Structure
CBT-E for adolescents involves two assessment/preparatory sessions followed by three main steps, one or more review sessions, and three post-review sessions (see Table 1). Treatment lasts about 20 weeks in patients who are not underweight. In contrast, the standard 40 weeks of adult CBT-E in underweight patients may be shortened to about 30 weeks, as adolescents tend to restore a normal body weight faster than adults [13]. Parents are required to participate in a solo interview lasting about 90 min during the first week of treatment. Following this, the patient and parents attend some to eight joint sessions of 15 to 20 min each immediately after the patient’s session.
A detailed description of the CBT-E version for adolescents can be found in manuals for therapists [14], patients [15], and parents [16].
Goals
The main goals of CBT-E for adolescents are the following [14]:
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Engage the young person in treatment by motivating them to recover and actively involving them in the change process.
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Help them eliminate the specific eating disorder features (e.g., preoccupation with shape, weight, and eating; dietary restraint and restriction; low weight; self-induced vomiting; laxative misuse; and excessive exercising).
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Interrupt the mechanisms maintaining these eating disorder features.
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Achieve lasting change and prevent relapse.
Assessment and preparation
The initial interview has two main goals: (i) to assess the nature of the young person’s eating problem and (ii) to engage them in the decision to begin Step One of CBT-E.
Parents are asked to allow the therapist to meet with the adolescent alone during this session. This private meeting is crucial for understanding the adolescent’s perspective on their eating problem and building a solid therapeutic alliance, ensuring the therapist is not perceived as the parents’ “agent. A key feature of the first CBT-E session is emphasizing that the therapist will operate entirely on the teen’s behalf rather than acting at the parents’ behest. Engaging the young person involves actively listening to their thoughts and concerns.
An essential strategy in the assessment/preparation phase of CBT-E is to explore with the young person whether their control over shape, weight, and eating is a choice or if it has become a problem. This is followed by formally educating the patient about the differences between the disease and the psychological models of eating disorders, along with their respective treatment implications (see Table 2).
The therapist then provides a brief overview of CBT-E, asking the young person to reflect at home on what has been discussed. For homework, the therapist asks the adolescent to write down a list of the pros and cons of starting Step One of CBT-E and any questions or concerns they may have.
In the second assessment and preparation session, usually held some days later, the therapist reviews the pros and cons the adolescent has written down and addresses any issues they may have raised. The aim of this session is to encourage (rather than coerce) the young person to decide to start Step One by bolstering their interest in change and addressing any questions they may have.
Step one – starting well and deciding to change
Step One lasts up to four weeks, during which the adolescent attends two 50-min sessions per week. In addition to fostering their engagement, the primary goal of Step One is to help the adolescent understand their eating disorder through the psychological model and to recognize the need for change (including weight regain if necessary). Additional goals include reducing their concerns about weight through the weekly collaborative weighing procedure and establishing a regular eating pattern.
By the end of Step One, the adolescent should be willing to attempt change and agree to take steps to regain weight if required. The sooner the adolescent adopts this viewpoint, the shorter Step One will be. However, if the adolescent does not agree to attempt change after eight sessions, CBT-E will be discontinued, and alternative treatments will be considered.
Review sessions
A review session is conducted at the end of Step One for non-underweight adolescents and at flexible intervals, typically every four weeks, during Step Two for underweight adolescents. These sessions focus on assessing progress, identifying emerging barriers to change, modifying the patient’s formulation as needed, and planning the following four weeks. Additionally, each review session has two key purposes:
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1.
Identify patients who are not doing well. It’s crucial to recognize patients who are not progressing well. Achieving a positive outcome is unlikely without addressing the underlying causes of their poor response.
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Adapt treatment. The treatment is adjusted based on the changing nature of the patient’s eating disorder to ensure it remains effective and relevant. This may include the decision to use the “broad” form of CBT-E.
Step two – addressing the change
This Step represents the main body of CBT-E. It aims to promote weight restoration (if necessary) and disrupt the main mechanisms maintaining the eating-disorder features. The way to achieve those goals varies considerably from adolescent to adolescent. To address the specific maintenance mechanisms of an individual patient, the “focused” form of CBT-E includes one or more of the following modules, as appropriate:
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Underweight and Undereating
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Body Image
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Dietary Restraint
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Events, Moods, and Eating
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Setbacks and Mindsets
For adolescents whose treatment is hindered by additional maintenance processes, the “broad” form of CBT-E is used. This version includes the following additional modules, which can be incorporated into the focused form as needed:
Step three – ending well
Step Three is the final stage of treatment, focusing on ending the treatment well. It consists of three appointments, each held two weeks apart. These sessions gradually shift to a future-oriented perspective, focusing less on the present. The goals of Step Three include maintaining the changes achieved during treatment and minimizing the risk of relapse. Additionally, any concerns from the adolescent and/or parent(s) about ending treatment are addressed, and specific treatment procedures (e.g., self-monitoring, in-session weighing) are gradually phased out. Toward the end of this step, the therapist collaborates with the patient to create a maintenance plan to address residual eating disorder features and prevent relapse.
Post-treatment review sessions
These sessions occur at 4, 12, and 24-weeks post-treatment. They aim to reassess the adolescent’s condition and determine the need for further intervention. Additionally, they review progress, update the long-term maintenance plan, and, if necessary (e.g., if the adolescent has not resumed having regular periods), evaluate the pros and cons of further weight gain.
Parental involvement
Parents attend two joint sessions with the patient during the treatment’s assessment and preparation phase. In the main phase of treatment, parents will need to attend one parent-only session and approximately six to ten joint sessions with the patient, which occur at the end of the individual sessions (see Table 3).
The first joint session with the patient during the assessment and preparation interview aims to inform family members about the nature of the eating disorder, the difference between the disease model and the psychological CBT-E model, and to provide an overview of CBT-E, focusing mainly on the roles of both parents and the patient in the treatment. The second joint interview is held after the patient’s second session to inform the family about the young person’s decision regarding starting Step One of the treatment.
The primary goal of the parent-only session in the first week of the treatment is to identify and address family factors that may hinder the patient’s attempts to change. Discussions also include creating an optimal family environment to support the child’s efforts to change. The joint sessions with patients and parents together during the treatment have two main aims: (i) To keep parents updated on the treatment process and the patient’s progress, and (ii) To discuss, with the patient’s prior agreement, how parents can help by creating an optimal family environment, supporting their child’s attempts to change, and assisting in implementing key treatment procedures.
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