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Enhanced Cognitive-Behavioral Therapy

CBT-E is structured and time limited, as is its precursor, CBT-BN, although it is more flexible and individualized. Treatment targets the mechanisms that maintain the ED, which are identified at treatment outset by an individualized case formulation of the client's specific ED behaviors and cognitions.

What follows is a brief outline of CBT-E, highlighting the central features of the treatment. It is, however, only an overview, and the reader is encouraged to study the detailed descriptions of CBT-E in one of two books: the treatment guide written by its developer (Fairburn, 2008) and a treatment guide on a similar version of transdiagnostic CBT (Waller et al., 2007). The version of CBT-E described here is the focused version, which has two recommended lengths, short and long. The short course is for individuals who are not underweight and involves approximately 20 sessions over 20 weeks, with the first 8 sessions held twice a week, the next 10 weekly, and the last 3 held every other week. The long course is for those with a BMI of 17.5 or less and involves approximately 40 sessions over 40 weeks. Sessions are held twice a week until patients are consistently gaining weight and then transition to weekly, moving to fortnightly toward the end of weight regain, then to once every 3 weeks toward the end of treatment.

Assessment Therapeutic Alliance and Orientation to Treatment

The assessment procedure usually takes two sessions. The main goal of assessment is to build a positive therapeutic relationship to create a firm foundation for treatment. Counselors achieve this relationship by expressing genuine curiosity about the client's current life, dreams, and fears; interest in helping him or her; instillation of hope; and validation of ambivalence, if present. When working with EDs, this stance is particularly important, because successful treatment involves clients giving up highly valued behaviors and beliefs. Although most clients with an ED will recognize some negative aspects of their condition (often binge eating or excessive preoccupation with controlling food, shape, and weight), they tend to believe that restriction or compensatory behaviors are vital to avoid gaining weight and becoming โ€œfat,โ€ thus they fear giving up these behaviors. The high drop-out rate, especially among clients with AN, reflects this fear of change. Acknowledging and validating the valued aspects of clients' EDs are crucial to building rapport, in that a shared understanding is developed and the counselor can work on increasing clients' motivation and courage to change. Clients will be encouraged to move outside their comfort zone in the short term to benefit in the long term by being free of an ED.

The counselor's stance should balance empathy with firmness (Fairburn, 2008; Vitousek, Watson, & Wilson, 1998). Our experience has been that clinicians new to the field of EDs or CBT-E are reluctant to be firm, fearing driving clients away. With the experience of being firm, they realize the importance and benefits. Moreover, therapeutic alliance is high in CBT for EDs when firmness is balanced with empathy (Waller, Evans, & Stringer, 2012), an example of which is the introduction of self-monitoring. The counselor's empathic understanding of how hard it might be to undertake needs to be balanced with a firm expectation of task completion.

Counselors should convey several essential points to clients about what to expect from treatment. CBT-E focuses on the present and the factors currently maintaining the ED cycle. CBT-E is a collaborative therapy, and it is especially suited to work with EDs because it encourages working together openly in a nonjudgmental way that involves clients in all aspects of treatment. It is a very active treatment, with an expectation of between-session work, such as self-monitoring and experimenting with new behaviors (e.g., trying out previously avoided foods). Therapy can be described as a marathon, with the client as the runner; the counselor as the coach, offering strategies and advice; and family and friends as cheerleaders, offering encouragement. The client has to do the hardest work to cross the finish line. Our experience has been that being honest up front about the hard work involved and the commitment of support builds trust and rapport.

It is vital that the counselor convey respect and understanding that change may be highly anxiety provoking, but equally critical that the counselor establish that treatment focuses on change. Establishing nonnegotiable aspects of treatment is important, for example, that the general goal of CBT-E is to normalize eating and reduce ED behaviors. Target behaviors differ among clients but commonly include restricting, binge eating, purging, and excessively exercising. Weight changes may occur; regain in those who are underweight through restriction and loss in those who binge eat without compensatory behaviors. Although weight regain is an overt goal for underweight clients, weight loss should never be a goal in treatment. It is important to ask clients in or above the healthy weight range if they are willing to put weight loss on hold for the duration of treatment (i.e., about 5 months) and give their best effort to overcoming their ED. They should be informed that actively seeking weight loss will interfere with ED treatment and that at the end of treatment, if they are still unhappy with their weight and want to lose weight, they are free to do so and the counselor will facilitate a referral to a registered dietitian with experience in EDs. Our experience has been that very few clients end therapy with this goal; they come to realize that their efforts at weight loss were counterproductive and develop more acceptance of their weight.

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