CBT-E  FAQ

We know there is a lot to consider when entering a treatment program.  In order to help you make an informed decision regarding if this is the right process for you, our staff have compiled a list of answers to the most of frequently asked questions about BANA`s CBT-E Treatment.  Just click on the tabs below for more information.

CBT-E, which stands for Cognitive Behavioural Therapy Enhanced for Eating Disorders, is the leading evidence-based treatment adults with eating disorders in outpatient settings. BANA selected CBT-E due to positive outcomes depicted in research; BANA’s own research indicates that approximately 2/3 of clients who enter CBT-E go on to make an excellent response.

CBT-E typically follows a “20-sessions over 20-weeks” protocol that begins more intensively (twice a week appointments), and gradually transitions to less frequent meetings (once a week, to bi-weekly). CBT-E is divided into four stages; each stage addresses different areas of concern that maintain the eating disorder.

For clients who are underweight and require weight restoration, CBT-E also has a “40-sessions over 40-weeks” protocol, whereby the first 20 weeks are focused on weight regain and maintenance. The BANA clinical team determines whether a client accesses the 20 or 40 week protocol – this decision is typically dependent on the client’s BMI and symptom severity.

CBT-E targets disordered eating, as well as maladaptive cognitions and behaviours around food, eating, weight and shape. The ultimate goal of CBT-E is to normalize eating, reduce symptoms, and work towards body acceptance.

CBT-T (which stands for “Cognitive Behavioural Therapy – Ten) is an abbreviated version of CBT-E, typically following a “10-sessions over 10-weeks” protocol that maintains weekly appointments throughout. Whereas CBT-E focuses more on cognitive approaches for change, CBT-T creates change with more of a behavioural approach.  Recent research has demonstrated that CBT-T yields similar results to CBT-E in half the time.

After a comprehensive, specialized eating disorder assessment is completed, the BANA clinical team meets to discuss the best interests of the client. From information collected directly from the client, paired with expert knowledge and clinical impressions, the clinical team determines whether a client would be best suited for CBT-E, CBT-T, or a referral elsewhere (such as more intensive eating disorder services, or an external community referral).

When deciding between CBT-E and CBT-T, the clinical team considers the client’s level of cognitive ability; their success in past treatments; the level of engagement in external resources; readiness and commitment to change/implementing tools; and comorbid diagnoses occurring.

When determining whether to refer a client to more intensive eating disorder programs, the clinical team considers the client’s severity of symptoms, BMI (automatically refer significantly underweight clients with a clinically-low BMI), and success in past treatments. Often, high-risk clients require medical monitoring, meal support, or symptom interruption in order to ensure their safety/wellbeing, and to improve their recovery outcomes.

If a client presents with primary concerns that appear to take precedence over the eating disorder, or if the client does not meet criteria for an eating disorder diagnosis, the BANA clinical team will offer a non-eating disorder related referral to external supports. BANA often refers to Canadian Mental Health Association, Windsor Essex Community Health Centre, the Sexual Assault Crisis Centre, and many other organizations and/or private practitioners within the Windsor-Essex community.

In order to access programs at BANA (such as CBT-E, CBT-T or skills trainings), a client must have an eating disorder diagnosis. For referrals, a diagnosis is not required.

Below are the typical steps that are followed for accessing BANA services (please note: these steps are a guideline, and may not always follow along exactly depending on client needs).

  • Contact BANA’s intake department (online intake form, or through our toll free number: 1-855-969-5530)
  • Complete intake (initial meeting and form completion)
  • Complete a comprehensive, specialized eating disorder assessment (approximately 2-hour session, comprised of an interview and psychometric testing)
  • Await results, while the BANA clinical team reviews the assessment and determines a diagnosis (if applicable) and treatment plan
  • Have follow up with intake team to learn about diagnosis (if applicable) and treatment plan
  • Be placed on waitlist for treatment (CBT-E or CBT-T), and simultaneously access skills trainings
  • When a client arrives at the top of the waitlist, a clinician will contact the client to schedule a meet-and-greet to overview treatment expectations and schedule sessions
  • Begin treatment CBT-E or CBT-T

The time of year, the number of available clinicians, and the complexity or readiness of clients already engaged in treatment often impact the length of wait before starting treatment. It is difficult to state a definite timeframe in terms of wait times, as they are constantly shifting.

On average, BANA’s wait times typically range between 4-8 months; however, BANA has seen both longer and shorter waitlists in the past.

Every client is unique; therefore, treatment length can vary drastically from client to client.

CBT-E typically follows a 20-sessions-over-20-weeks protocol (approximately 5 months). However, after session 20 clients are placed on a “5-month break” that is considered part of treatment. Thereafter, clients are re-assessed to determine if further treatment is needed.

CBT-T typically follows a 10-sessions-over-10-weeks protocol (approximately 2.5 months). However, after session 10 clients engage in check-ins periodically over the span of 3 month’s post-treatment.  Thereafter, clients are re-assessed to determine if further treatment is needed.

