CBT for Eating Disorders: Social Work Intervention Guide

Introduction to Eating Disorders

An eating disorder is characterized by abnormal eating habits involving excessive or insufficient intake of food that is detrimental to an individual's physical and mental well-being. There are two most common types, though other types also exist. The first is bulimia nervosa, which involves excessive eating coupled with frequent vomiting. The second is anorexia nervosa, which involves an immoderate restriction of food leading to irrational weight loss. Other types of eating disorders include eating disorders not otherwise specified (EDNOS), which essentially describe a person exhibiting both anorexic and bulimic behaviors; binge eating disorder, which is compulsive overeating without any compensatory behavior; and pica, which is a craving for certain non-food items such as glue, plaster, or paper. It is estimated that roughly 10–15% of eating disorder cases occur in males, and statistics show that women are at a higher risk of developing eating disorders than men (Walsh & Devlin, 1998).

This higher risk is associated with the high degree of westernization, which promotes binge eating. It is estimated that eating disorders occur in roughly a quarter of the American population, with interactions between homeostatic, motivational, and self-regulatory control processes primarily contributing to their development (Doll, Petersen, & Stewart-Brown, 2005).

The exact cause of eating disorders is not known, but evidence suggests that they are linked with other medical and psychological conditions. One study found that girls with attention deficit hyperactivity disorder (ADHD) are more likely to develop an eating disorder than a comparator group without ADHD. A separate study showed that the incidence of anorexia nervosa in women suffering from post-traumatic stress disorder (PTSD) was quite high, and bulimia nervosa was more likely to develop in girls who had been in foster care. Other studies have shown a higher incidence of eating disorders among those who face teenage social pressure or who idealize certain body types portrayed as desirable in the media (Padierna, Quintana, Arostegui, Gonzalez, & Horcajo, 2000).

These findings suggest that eating disorders are frequently associated with other medical and psychological conditions. However, additional studies also indicate that eating disorders can occur for genetic reasons (Rayworth, Wise, & Harlow, 2004).

CBT as the Intervention Strategy

The intervention strategy chosen to help treat eating disorders is cognitive behavioral therapy (CBT). The major advantage of CBT is that it postulates that an individual's feelings and behaviors arise as a result of their thoughts rather than as a result of external stimuli. This helps to change the way the person thinks and reacts to situations that contribute to the disorder, and thus by changing how they think, it becomes possible to treat the disorder (Rie, Noordenbos, & Furth, 2005).

CBT addresses both the cognitive and behavioral aspects of the patient in order to arrive at the best treatment option. In this way, treatment focuses on changing the patient's thoughts and ideas, which in turn changes their actions. This strategy places emphasis on minimizing the number of negative thoughts the patient holds regarding their body or themselves, which helps to reduce harmful eating behaviors (Patton, Selzer, Coffey, Carlin, & Wolfe, 1999).

CBT encourages the person to tolerate negative thoughts and feelings, which helps them change how they think about food and stop looking to food or their bodies as sources of comfort for those negative feelings. It emphasizes the importance of changing cognition in order to change behavior, and it also involves rewarding the person for any achievements made during the treatment process, since CBT is a goal-focused approach (Padierna, Quintana, Arostegui, Gonzalez, & Horcajo, 2002).

One limitation of CBT is that the patient needs to have a specific underlying issue to address in order to treat their eating disorder; in the absence of such an issue, treatment becomes more difficult. CBT has, however, been proven to be quite effective in treating eating disorders. Another limitation is that CBT does not inherently encourage weight loss, which may pose a challenge for overweight or obese binge eaters, since treatment of the disorder is not automatically coupled with achieving and maintaining a healthy weight — two goals that would ideally be addressed together.

CBT can be carried out in four phases. The first is the assessment phase, in which the social worker gets to know the patient. This is the foundation of the intervention, as it allows the social worker to understand the issues facing the patient and conduct a thorough evaluation of why the client is seeking treatment. The assessment is typically conducted over two to three sessions, during which the social worker asks a series of questions — some of which the patient may find uncomfortable, but which are essential to the treatment process. The patient is always free to decline to answer any question. The social worker may also use a standardized questionnaire with follow-up questions to uncover the underlying issues presented.

