanding and pervasive negative view of themselves. It is largely independent of the person's actual performance in life (ie, it is unconditional) and is not secondary to the presence of the eating disorder. The presence of CLSE results in the individual striving especially hard to control eating, weight, and shape to retain some sense of self-worth. It is generally a barrier to engaging in treatment as patients do not feel they deserve treatment nor do they believe that they can benefit from it.

If it is to be directly addressed in treatment, it is added to the patient's formulation in Stage two and tackled alongside, although slightly later than, the steps addressing the overevaluation of shape and weight. This involves educating patients about the role of CLSE in maintaining the eating disorder and contributing to other difficulties in their life. Patients are helped to identify and modify the main cognitive maintaining processes, including discounting positive qualities and the overgeneralization of apparent failures. Previous views of the self are reappraised, using both cognitive restructuring and behavioral experiments, to help patients to reach a more balanced view of their self-worth.

Addressing interpersonal problems

Interpersonal problems are common among patients with eating disorders, although they generally improve as the eating disorder resolves. Such problems may include conflict with others and difficulties developing close relationships. If these problems, and the resulting effects on mood, directly influence the patient's eating, they may be addressed through the use of proactive problem solving and functional mood modulation and acceptance (as described earlier). However, in some cases interpersonal problems powerfully maintain the eating disorder through a variety of direct and indirect processes or they interfere with treatment itself. Under these circumstances, they need to become a focus of treatment in their own right.

The strategy used in CBT-E is to use a different psychological treatment to achieve interpersonal change, namely Interpersonal Psychotherapy (IPT). This is an evidence-based treatment that helps patients identify and address current interpersonal problems. In style and content IPT is very different from CBT-E. For this reason it is not “integrated” with CBT-E as such: rather, each session has a CBT-E component and an IPT one. More detailed information about IPT and its use with patients with eating disorders is available in a recent book chapter. 34

Stage four, the final stage in treatment, is concerned with ending treatment well. The focus is on maintaining the progress that has already been made and reducing the risk of relapse. Typically there are 3 appointments about 2 weeks apart. During this stage, as part of their preparation for the ending of treatment, patients discontinue self-monitoring and begin weekly weighing at home.

To maximize the chances that progress is maintained, the therapist and patient jointly devise a personalized plan for the following few months until a posttreatment review appointment (usually about 20 weeks later). Typically this includes further work on body checking, food avoidance, and perhaps further practice at problem solving. In addition, patients are encouraged to continue their efforts to develop new interests and activities.

There are 2 elements to minimizing the risk of relapse. First, patients need to have realistic expectations regarding the future. Expecting never to experience any eating difficulties again makes patients vulnerable to relapse because it encourages a negative reaction to even minor setbacks. Instead, patients should view their eating problem as an Achilles heel. The goal is that patients identify setbacks as early as possible, view them as a “lapse” rather than a “relapse,” and actively address them using strategies that they learned during treatment.

Underweight patients

The strategies and procedures described so far are also relevant to patients who are underweight (mostly cases of anorexia nervosa but some cases of eating disorder NOS). However, CBT-E has to be modified to address certain characteristics of these patients.

The first priority is to address motivation, as often these patients do not view undereating or being underweight as a problem. This may be done in several ways and relies on a good therapeutic alliance. The patient is provided with a personalized education about the psychological and physical effects of being underweight. This helps them to understand that some of the things that they find difficult (eg, being obsessive and indecisive, being unable to be spontaneous, being socially avoidant, lacking sexual appetite) are a direct consequence of being a low weight rather than being a reflection of their true personality. The patient is helped to think through the advantages and disadvantages of change, including a consideration of how things are likely to be in the future if they choose not to change and how this would fit with their aspirations. The therapist shows intense interest in the patient as a person, beyond the eating disorder, and helps them to reflect on the state of all aspects of their life, including their relationships, their physical and psychological well-being, their work, and their personal values. The patient is encouraged to experiment with making changes to learn more about the pros and cons of their current behavior. The goal is for patients themselves to decide to regain weight rather than this decision being imposed by the therapist. If this is successful, it greatly assists subsequent weight regain.

Second, the undereating and the consequent state of starvation must be addressed. It is important to help patients to realize that undereating, and being underweight maintain the eating disorder and this is illustrated in a personalized formulation. Once the patient has agreed to regain weight it is explained that weight regain should be gradual and steady and that they should aim to maintain an average energy surplus of 500 calories each day to regain an average of 0.5 kg (1.1 lb) per week. The therapist helps the patient to devise and implement a daily plan of eating (which may be supplemented by energy-rich drinks) that meets this target.

Treatment needs to be extended from the typical 20 weeks to about 40 weeks to allow sufficient time for patients to decide to change, to reach a healthy weight, and then practice maintaining it. It can be helpful to involve others in the weight-gain process to facilitate the patient's own efforts. This is especially so with young patients who are living at home with their parents.

Final comments

Hopefully it will be clear from this brief account of CBT for eating disorders that major advances have been made and are continuing to be made. Perhaps most prominent among these is the adoption of a transdiagnostic approach to treatment whereby treatment is no longer for a specific eating disorder (eg, bulimia nervosa) but is directed at eating disorder psychopathology and the processes that maintains it. As a result, an empirically supported treatment approach has evolved that is suitable for all forms of eating disorder and one that is highly individualized.

Many challenges remain. First and foremost, treatment outcome needs to be further improved, especially in the case of patients who are substantially underweight. Second, understanding more about the way in which treatment works, and the active ingredients of treatment, could inform the design of a more potent version. Doubtless some elements could be discarded whereas others may need to be enhanced. 35 We need treatments that are effective and efficient. Last, we need to facilitate the dissemination of evidence-based practice. Many patients receive suboptimal treatment. There are several possible reasons for this but prominent among them is the fact that few therapists have received the necessary training.

C.G.F. is supported by a Principal Research Fellowship from the Wellcome Trust (046386). R.M., S.S., and Z.C. are supported by a program grant from the Wellcome Trust (046386).

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    New York: Guilford Press; 2020. F2.1 - CBT-E map for adolescents with eating disorders F2.2 - The four levels of care of multistep CBT-E for adolescents with eating disorders T3.1 - Topics to be addressed when assessing the nature and severity of the eating disorder T3.2 - Main points made when describing CBT-E to the young underweight patients

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    Enhanced cognitive behavioral therapy (CBT-E) has been described and put to the test as a transdiagnostic treatment protocol for all EDs, including EDNOS. Initial research in the UK suggests that CBT-E is more effective for EDs, especially bulimia nervosa (BN) and EDNOS, than the earlier version of CBT.

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    The eating disorders provide one of the strongest indications for cognitive behavioral therapy (CBT). Two considerations support this claim. First, the core psychopathology of eating disorders, the overevaluation of shape and weight, is cognitive in nature. Second, it is widely accepted that CBT is the treatment of choice for bulimia nervosa 1 ...

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