Which therapist a client is assigned is dependent on therapist-availability. BANA clinicians carry full caseloads, and typically pick-up new clients when an opening becomes available in their schedule. Therapists contact clients who are at the top of the waitlist to inquire about starting services.

Client’s do not typically have choice over their assigned therapist, unless there is an evident conflict-of-interest or previous-standing relationship. If a client is returning to BANA programming, BANA attempts to pair the client with their previous therapist to maintain the therapeutic alliance. Upon returning to BANA, a client can request to be paired with a specific therapist; however, this does not guarantee that they will be working with said therapist.

Once a therapist has been assigned, clients cannot “switch” therapists. Exceptional circumstances will be considered; however, BANA encourages clients and therapists to overcome their differences and work together, as this is an opportunity to learn new skills, and to practice patience, acceptance, and tolerance. Because BANA is a non-profit organization, it does not have the resources to accommodate therapist-preferences for non-exceptional reasons. Furthermore, switching therapists can slow down the treatment process and lengthen wait times.

CBT-E Breakdown:

Please note *** due to the uniqueness of every client, the following is a general guideline for treatment and may not be adhered to exactly

Divided into 4 stages, and is followed by a planned 5-month break

  • STAGE ONE = roughly sessions #1-8; meet twice a week
    • Focus primarily on beginning the self-monitoring and collaborative weighing processes; psychoeducation; regulating eating; symptom reduction; developing urge tools.
  • STAGE TWO = one session (typically session #9); move to meeting once a week
    • Review progress and change up to this point, and plan for stage 3.
  • STAGE THREE = roughly sessions #10-17; continue to meet once a week
    • Typically incorporates body image work and eating intuitively. Depending on client needs, may also incorporate addressing dietary restraint; moods/emotion regulation; improving personal functioning; perfectionism and/or procrastination; and addressing core low self-esteem.
  • STAGE FOUR = roughly sessions #18-20; meet bi-weekly
    • Focus on relapse prevention by strengthening problem-solving skills; planning for triggers and setbacks; developing a recovery maintenance plan; and phasing out treatment
  • 5 MONTH BREAK
    • Focus on maintaining changes, and continuing to work on remaining challenges. Used as a “trial and error” period of recovery, which is followed by a check-in, potential reassessment, and further treatment planning if needed.

CBT-T Breakdown:

Please note *** due to the uniqueness of every client, the following is a general guideline for treatment and may not be adhered to exactly

      • 10 weekly sessions, followed by 1 month and 3 month check in appointments
      • Topics addressed parallel those in CBT-E; however, less regimented session-by-session structure

CBT-E protocol requires clients to attend twice-a-week sessions for the first 4 weeks of treatment. Research has demonstrated that the best predictor of success in recovery is positive change within the first 4 weeks of eating disorder treatment. In order to push for early change and establish momentum, stage one of treatment is the most intensive.

It is not uncommon that clients need extra time to solidify change. In some cases, clinicians advocate for their client(s) to get additional sessions of CBT-E, so long as the client has been engaging tools and skills, committing to behavior changes and goals, and prioritizing treatment thus far.

After CBT-E or CBT-T sessions are completed, clients engage in check-ins to assess how recovery is going. If a client is continuing to struggle after treatment, they will be re-assessed in order to determine an updated diagnosis and – potentially – a new treatment plan.

Clients who need more support post-treatment may receive individual “booster” sessions or check-ins, be invited to a treatment group or skills training, or referred to other resources in the community.

At BANA, there are general expectations for clients engaged eating disorder treatment:

  • Following BANA policies and procedures
  • Attendance in scheduled sessions, or contacting BANA to cancel/reschedule when unable to attend
  • Required weekly weighing, done collaboratively with clinician or dietitian
  • Completion of daily self-monitoring logs
  • Completion of assigned homework
  • To regulate eating, with the support of the BANA clinical team
  • Attempts to use treatment tools or meet collaboratively outlined goals, when applicable

WEEKLY WEIGHING

Once a week, clients will be weighed through a collaborative weighing process. Weighing is a pertinent part of treatment, and clients will be taught how to understand weight fluctuations, as well as how to challenge beliefs about weight/“number on the scale” and it’s relation to food and eating.  When applicable, weekly weighing is also utilized to monitor weight restoration or maintenance.

SELF-MONITORING LOGS

Clients will be asked to complete daily self-monitoring logs. BANA asks that these logs are completed in “real time”, meaning as events are occurring. This “real time perspective” provides the most accurate picture of the eating disorder, and allows clients to develop awareness around their behaviours, moods, and thoughts.

Self-monitoring logs request information on wake and sleep times; eating and drinking times – along with food content, quantity and portion sizes; eating disorder symptoms that occurred; length and type of exercise engaged in (if applicable); as well as thoughts, events and emotions that occurred throughout the day.

REGULAR EATING

A core foundation of any eating disorder treatment is regular (or mechanical) eating – sometimes referred to as “eating by the clock”. Generally speaking, this refers to the time of which and how frequently a client is eating.

Clients will be asked to aim for 3 meals and 3 snacks a day, going no more than 3-4 hours without food. Clients, their clinician and dietitian will set goals and develop tools to assist the client in this process.

