Challenging the ‘Gold Standard’: Why CBT Alone Isn’t Enough for Eating Disorders

by | 15 Jun 2024 | Eating Disorders | 6 comments

In the field of Eating Disorders, Cognitive Behavioural Therapy (CBT) often takes centre stage as the “gold standard” treatment.  Its prominence is largely due to its structured, manualised nature, which makes it easy to study and to replicate in research settings.  But this focus on CBT has significant implications that we need to address.

So, let’s unpack this a little.  CBT’s structured, step-by-step format offers researchers the notion of consistency—the format can be followed by different practitioners and for different studies.  In the research world, the outputs of this type of controlled process are considered to be more robust scientific evidence.  This feature also creates a feedback loop: the more CBT is studied, the more it is considered the best treatment option.  This, in turn, attracts more funding and more research efforts.  Other, non-manualised approaches to therapy, treatment, and support, being more variable depending on the client, therapist, and context, are not seen as specifically measurable (and therefore are not as easily researchable), so they become sidelined and labelled as ‘unevidenced’.

Now, I might be biased because my background is in person-centred and integrative approaches to therapy – and CBT does have some proven efficacy – but, in my opinion, enough clients do not respond fully to CBT for us to consider it the best that could possibly be offered.  There are enough people reporting finding CBT too rigid, feeling unheard in the process, and therefore being disconnected from their therapist for us to want more.  This is especially so when we recognise that we’ve known for a long time that good therapy outcomes are related to good therapeutic relationships.

The focus on CBT is a problem; a problem that, for some, is harmful and even traumatic.  Many of my clients, for instance, actually come to me because they feel that CBT alone hasn’t addressed their needs.  It may be that CBT has helped them a little, but they want more from therapy; possibly it hasn’t even helped them at all, or as indicated above, it may have harmed them.  Particularly, people often come to me with a desire to make sense of their personal experiences and their underlying issues as part of recovery.

Another important point to make is that the focus on the use of manualised approaches to treatment often reinforces the very issues underlying Eating Disorders.  Clients frequently share that they feel “too much”, unheard, or invalidated in these settings.  Such feelings can exacerbate the Eating Disorder and make recovery even more challenging.

There is no denying that Eating Disorders are complex and varied – so I really must ask, why would we ever expect a treatment approach for this to be simple?

I think, in part, this issue is an indication of fear in permeating the field.  A manualised approach reassures the clinician about what to do from session to session and can provide a sense of confidence amidst the fear.  With the high risk of mortality often associated with Eating Disorders, people want to feel confident in an approach to support those affected.  And of course, researched and proven approaches are vital, but all types of treatment approaches need that same investment in terms of research funding if we are to truly know what is ‘gold standard’ Eating Disorder care.  I think that sometimes the best research data available is what clients say about their experience – not necessarily just scored and coded: qualitative data that takes a greater account of nuance. Sucess can’t always be measured in simple numbers.

In my practice, I employ a more holistic, person-centred approach that includes elements of existential therapy, psychoeducation, interpersonal therapy, and sometimes trauma-focused therapy.  My approach doesn’t fit neatly into a manualised process that would produce the format preferred in research, but it resonates with many of my clients, so I keep going.

I feel that one of the really valuable aspects of my approach is that it provides the client space to explore experiences, feel heard, and work through what brought someone to this point.  That’s not to say I have discarded behavioural tools, because I use those too – but recognising that these tools, while they may be beneficial, aren’t always enough or the right fit for everyone.

I don’t want to discount CBT – let me be very clear, it does have its place and it is immensely helpful for some people – but the people it doesn’t help also deserve to have options.  Currently, it seems that they are mostly left feeling hopeless – as if they’ve ‘failed’ because the ‘gold standard’ treatment didn’t work.  This narrative of ‘failure’ is honestly heartbreaking; when a person doesn’t respond to CBT, they often feel as if they’ve hit a dead end and they’re left questioning their ability to recover because the most ‘trusted’ method didn’t work for them.  Of course, someone would feel hopeless in such a situation!  Our responsibility, therefore, should be to provide hope, other options, other configurations, less travelled paths that are worth a try…. What works wonders for one person may not be suitable for another, and the other person might very well be helped by something that in turn, wouldn’t have worked for the previous people.

