Demystifying Eating Disorder Therapy
CBT, CBT-E, DBT… Have you ever wondered what all those letters stand for and why they are so often talked about at The Emily Program and by other eating disorder professionals? If so, this is the post for you. Let’s dissect these terms, help you understand them, and explain why they are important to the work clients and clinicians do every day.
Cognitive Behavioral Therapy (CBT)
“By correcting erroneous beliefs we can lower excessive reactions.” – Aaron Beck, MD
Cognitive behavioral therapy (CBT) was developed by Dr. Aaron Beck in the 1960s. His work focused on how the conscious mind plays a role in how people interact with the world around them. Prior to his work, most therapeutic models focused on the unconscious mind—concepts like impulses, analyzing unconscious thoughts, conditioning, and “uncontrollable thoughts.” Dr. Beck changed mental health by introducing the belief that our thoughts are fundamental to how we interpret our experiences and consequently behave or respond. Dr. Beck and many other researchers have discovered that by identifying, monitoring, and effectively changing our thoughts, we can change or alter our maladaptive perceptions, leading to positive behavioral change.
So, how does it work? The fundamental premise of CBT is simple: Our thoughts have a direct and influential relationship with our emotions and our behaviors. In treatment, a client reports their beliefs, feelings, and behaviors to the therapist. These thoughts, sometimes referred to as “schemas,” underlie the way the person understands and manages experiences every day. Often these schemas are not obvious and are referred to as “automatic thoughts.” These automatic thoughts require the client to focus their awareness on them to ultimately change the maladaptive thoughts to healthy and effective thoughts. In therapy, these thoughts are identified and explored, and the focus to change the thoughts is at the forefront of discussion. A very classic example: A client believes “I am a bad/not a good person” (schema) and their response (behaviors and emotions) to this thought results in social withdrawal, isolation, sadness, and low self-esteem. As a result, if this person receives a compliment (or other narrative discrepant to their thinking), they are likely to dismiss it as untrue, which then perpetuates the negative thinking.
This leads us to another primary concept in CBT, “cognitive distortions” or “distorted thinking.” Distortions in our beliefs often change a person’s normal (rational) perceptions and create irrational and inflexible beliefs (schemas). These distorted thoughts (schemas) can be extreme and result in negative and unforgiving self-criticism. This chain of events leads to more distorted thoughts, creating a pattern. CBT therapists work with clients to reduce thoughts/beliefs that are framed as absolutes, such as “always,” “never,” or “every.” Thinking in absolutes leads to all-or-nothing thinking. This all-or-nothing thinking continues to increase distorted thoughts that fit the negative schema or thought (e.g., “I always fail” or “I am always wrong”).
So, in sum, CBT focuses on how our thoughts (schemas) impact our emotions and cause behavior. Relating it to eating disorders, therapists look specifically at schemas related to a client’s relationship with food and the associated emotions and behaviors. Emily Program therapists use these principles every day in their work with clients. CBT has been researched extensively, leading us to recognize it as an evidence-based treatment for many mental health disorders, including eating disorders and many co-occurring conditions. Research has also advanced CBT specifically for eating disorders in an approach called CBT-E.
Enhanced Cognitive Behavioral Therapy for Eating Disorders (CBT-E)
“Eating disorders are essentially cognitive disorders.” – Christopher G. Fairburn, DM
Christopher Fairburn, DM, a primary researcher of CBT-E, writes, “The root of eating disordered psychopathology lies in the over-evaluation of the body, perfectionistic standards, and the idea of control.” Dr. Fairburn has written extensively on the ways in which the concepts of cognitive behavioral therapy match with eating disorder treatment.
CBT-E uses specific strategies to target symptoms associated with eating disorders. These strategies are outlined in Dr. Fairburn’s text, Cognitive Behavioral Therapy and Eating Disorders (2008). In this text, Fairburn categorizes eating disorders as “transdiagnostic,” meaning that eating disorder diagnoses have symptoms that tend to overlap. CBT-E is considered a transdiagnostic treatment meant to address the underlying mechanisms that maintain all eating disorders.
The primary goal of the CBT-E therapist is to keep the patient engaged in treatment and to maintain a positive and effective therapeutic relationship. The relationship between the therapist and client is essential. The therapist and client collaborate, actively evaluate, and work toward understanding the relationship between a client’s eating disordered schemas, emotions, and behaviors. A fundamental element of CBT-E is identifying the processes that maintain the eating disorder psychopathology. Many individuals with an eating disorder tend to be concerned with their weight and body image. Individuals then tend to develop a schema filled with negative self-judgments and critical self-evaluations. These negative body image schemas are repeated frequently and are likely to become automatic, thereby maintaining the eating disorder and increasing symptom severity.