Regular eating has been shown to:

  • Reduce majority of episodes of binge eating
  • Address restricting and fasting behaviours, thereby reducing physiological and psychological deprivation
  • Provide a sense of control around eating
  • Allow for stronger, more trust-worthy hunger and fullness cues to return
  • Reduce preoccupation with eating and food
  • Paired with healthy exercise, allows the body to find it’s “set point”
  • Provide direction for food portioning and balancing work, as well as intuitive eating

HOMEWORK

After every session, clients will be assigned homework. It is expected that client’s complete homework, as well as consider how homework can be applied ongoingly in order to create change. Homework is a foundational part of treatment, as it strategically encourages clients to incorporate new skills and tools in their day-to-day lives, and within the environment at which the eating disorder was developed and/or maintained.

If homework is incomplete, the clinician and/or dietitian will address this with the client, and problem-solve barriers. Homework may include an assigned reading, reflection activity, worksheet, behavioural experiment, exposure exercise, meeting a goal, etc.

Eating and body image are intrinsically linked. Typically speaking, when eating changes, so does the body and vice versa. If eating is disordered or symptoms remain unchallenged, it can result in maladaptive thinking regarding body shape and weight and how these may be influenced or changing. Because eating disorders incorporate both eating and body dissatisfaction, both need to be addressed in order to maximize on recovery.

There are some exceptions to this, such as in the case of ARFID. Exceptional circumstances are considered in treatment planning.

BANA welcomes supportive persons in sessions. It is not uncommon that loved ones attend sessions with clients in order to better understand the nature of the eating disorder, and their role in their loved-one’s recovery (including tips on how to support).

BANA asks that clients provide advanced notice before bringing a support person with them to an appointment. Advanced notice allows for the clinician and/or dietitian to plan the session accordingly, and to seek written consent from the client for confidentiality purposes.

All of BANA’s services and programs are free of charge. BANA is a non-for-profit organization, funded by the public.

Life can be unpredictable, and it is not uncommon that circumstances arise during the course of treatment that makes it difficult for the client to fully engage in treatment demands.

Client’s engaged in CBT-E or CBT-T have a one-time option of putting treatment on “pause”. Doing so will pause CBT-E sessions for a period of one-month, allowing the client time to attend to other life circumstances. After the pause is complete, the client and their clinician will meet to discuss where the client is at, and make a plan to get “back on track” (if applicable); thereafter, treatment will resume at the session number where it was left off.

In some cases, one-month is not enough time to suffice. Should this be the case, clients have the option of returning to the bottom of the treatment waitlist – this should provide additional time to attend to other life circumstances.

Because treatment at BANA is voluntary, a client can terminate their treatment at any time, and will be welcome to return to BANA in the future should they find themselves in a better position to fully engage in programs.

At BANA and within eating disorder treatment, the role of the dietitian varies and is especially influenced by client need. In many cases, work with the dietitian is a vital component to treatment.

Work with the BANA dietitian includes psychoeducation about the body, nutrition, food and eating; support around regular and intuitive eating; striving for balance; weakening the diet mentality and challenging food rules; and increasing awareness of and connection to one’s body. Exercise, symptom-reduction, sleep hygiene and water intake are also commonly incorporated.

The frequency of dietetic sessions may be different for every client. Within CBT-E, clients may access the dietitian for approximately 7 sessions (these sessions fall outside of the 20 sessions with the clinician). For CBT-T, the dietitian is not typically utilized – but there have been exceptions to this. The dietitian may also be accessed through unique treatment plans, such as individual supportive sessions for nutrition and health, or for psychoeducation. These are approximations, and may vary from client to client.

Treatment at BANA can be offered virtually; however, it is best that the client and BANA clinical team make this decision together in order to ensure it is in the best interest of the client’s recovery.

Virtual treatment requires the client to have a private space with internet access, free from distractions and interruptions. Treatment materials, as well as session links, will be exchanged via email; therefore, the client will be required to have an email address, and to check it regularly. Clients will be required to send their clinician and/or dietitian their completed self-monitoring logs before every session. Clients who opt for virtual treatment will be required to have a scale at home, as collaborative weighing will still be an integral part of the treatment process and will be completed weekly.

For virtual sessions, BANA utilizes the “OTN” and/or the secure version of the “ZOOM” video-conferencing platforms.

Eating disorders have been commonly shown to co-occur with other mental health diagnoses. Many BANA clients are engaged in eating disorder treatment while simultaneously accessing other supports in the community.

Beginning eating disorder treatment with a client who is accessing other mental health supports will depend on the level of intensity of those services. Furthermore, BANA often seeks consent from the client to consult with other mental health supports in order to harmonize care and avoid duplication of services.

BANA offers services in English and French, as there are members of staff who are francophone. For services in other languages, translators can be used.

For accessibility purposes, BANA has been working hard to convert materials into multi-media formatting, as well as to offer materials through a variety of platforms. Materials can be accessed through hard copies, online through the BANA website, electronically through secure email or USB’s, and in some cases can be provided in audio-recording or video format.

TOGETHER

We Can Find Solutions