A Primer on CBT for Eating Disorders

Cognitive behavior therapy (CBT) is, as we’ve previously described, a well-studied psychotherapy and it’s often the first type of treatment recommended for adults and teens with bulimia nervosa and binge-eating disorder.

CBT to address binge-eating disorder and bulimia nervosa has a lot of research support. CBT consistently helps people to reduce or completely stop binge eating (and purging, if relevant) and, in several studies comparing it to other types of talk therapy, to get results more rapidly. While there are medications that can also be used to treat bulimia nervosa and binge-eating disorder, CBT has been shown to be more effective than medication alone.  

In CBT for eating disorders, the CBT model that thoughts, actions, and feelings are interconnected, is applied to the themes of eating and body shape and weight concern (and related behaviors). Importantly, CBT is not designed for weight loss, although some patients experience weight stabilization; rather, it is designed to help people normalize their eating pattern and address problematic thought patterns and behaviors related to eating, exercise, and body image.

At the beginning of treatment, the therapist and patient work together to understand the connections between an individual’s symptoms and to create a road map for treatment.

The road map is less about the origins of the eating disorder and more about the current, problematic cycle. The CBT model of eating disorders suggests that low self-esteem lays the foundation for body shape and weight becoming overly important (in order to feel better). These beliefs lead to behaviors designed for weight loss, like strict rules about what and when to eat, which in turn sets the stage for a cycle of restriction, binge eating, and sometimes purging. The model – and the CBT roadmap for addressing the cycle – are depicted below.

Putting the Road Map to Use

The CBT diagram – especially when it is personalized to the individual – illustrates the cycle that needs to be broken for recovery to occur. Even though beliefs and feelings about oneself often ignite the cycle, in CBT, the therapist and patient work together to systematically interrupt the cycle, typically starting with behaviors and then addressing thoughts as needed. Here are some examples of how this occurs:

Ways of Working on Behaviors (the “B” in CBT)

• Introducing and practicing “regular eating” (defined as 3 meals + snacks, at typical times) is used to interrupt the cycle between restriction and overeating
• Tracking (also called “self-monitoring”)– in written or electronic form – is used to increase awareness of behaviors (and thoughts and feelings) and to evaluate experiments
• Reintroducing feared foods in moderation and with careful planning
• Identifying and practicing strategies for coping with urges to binge eat or purge
• Planning to face difficult situations head-on, such as eating in a group, wearing previously-avoided clothing, or exercising in moderation
• Learning to tolerate having information about weight without frequently checking or avoiding the scale
• Analyzing setbacks using behavior chains to evaluate moment-to-moment triggers of specific eating disorder symptoms, such as an episode of fasting or bingeing, and brainstorm alternative, healthy coping options

Behavioral change is hard and in CBT, it’s accomplished by joining forces with your therapist who is there to provide guidance and support.

Ways of Working on Cognitions (the “C” in CBT)

• Increasing awareness of “automatic thoughts,” defined as beliefs that operate just under the surface of our awareness, but which greatly affect our behavior and feelings
• Labeling “thought traps” such as fortune telling (i.e., “If I don’t lose weight, no one will want to date me”) or all-or-nothing thinking (i.e., “I had one cookie so I might as well eat the whole package”). For more examples, see our posts on common problematic thoughts about foods and body shape and size.
• Collecting and reviewing evidence for and against a thought to evaluate how “true” it is and practicing trying on alternative perspectives (See this related post.)
• Paying attention to biases in thinking, such as the tendency to interpret neutral information as negative
• Refining key strategies to gradually respond to unhelpful thoughts with rational responses

In addition to the cognitive and behavioral interventions described above, patients commonly work with their CBT therapist on identifying and staying connected to motivators for change. People also learn the steps of problem-solving, including how to develop and evaluate potential new solutions to challenges in recovery to prevent relapse. Finally, as the end of treatment is approached, time is spent considering how to maintain and continue to make progress.

At the New York State Psychiatric Institute, CBT for eating disorders is one of the evidence-based outpatient treatments we offer at no cost to teens and adults as part of our clinical research program. If you are interested in participating in research and/or receiving treatment for an eating disorder, check out more information about our clinic.

Additional Resources

• For patients and families: Overcoming Binge Eating by Dr. Christopher Fairburn; Beating Your Eating Disorder by Dr. Glenn Waller
• For clinicians: Cognitive Behavior Therapy and Eating Disorders by Dr. Christopher Fairburn; Cognitive Behavior Therapy for Adolescents with Eating Disorders by Drs. Riccardo Dalle Grave and Simona Calugi

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