Why we don’t deliver the most popular eating disorder therapy

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Cognitive Behaviour Therapy Enhanced (CBT-E) is an outpatient CBT treatment designed to treat adults with eating disorders. It is currently the most popular form of eating disorder treatment in Australia for adults and is generally the first therapy a psychologist will learn if wanting to work with eating disorders. Before exploring the reasons why we don't deliver CBT-E at Exhale, let's first take a look at what CBT-E is and who it helps.

Cognitive Behavioural Therapy - Enhanced for Eating Disorders

CBT-E is a structured and time limited therapy that involves an initial assessment session, followed by 20 treatment sessions across 20 weeks. Treatment length is sometimes modified due to the individuals presentation and needs.

CBT-E uses cognitive and behaviour therapy techniques with the aim to assist individuals to develop healthy coping skills and reduce eating disorder behaviours. It involves:

• Developing an understanding of the development and maintenance of the eating disorder
• Developing a formulation
• Addressing the topics of mood, body image concerns, dietary restraint, and triggering events
• Maintaining changes
• Managing Setbacks
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The key features of CBT-E are:

• A detailed daily food diary kept in real time (not written up later)
• Weekly weigh-ins at the beginning of each session where the weight is plotted on a graph
• From early on working towards eating regular meals and snacks (and refraining from eating in-between meals and snacks)
• Using CBT strategies to reduce compensatory behaviours
• Using CBT strategies to reduce body checking

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How was CBT-E developed?

CBT-E was developed in the across the 1970s and 1980s by Christopher Fairburn and his colleagues at the Centre for Research on Eating Disorders Oxford. It adapts and expands CBT strategies to specifically target eating disorders and their maintaining cognition and behaviours. CBT-E was initially developed for Bulimia Nervosa (CBT-BN), and then adapted for all eating disorders.

‍CBT-E is Transdiagnostic‍

In the medical model, different types of eating disorders (such as Bulimia Nervosa, Binge Eating disorder etc.) are viewed as distinct conditions with each requiring its own form of treatment.

In contrast, CBT-E holds a transdiagnostic view of eating disorders. This means, it views the processes that maintain:

• Otherwise Specified Feeding and Eating Disorder (OSFED)
• Anorexia Nervosa (AN)
• Bulimia Nervosa (BN)
• Binge Eating Disorder (BED)

as largely the same. Consequently, the treatment is the same (with minor modifications) regardless of the diagnosis.

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Exhale Psychology Centre and the Transdiagnostic View

At Exhale Psychology Centre, we hold the transdiagnostic view of eating disorders, focusing on treating the presenting issues eg. Urges to restrict, purging etc, rather than focusing on the specific eating disorder diagnosis.

That said, we recognise that some eating disorders can be quite different in nature and require a different approach, such as with Avoidant/Restrictive Food Intake Disorder (ARFID).

Who does Cognitive Behaviour Therapy-Enhanced help?

CBT-E is an extremely well researched therapy, and has shown to be particularly effective for treating adolescents (1). Individuals receiving CBT-E report significant improvements by session 18, and these improvements tend to be maintained. Around 45% of people make a full recovery with just 18 sessions of CBT-E (2). This is extremely significant given the insidious nature of eating disorders.

People who received CBT-E for bulimia have reported significant reductions in depression and anxiety symptoms, and report profound improvements in their quality of life (3).

CBT-E Limitations

Although CBT-E is viewed as the gold standard treatment for eating disorders, it does not work for everyone. Around 50% of people do not recover after receiving CBT-E, some show no improvements, and roughly 25% if people drop out early due to dissatisfaction (4).

CBT-E does not target serious comorbities that can maintain eating disorders, such as treatment-resistant depression, trauma, etc. At present, there is not adequate evidence to demonstrate that individuals with complex presentations benefit from CBT-E. Individuals with serious comorbidities tend to be excluded from research studies (due to the complex variables) and when they are included dropout rates are high and outcomes are poor (5).

Part of the foundation of CBT-E is the view that the majority of difficulties for individuals will resolve when they weight restore/ their eating disorder behaviours reduce/ their intake stabilises. Unfortunately, this is not the case for individuals with multiple comorbidities in which the eating disorders appears to be a dysfunctional coping strategy (rather than the core psychopathology).

