Adaptations for Clinical Groups and Settings

CBT-E has been adapted for use in different clinical settings:

  1. Outpatient Adult
  2. Outpatient Adolescent
  3. Intensive Outpatient
  4. Inpatient
Outpatient CBT-E for Adults

The outpatient version is recommended for most adult patients with eating disorders. As evaluated in research trials, CBT-E is a time-limited treatment (i.e. 20 weeks in non-underweight patients; 40 weeks in underweight patients). In some cases the treatment needs to be shortened, for example in patients with binge-eating disorder, if the binge eating rapidly ceases and there is little other psychopathology to address. More often there is a case for extending treatment; examples include when the treatment has been disrupted (e.g. by the development of clinical depression or an interpersonal crisis); when a patient benefits from the treatment but is still significantly impaired; experiencing a setback not long after the treatment has finished. Under these circumstances, the treatment should be continued for some additional months with a detailed review of progress every four weeks to ensure continuation is justified.

Outpatient CBT-E for Adolescents

CBT-E has been adapted for adolescents taking into account two distinctive characteristics, namely physical health and parental involvement. Indeed, some medical complications associated with eating disorders (e.g. osteopenia and osteoporosis) are particularly severe in this age range, therefore periodical medical assessments and a lower threshold for hospital admission are integral parts of CBT-E for adolescents. The treatment lasts 20 weeks in non-underweight patients, and about 40 weeks in underweight patients. As in the adult version of CBT-E, it can be delivered in the focused or broad form with this age group.

Parental involvement in the treatment is required in the great majority of cases. They are asked to participate alone in an interview lasting approximately 90 minutes during the first week of the treatment. Subsequently, the patient and parents are seen together in sessions four to six (in patients who are not underweight) or sessions eight to ten (in patients who are underweight). Further, 15–20 minutes sessions are held immediately after the patient’s individual session.

Intensive Outpatient CBT-E

The treatment is designed for patients who may need greater input than outpatient CBT-E can provide, but whose condition is not sufficiently severe to warrant hospitalisation. This form of treatment uses all of the procedures and strategies of outpatient CBT-E, but also includes several features developed specifically for this new approach.

Intensive treatment lasts for a maximum of 12 weeks, but may be shorter if patients successfully make progress in the areas in which they were struggling with outpatient CBT-E (e.g. lack of progress in weight regain; reducing binge eating; regular meals). The treatment can be flexibly adapted to both the clinical needs of the patient and the logistical characteristics of the clinical service that delivers the treatment. However, the optimal treatment in our view should include the following procedures on weekdays: (i) supervised daily meals; (ii) individual CBT-E twice weekly; (iii) sessions with a CBT-E trained dietitian to plan and review weekend meals; and (iv) regular reviews with a CBT-E trained physician. Towards the end of intensive treatment, patients who have responded well are gradually encouraged to eat meals outside the unit, thereby allowing the treatment to evolve into conventional outpatient CBT-E.

Inpatient CBT-E

Inpatient CBT-E is designed to ensure a unified, rather than varied, approach to the patient’s treatment. The program maintains all the main strategies and procedures of CBT-E, which are delivered in both individual sessions and in a group format, but with three main features that distinguish it from the outpatient-based version. First, the treatment is delivered by a non-eclectic multidisciplinary team, comprising physicians, psychologists, dieticians, and nurses, all fully trained in CBT-E. Second, assistance with eating is provided in the first weeks of treatment to help patients overcome their difficulties in real time. Third, the adolescent patients continue their course of study during the hospitalisation. Inpatient CBT-E also includes additional elements designed to reduce the high rate of relapse that typically follows discharge from hospital. For instance, the inpatient unit should be open, and patients are free to go outside. In this way, they continue to be exposed to the types of environmental stimuli that tend to provoke their eating disorder psychopathology, but with full access to staff support. Furthermore, during the weeks immediately preceding discharge, a concerted effort is made to identify likely environmental setback triggers, which are then addressed during the individual CBT-E sessions. Moreover, towards the end of treatment, parents are helped to create a positive, stress-free home environment in readiness for the patient’s return.

Further Reading:

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). Philadelphia: Elsevier.

Dalle Grave, R., El Ghoch, M., Sartirana, M., & Calugi, S. (2016). Cognitive Behavioral Therapy for Anorexia Nervosa: An Update. Current Psychiatry Reports, 18(1), 2. doi:10.1007/s11920-015-0643-4.

Dalle Grave, R. (2013). Multistep cognitive behavioral therapy for eating disorders: Theory, practice, and clinical cases. New York: Jason Aronson.

Fairburn, C. G. Cognitive Behavior Therapy and Eating Disorders. New York: Guilford Press, 2008.