We need to advocate for a broader understanding and acceptance of different therapeutic approaches within the Eating Disorder treatment community.  This includes pushing for more research funding and studies on varied methodologies.  It’s about giving clients options and recognising that recovery can take many forms.  Ultimately, it’s about acknowledging the complexity of Eating Disorders, with the corresponding necessity for diverse treatment modalities.  No single approach will work for everyone, and by broadening our perspective and investing in varied therapeutic techniques, we can better support those affected, rather than spending our time trying to find a ‘cure’ for all, that probably doesn’t exist.

Let’s ensure that all individuals have access to the care they need.  By embracing a more holistic, client-centred approach and advocating for comprehensive training and research in all therapeutic modalities, we can provide a more inclusive and effective support system for those struggling with Eating Disorders.  It’s about giving everyone a fair chance at recovery, and that starts with acknowledging and valuing the diverse ways in which healing can occur.

Is this controversial? What are your thoughts?

6 Comments

  1. Donna Vyskocil

    Completely agree and I feel the same about DBT in PD services. Too rigid and almost like reading from a script. And no two people are the same therefore a one size fits all approach is often not effective

    Reply
  2. Becky Grace Therapy (MBABCP) CBT Therapist - CBT EMDR

    Thank you, I agree. I’m a CBT Therapist who has worked delivering CBT E & T in NHS ED Services. It’s one of the reasons I left after a year and much sooner than I would have liked. As someone with 30 years lived experience too, a larger body, neurodivergent and struggled with identity/sexuality, I often felt moral injury working with these models under rigid systems, structures who weren’t open to challenges to the ‘treatment’ structure.

    Reply
    • Kel_MHB

      Thanks so much for sharing your experience Becky!

      Reply
  3. Cindy Hansen

    To move forward, we have to address the key elements of CBT that make it so popular.

    My solution is to add a therapy outcome monitoring system to the process.

    By assessing the amount of distress the person is experiencing, paying attention to the goal they are trying to achieve and the therapeutic alliance, the new therapy outcome monitoring system By Holistic Research Canada can provide practice based evidence of what is working and what is not working reassuring the clinician when they are on the right track and signalling when adjustments are needed.

    Having work for 20 years in the field of therapeutic outcome monitoring systems, I have devised a new system that does not involve a person completing long assessments every session. They only need to Input their answers to two questions at the beginning of a session and two questions at the end of the session. And their answers can prompt the clinician to ask additional questions that they can mark down qualitative and quantitative responses to in their notes.

    It includes a scoring system that is more sophisticated than using a reliable change index or a crossing of the clinical cut off, but not so complex that it cannot be implemented in any EHR or practice management system.

    Reply
  4. Deanne Jade, MBPsS

    I’m Deanne Jade of the National Centre for Eating Disorders, and have 40 years experience working with eating disorders plus more. I concur with some aspects of your blog and find some ideas and maybe some of the replies worrying.

    We also have a method of assessing people that does not require “long assessments every session” and we do not follow a manualised approach. Our large team is doing amazing work following a treatment approach that is rooted in CBT principles with as many bolt-ons that the client needs and that suits the therapy moment. The client deserves evidence- based practice with sensitivity to every comorbidity such as internalised stigma, neurodivergence, trauma and so on,

    We also submit our therapists to a great deal of experiential work so that they have faced up to their own issues and biases. Bias in a therapist is fatal.

    Enhanced CBT is not “CBT” and is not “manualised CBT”. Eating disorder therapists need a huge CPD including nutrition, physiology, neuroscience, a range of therapy approaches not a one size fits all approach. We have known this for decades.

    You write nothing new but risk leading vulnerable people to think that CBT causes harm.

    CBT properly done NEVER causes harm. Untrained therapists cause harm and therapists without a knowledge of cognitive approaches such as Socratic enquiry cause harm.

    There are many therapists out there who claim eating disorder expertise, simply because they have worked with patients for many years. I wonder what CPD is in their history. Our clients deserve therapists with proper training, able to evaluate many approaches and their practice properly supervised by an eating disorder specialist.

    Reply
    • Kel_MHB

      Thank you for reading and taking the time to respond to my blog post). I appreciate that you have extensive experience and are dedicated to the field of Eating Disorders(, as am I). It seems we share many common goals and values in our work, and I am grateful for this opportunity to engage in such an important dialogue.