CBT-E Treatment and the Next Steps
Much like in CBT, CBT-E starts by identifying the client’s cognitive schemas (thoughts) that are sustaining the eating disorder and then implementing interventions that successfully produce behavior change. This first phase of treatment is very collaborative between the client and the therapist who work together to develop a plan and often create a visual diagram. Many clients find that this process allows them to visually observe what is sustaining their symptoms and behaviors, and the illustration helps them to separate from their eating disorder.
The next phase of treatment incorporates the behavioral strategies mutually agreed upon earlier by the client and therapist. Monitoring of symptoms, urges, and emotions is a focus. Client participation in self-monitoring is key in treatment and can negatively or positively impact treatment outcomes. Self-monitoring records, often seen as homework for clients, increase client awareness and can be discussed and reviewed in therapy sessions. This homework and the review of it is also a key component of both CBT and CBT-E. The final phase of CBT-E includes termination where the focus is on relapse prevention planning, review of client progress, and discussion about future obstacles in recovery.
Dialectical Behavioral Therapy (DBT)
In the late 1980s, Dr. Marsha Linehan developed DBT as a modified form of CBT to treat people with borderline personality disorder and chronic suicidality. DBT focuses on psychosocial aspects of therapy, emphasizing the importance of a collaborative relationship, client support, and the development of skills for managing emotional situations. Since the inception of DBT, research has demonstrated its effectiveness in treating several mental health conditions, including but not limited to eating disorders. DBT treatment focuses on mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation.
You might be asking: How is CBT different than DBT? There are several distinctions and differences, but put simply, DBT is based on an affect-regulation model instead of a cognitive one. Eating disorder symptoms are thought of and understood to be mechanisms to cope with emotional vulnerability, as opposed to problems in cognition or poor interpersonal relationships.
DBT has four areas of focus: mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness. Mindfulness is considered a foundation for the other skills taught in DBT; it helps individuals accept and tolerate the emotions they may feel when challenging the ways that they have typically responded to situations. Distress tolerance skills focus on the ability to accept, in a non-evaluative and nonjudgmental fashion, oneself and situations encountered. The goal of distress tolerance is to learn how to calmly recognize negative situations and their impact. Emotional regulation skills are based on the idea that intense emotions are a learned response to difficult or unpleasant experiences. Emotional regulation skills are taught in four modules: understanding and naming emotions, changing unwanted emotions, reducing vulnerability, and managing extreme conditions. Interpersonal effectiveness skills taught in DBT skills training are very similar to those taught in many interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.
You might wonder: Why all these different approaches? Well, just like in life, we all respond differently and have different preferences in learning and in making change. Not all situations are appropriate for comprehensive CBT, CBT-E, or DBT. Some clients respond well to one modality and less well to others. We need to be able to approach all people uniquely, fitting treatment to the individual instead of the individual to the treatment.
All of the therapeutic approaches discussed here have shown to be highly effective in helping people with eating disorders. The skills that are designed in each of these approaches are taught in all levels of care, including residential, partial hospitalization/intensive day program, and intensive outpatient. They are then carried forward into outpatient programming when clients discharge from higher levels of care.
Regardless of modality, it is important to seek professional help and treatment if you or a loved one is experiencing eating disordered symptoms. Eating disorders are very serious illnesses and are among the highest in mortality rates across all mental health. Compassion, growth, and collaboration between a therapist and the patient are elemental in eating disorder treatment.
Fairburn, C.G. (2008). Cognitive behavioral therapy and eating disorders. New York, NY: The Guilford Press.
ABOUT THE AUTHOR
Krista Crotty, LMFT, PsyD
Krista is the National Director of Brain-Based Therapies and a Clinical Education Specialist. Clinically she draws from a variety of methods, including TBT-S, EMDR, cognitive behavioral therapy (CBT), FBT, and acceptance and commitment therapy (ACT), and often incorporates the use of the creative process in conjunction with the more traditional therapeutic process. She earned her Masters of Science from Fuller Theological Seminary, School of Psychology and her Doctorate in Clinical Psychology with an emphasis in family and pediatrics from Azusa Pacific University. She trained at Harbor UCLA Medical Center and Loma Linda Children’s Hospital in neuropsych. Away from work, Krista loves being a mom to her three boys, playing outside, going on adventures with her family, skiing, hiking, biking, and camping.