Cognitive Behavioral Therapy
CBT May Be Problematic for the Treatment of Eating Disorders
Let’s consider neurodivergence.
Posted January 30, 2023 | Reviewed by Ekua Hagan
- An enhanced version of cognitive behavioral therapy, CBT-E, specifically treats eating disorders but assumes the patient is neurotypical.
- Seeing eating disorders as only cognitive-based fails to explore the possible interaction of lived experiences.
- A neurodivergent individual may not benefit from focusing heavily on the thoughts pertaining to their eating disorder.
Cognitive behavioral therapy (CBT) is the most commonly recommended course of treatment for eating disorders—so much so that CBT has its own enhanced version specific to the treatment of eating disorders called CBT-E. However, CBT-E’s approach was created from the assumption that the person undergoing treatment was neurotypical, or not displaying any signs of neurodivergence.
There is a great deal of research beginning to explore the link between neurodivergence and eating disorders. A key piece in assisting neurodivergent individuals with their mental health recovery is building understanding, validation, and care surrounding their unique differences. However, CBT-E’s techniques may require a neurodivergent individual to conform to a neurotypical way of functioning in order to see successful results.
Why Does the Research Point to CBT?
Almost all the research studies on treatment approaches for eating disorders point toward cognitive behavioral therapy as the leading intervention. Why is that? Well, this could be for several different reasons, some of which include:
- The majority of research for eating disorders is done within institutions, such as university-funded programs, community centers, treatment facilities, or hospitals—basically, any place equipped with the money and structure to undergo research. The research funding is given to programs that are able to be translated into data. CBT is a very structured and manualized treatment option, which pairs well with receiving funding for research.
- There has been a widely accepted belief within the mental health profession that eating disorders are thought disorders—meaning, eating disorders are fueled by the thoughts and perceptions surrounding food, body image, and self-image. CBT is a cognitive-based therapeutic intervention that looks at the interaction between thoughts, emotions, and behaviors. However, seeing eating disorders as only cognitive-based disorders fails to explore the possible interaction of lived experiences—such as sensory sensitivities or traumatic histories—and a person’s physical experience of their body and food.
- There is a discrepancy between the researchers and the practitioners. After all, the research derives from organizations conducting studies, whereas many practitioners are treating individuals in their private practices. These individual practices may be using different treatment modalities without the results of the effectiveness of these approaches being published.
Current Outcomes for CBT in Eating Disorders
The outcome studies regarding the effectiveness of CBT in the treatment of eating disorders show mixed results. There is evidence proving short-term symptom improvement but studies fail to produce promising results in the long term.
In fact, many studies don’t even offer a long-term follow-up. But based on readmission rates at treatment facilities, there is enough research to suggest the following facts:
- Among individuals with eating disorders, there is a relapse rate upwards of 70 percent with the highest rates being within the first year of treatment.
- Seventy percent of individuals with eating disorders require readmission to treatment facilities.
- A minimum of 30 percent of individuals who have been treated at eating disorder facilities will remain chronically ill for 10-20 years after their initial discharge.
- Eating disorders are the second deadliest mental illness.
So, why are mental health professionals satisfied with saying CBT is the recommended approach to treatment when the outcomes for individuals with these disorders are rather stark?
The Problem With the System
The recommendation for CBT as the leading treatment option for eating disorders results from a very complicated mental health system. The system within which eating disorders are treated more often than not requires individuals to adhere to certain stipulations, even if these stipulations aren’t necessarily the most therapeutic approach.
Here are a few ways in which the system lends itself to certain recommendations over others:
- What gets funded: CBT is the therapeutic intervention able to more easily receive funding due to its structured and manualized approach.
- Eating disorder facilities: The research pointing to CBT comes primarily from eating disorder treatment programs. And, if the research shows promising outcomes, even in the short term after individuals attended these facilities, then these facilities can promote themselves as the leading experts in eating disorder treatment. The danger of this is that these facilities require individuals to adhere to specific recommendations and conform to a structured environment even when doing so may be distressing or traumatic for the individual. This is especially true for neurodivergent individuals.
- What insurance will cover: CBT is used within nearly every eating disorder treatment facility, and individuals who attend these treatment facilities are typically able to do so due to their access to private insurance. However, private insurance companies have strict stipulations when it comes to providing coverage and what they wish to see in terms of progress among eating disorder patients. For example, these stipulations typically involve medication compliance for anyone presenting with mood disturbances. This is the case even though research shows that medication for eating disorders is not a primary recommendation in early treatment due to the confusing overlap between perceived mood disturbances and malnourishment.
The Effect of Neurotypical Recommendations on Neurodivergent Individuals
The mental health system pigeonholes individuals with eating disorders in a specific approach to treatment. However, these approaches aren’t necessarily conducive to long-term change.
CBT is a cognitive-based intervention that focuses primarily on the interaction of an individual’s thoughts, emotions, and behaviors. However, a neurodivergent individual may not benefit from focusing heavily on the thoughts pertaining to their eating disorder, as their eating disorder is more likely to be a byproduct of their unique interaction with the world and their physical body.
For example, an individual with autism who is struggling with anorexia may have developed the disorder due to an increased sensitivity to sensory input from the world around them. Focusing on the thought surrounding their sensory sensitivities and aversion to food and then labeling this thought as distorted—as would be common practice within a CBT framework—would invalidate this individual's lived experience.
Cognitive Behavioral Therapy Essential Reads
How to Change
Since there is a large overlap between neurodivergent individuals and eating disorders, researchers and practitioners need to begin questioning the current framework for working with these disorders.
The poor outcomes for individuals with eating disorders already suggest a need for reform and, now, perhaps with the increased interest in having conversations surrounding neurological differences among sufferers, there can be a shift in the recommended approaches.
In the meantime, mental health providers who are in their own practices or who are in positions of leadership within eating disorder facilities can consider implementing opportunities for individualized, nuanced treatment approaches tailored to each client. This shift can help reduce the harmfulness of the current interventions.
de Jong, M, Spinhoven, P, Korrelboom, K, et al. Effectiveness of enhanced cognitive behavior therapy for eating disorders: A randomized controlled trial. Int J Eat Disord. 2020; 53: 717– 727. https://doi.org/10.1002/eat.23239
Hilbert, A., Hoek, H. W., & Schmidt, R. (2017). Evidence-based clinical guidelines for eating disorders: international comparison. Current opinion in psychiatry, 30(6), 423–437. https://doi.org/10.1097/YCO.0000000000000360
Keel, P.K. and Brown, T.A. (2010), Update on course and outcome in eating disorders. Int. J. Eat. Disord., 43: 195-204. https://doi.org/10.1002/eat.20810
Marzola, E., Longo, P., Sardella, F., Delsedime, N., Abbate-Daga, G. (2021, July 23). Rehospitalization and “Revolving Door” in Anorexia Nervosa: Are There Any Predictors of Time to Readmission? Frontiers Psychiatry, 25(2), 276-279. https://doi.org/10.3389/fpsyt.2021.694223
Rawal, A., Park, R. J., & Williams, J. M. (2010). Rumination, experiential avoidance, and dysfunctional thinking in eating disorders. Behaviour research and therapy, 48(9), 851–859. https://doi.org/10.1016/j.brat.2010.05.009