Phases of the CBT Intervention

The assessment may reveal anorexia or bulimia, as well as symptoms of comorbid psychiatric disorders. A diagnostic workup may be conducted using MRI, fMRI, SPECT, and PET scans to detect any tumors or lesions that may be causing the eating disorder. Psychological diagnosis may be performed using psychometric tools such as the Eating Attitude Test, Body Attitude Test, SCOFF Questionnaire, or the Eating Disorder Examination Interview. Eating disorders should also be differentially diagnosed from other conditions — such as Lyme disease or Addison's disease, which can cause anorexia, or hypo- or hyperthyroidism, which may mimic eating disorder symptoms (Munoz et al., 2009).

The second phase is treatment planning. After the initial assessment, the social worker discusses their impressions and observations with the patient, along with how they intend to address the patient's issues. The social worker also discusses with the patient the areas of their life that need to change in order for treatment to succeed. In eating disorders, the primary treatment goal is to resume normal eating behavior. The treatment plan will focus on this goal by ensuring that the patient resolves any self-esteem issues or other contributing factors that give rise to the eating disorder (Mond, Hay, Rodgers, Owen, & Beumont, 2005).

The third phase is the therapy phase, which in the case of CBT is divided into two sub-phases. The first is the cognitive stage, in which the social worker works with the patient to understand how the patient thinks. The social worker and patient discuss past events and how the patient has reacted to them, seeking to identify the ideas and thoughts that contribute to the eating disorder and making those patterns visible to the patient. The second is the behavioral stage, in which the social worker works with the patient to develop new ways of thinking. Here, the social worker seeks to change the patient's ideas, thoughts, and behaviors in order to establish new patterns of thinking. Cultural competence is especially important during this phase, as it is only through culturally informed practice that the social worker can fully understand and address the issues facing the patient (Martin et al., 1999). Cultural competence also allows the social worker to treat the patient with respect and to avoid any communication that may harm the therapeutic relationship.

The fourth and final phase is the termination phase, in which the social worker and patient work together to ensure that the changes initiated in the therapy phase are sustained and that there is no relapse. This involves the social worker highlighting the changes the patient has made and the gains from those changes. The patient also learns how to apply CBT principles independently and understands that these principles work best when used together rather than in isolation. If the patient has not recovered by this phase, the social worker may choose to refer them to another provider or to continue with the therapy phase until the treatment goals are achieved. The appropriate time for termination is reached when the patient is able to eat normally and consistently avoid harmful eating behaviors.

In applying CBT as the intervention, referral is a likely option for patients with eating disorders, primarily because eating disorders are often chronic and co-occur with other conditions. The client must be willing to disclose the underlying issues that, in the social worker's assessment, contribute to the eating disorder. Clients may enter the counseling system voluntarily, through a referral from a friend or family member, or through a recommendation from a health care provider. For many patients, there is likely a history of seeking other forms of medical treatment before presenting to a counselor.

As a social worker, the primary role in this context falls within the long-term care segment of the continuum of care, since treatment of an eating disorder is classified as rehabilitative care. This is because CBT aims at reforming the individual's cognitive and behavioral patterns in order to achieve the goals of treatment.

The social worker differs from other practitioners in that they have a responsibility for social education — informing the patient about the available options and other overlapping aspects relevant to the case. The social worker is expected to provide more holistic care than a physician, including family therapy, counseling, and community development. This broader role requires the social worker to understand the patient from a wider perspective and to assume a greater leadership and advocacy role in the treatment process.

Utilization of mental health services has been a persistent challenge, as many individuals face barriers to receiving care. One major factor is the social stigma attached to mental illness. Society often characterizes people with mental illness as "crazy" or socially unfit, which discourages many from seeking care. Another factor involves cultural beliefs about the causes of mental illness; in some communities, mental illness is attributed to curses or spiritual harm, which causes individuals to feel shame about disclosing their mental health status.