^{Why we don’t offer CBT-E at Exhale Psychology Centre}

There are five key reasons why we don't offer CBT-E at Exhale;

1. Almost all eating disorder psychology practices in Australia primarily deliver CBT-E. While CBT-E can be extremely beneficial to some individuals, our practice was set up, in part, to help the people that are not a fit for CBT-E or have found CBT-E to be unsuccessful for them
2. CBT-E has shown to be unhelpful for clients with complex comorbidities (the population group we aim to treat)
3. Clients that are pre-contemplative (are not ready to change) are generally excluded from CBT-E research so there is no evidence to show it is helpful for these clients
4. We value offering personalised treatment (eg. if the person is in crisis we value being able to put aside the long-term work to focus on crisis management, address a relationship conflict etc) whereas manualised treatments are not designed for/intended to be delivered in this way
5. We strongly value delivering neuroaffirming therapies. The inflexibility of manualised treatments such as CBT-E have been widely criticised by the neurodivergent community as non-inclusive and non-affirming

Another key reason we do not deliver CBT-E (and other weight focused therapies such as the Maudsley Method) is that we firmly believe that full eating disorder recovery is possible without ever knowing your weight or doing weight exposures. Being a size inclusive practice, we have a strong preference for delivering non-weight focused eating disorder treatment. Weight focused therapies were developed based on the following assumptions:

• People with eating disorders are underweight
• Regular weighing (exposure therapy) will reduce clients preoccupation with their weight. While this is true for some, many report that it actually enhances it
• Close self-monitoring of food intake will reduce a client's preoccupation with their intake. Again, while this can be true for some, many clients are already doing this and report that the hours spent tracking food is part of their eating disorder
• Exposure therapy strategies such as weighing clients following eating fear foods will ‘prove’ that they won’t gain weight overnight. We feel that this reflects and perpetuates the medicalised fat phobic mentality that fear foods are acceptable only if they do not result in weight gain. It also assumes that the clients weight won't be higher. Given the significant weight fluctations that can occur based on fluid intake and retention, bowel movements, hormones, menstrual cycle etc, the results of these 'experiments' can be distrastrous
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Unfortunately, many of our clients have been told things such as “don’t worry, we won’t let you get fat” in the context of weight exposure therapy. 

Our concerns with weight-focused treatment is that:

• ‍‍Less than 6% of people with eating disorders are underweight
• The vast majority of individuals with Anorexia Nervosa (restrictive based eating disorder) are not underweight
• Many of our clients struggle with weight gain that does not reflect their intake due to chronic health issues or a metabolism that has adapted to chronic dieting
• Many of our clients weight themselves excessively and reported that the regular weighing does not lead to decreased anxiety but instead has maintained pre-occupation

It is also worth noting that in many CBT-E studies, the primary outcome measure (how they tell that the therapy has “worked”) is that the client has hit and maintained the weight target of BMI 20. While there is no doubt that being underweight is an indicator of malnourishment, being a BMI of 20 and above is not an indicator of adequate nourishment or of mental health. This outcome measure is also not useful or appropriate for individuals with eating disorders who are not underweight.

We are supportive of clients who would like to be weighed periodically for exposure therapy purposes, but we do not support weighing clients who do not wish to be weighed.

One caveat is that in cases of severe malnourishment, weight monitoring is sometimes medically required. In these cases, we believe blind weighs by a medical professional (eg. GP) is best, with the client facing away from the scales and not having their weight commented on.

If not CBT-E, then what?

We offer the following eating disorder treatments, which are all non-weight focused, size inclusive, trauma-informed, and neuroaffirming;

• Specialist Supportive Clinical Management (SSCM)
• Focal Psychodynamic Therapy for Eating Disorders
• Dialectical Behaviour Therapy for Eating Disorders
• Schema Therapy

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1. Grave, R.D., Conti, M., Sartirana, M., Sermattei, S., & Calugi, S. (2021). Enhanced Cognitive Behaviour Therapy for Adolescents with eating Disorders: A Systematic Review of Current Status and Future Perspectives. Italian Journal of Eating Disorders and Obesity.

2. Fairburn, A (2015). A Transdiagnostic Comparison of Enhanced Cognitive Behaviour Therapy (CBT-E) and Interpersonal Psychotherapy in the Treatment of Eating Disorders. Behaviour Research and Therapy 70, 64-71.

3. Wonderlich, S.A., Peterson, C.B., Crosby R.D., Smith, T.L., Klein, M.H., Mitchell, J. E., & Crow, S. J. (2014). A Randomized Controlled Comparison of Integrative Cognitive-Affective Therapy (ICAT) and Enhanced Cognitive-Behavioural Therapy (CBT-E) for Bulimia Nervosa. Psychological Medicine, 44, 543-553.‍

4. Linardon, J., Hindle, A., & Brennan, L. (2018). Dropout from Cognitive-Behavioral Therapy for Eating Disorders: A Meta-Analysis of Randomized, Controlled Trials. International Journal of Eating Disorders, 51, 381-391.

5. Kessler, U., Kleppe, M.M., Rekkedal, G.A., Ro, O., & Danielsen, Y. (2022). Experiences When Implementing Enhanced Cognitive Behavioural Therapy as a Standard Treatment for Anorexia Nervosa in Outpatient at a Public Specialised Eating-Disorder Treatment Unit. Journal of Eating Disorders, 10:15.