      I believe there may have been a misunderstanding regarding the intent of my blog. My aim was not to dismiss the value of CBT or suggest that it inherently causes harm, but rather to highlight the need for a broader spectrum of therapeutic approaches to accommodate the diverse needs of individuals with Eating Disorders. The emphasis on CBT in research and practice can sometimes overshadow other valuable methodologies, and I advocate for a more inclusive approach to treatment.

      I agree wholeheartedly that clients deserve evidence-based practice that is sensitive to their unique comorbidities, such as internalised stigma, neurodivergence, and trauma. It sounds as if we align on the necessity for a comprehensive and adaptable approach to therapy, integrating various modalities to best support each client.

      Your point about the importance of therapists undergoing experiential work to address their own biases is absolutely crucial. Bias in therapy can indeed be detrimental, and ongoing professional development is vital for maintaining high standards of care. My background includes extensive training across multiple therapeutic approaches, which includes CBT, together with a significant focus on addressing bias, both in practice and research.

      Where we might differ is in the assertion that “CBT properly done NEVER causes harm.” While I appreciate your confidence in a well-executed CBT approach, I believe it is essential to acknowledge the well-documented lived experiences of those who feel they have been harmed by it. Such absolute statements can run the risk of invalidating these experiences. Therapy is a deeply personal process, and what works well for one person may not be suitable for another. It is crucial to remain open to these diverse experiences and to continue evolving our practices based on client feedback.

      Additionally, there is increasing conversation about the issue of bias within research. As per the main focus of this article, CBT is fortunate to get much more funding for research, which creates an echo chamber effect. This is increasingly being questioned within current research and practice and is part of the growth within the research field. You might be interested in:

      • Psychotherapies for eating disorders: findings from a rapid review by Haley Russell, Phillip Aouad, Anvi Le, Peta Marks, Danielle Maloney, National Eating Disorder Research Consortium, Stephen Touyz & Sarah Maguire.

      • An open invitation to productive conversations about feminism and the spectrum of eating disorders (part 2): Potential contributions to the science of diagnosis, treatment, and prevention (April 2022) by Andrea Lamarre, Michael P. Levine, Susan Elis Holmes, and Helen Malson. DOI: 10.1186/s40337-022-00572-3.

      There are many more instances, if you would wish me to make further recommendation, but these are two good pieces.
      .
      For further exploration into the broader conversation surrounding the effectiveness and limitations of CBT in treating Eating Disorders, some good references are:
      • Wilson, G. T. (2005): Discusses the limitations of CBT for eating disorders and the need to consider alternative treatments. DOI: 10.1146/annurev.clinpsy.1.102803.144250
      • Galsworthy-Francis, L., & Allan, S. (2014): Reviews the efficacy of CBT for eating disorders and highlights instances where it may not be effective. DOI: 10.1016/j.cpr.2014.01.002
      • Mills, J. S., & Polivy, J. (2014): Explores how CBT, when not appropriately tailored, can reinforce problematic thinking patterns. DOI: 10.1016/j.adolescence.2014.02.011
      • Swan, J. S., & Andrews, B. (2003): Highlights the risk of CBT being perceived as invalidating by patients. DOI: 10.1037/0022-006X.71.1.123
      • Pinto, A. M., & Bloch, P. (2016): Points out that the manualised nature of CBT can neglect individual patient needs. DOI: 10.1186/s40337-016-0101-2

      I am very much aware of the importance of having a well-rounded therapeutic skill set and proper supervision. It is vital that we, as practitioners, continually refine our skills and knowledge in order to offer the best possible care. However, it is worth noting that valuable expertise and competence can come from various training backgrounds and experiences, and do not result solely from a specific training program.

      In my blog, I aimed to address the cyclical nature of research and funding within the field of Eating Disorders, and the impact this has on the development and recognition of diverse therapeutic approaches. Our clients do indeed deserve the best, and this includes access to a wide range of evidence-based treatments that are tailored to their individual needs.

      Thank you again for your engagement and for sharing your perspective on this important issue. I hope that you will feel free to continue this dialogue if you consider that it can be productive.

      Kindest regards
      Kel

      Reply

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Kel O'Neill

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