Enhanced CBT for eating disorders

1. Introduction

Version followed: Fairburn (2008) Cognitive Behavior Therapy and Eating Disorders: adult outpatient CBT-E, in the 20-session version (not significantly underweight) and the 40-session version (underweight). The focused form is the default and the broad form adds modules. Where the adolescent adaptation (Dalle Grave & Calugi, 2020) differs, this is flagged. The manual itself and the full text of Murphy, Straebler, Cooper & Fairburn (2010) are not drawn on. The Stage One procedures and the Stage Three module structure follow the published section outline of Murphy et al. (2010). In the 2008 version the broad form has three modules, not four, and mood intolerance is handled in the focused form. The rationale for the body-checking work follows Shafran et al. (2007). Step-level detail inside the modules (record layout, body-checking, comparison, avoidance and feeling-fat steps, broad-form steps) rests on co-developers' summaries (Credo-Oxford, Dalle Grave, CEBC) and recollection of the manual, and stays tagged [uncertain].

Enhanced cognitive behaviour therapy (CBT-E) is a transdiagnostic, individualised psychological treatment for eating disorders. It covers anorexia nervosa, bulimia nervosa, binge eating disorder and other eating disorders. It was developed at the Centre for Research on Eating Disorders at Oxford (CREDO) from Fairburn's earlier CBT for bulimia nervosa. [source: Credo-Oxford; Dalle Grave, Encyclopedia]

How change happens. The model holds that the processes keeping eating disorders going are largely shared across diagnoses. At the core is overvaluation of shape, weight and their control: judging self-worth largely or exclusively by them. This drives strict dieting and other weight-control behaviour. Dieting in turn sets up binge eating (with compensatory purging) or produces low weight and starvation effects, which then maintain preoccupation. Events and moods also alter eating. [source: Credo-Oxford; Dalle Grave, Encyclopedia; Fairburn, Cooper & Shafran 2003]

The 2003 transdiagnostic theory names four additional ("external") processes that maintain the disorder in some patients: clinical perfectionism, core low self-esteem, mood intolerance and interpersonal difficulties. In the 2008 treatment, mood intolerance is addressed in the focused form (within the events, moods and eating work), and the broad form adds modules for the other three. [source: Murphy et al. 2010 outline (EM-consulte), whose single broad-form section is "Addressing Clinical Perfectionism, Low Self-esteem, and Interpersonal Problems"; Dudek et al. 2014; Cooper & Fairburn 2011 abstract; Fairburn, Cooper & Shafran 2003]

Treatment builds a personal formulation of these processes with the patient. It then disrupts them through behaviour change, and the patient analyses how each change affects their thinking. The patient's sense of control and autonomy is built up throughout. [source: Dalle Grave webinar]

2. Framework

Format. Individual outpatient sessions of about 50 minutes, preceded by assessment. CBT-E for adults was designed for outpatients. There are intensive day-patient and inpatient versions (Dalle Grave 2012) and a version for younger people. [source: Credo-Oxford; CEBC]

Which length:

Not significantly underweight (adult BMI roughly 18.5 to 39.9): 20 sessions over 20 weeks. [source: Credo-Oxford; Dalle Grave, Encyclopedia]
Underweight (adult BMI roughly 15.0 to 18.49): about 40 sessions over 40 weeks, with weight regain built in. [source: Credo-Oxford; Dalle Grave, Encyclopedia]
Below the outpatient range, or medically unstable: intensive (day-patient or inpatient) CBT-E or other higher-level care. [synthesis, drawn from the BMI ranges above; check local medical criteria]
Adolescents (12 to 19): 20 sessions if not underweight, and 30 to 40 if underweight (BMI below about the 25th centile), plus parent sessions. [source: Dalle Grave webinar; CEBC]

Typical session structure. In-session weighing at the start, then a joint review of the monitoring records, then setting the agenda together. Next comes work on one or two agenda items, then a summary and agreed homework. [source: Springer EWD 2023 trial description; Fairburn 2008 ch. 5–6; uncertain on exact order]

Assessment and preparation (before Stage One):

Goals: establish the diagnosis and the eating-disorder features, assess medical risk and comorbidity, and decide on suitability and the version to use. Prepare the patient: explain the treatment's nature, its demands and the need for it to take priority. [source: Fairburn 2008 ch. 4 title; Dalle Grave webinar, which gives 2 pre-treatment assessment sessions for adolescents]
Measures: the Eating Disorder Examination interview and the EDE-Q, plus the Clinical Impairment Assessment (CIA). These are licensed instruments reproduced in the manual's appendices; do not copy items. [source: Guilford contents]
Hold-off rule: treatment cannot start, and must be suspended, if the patient does not agree there is a problem to address. Dalle Grave notes this is uncommon. [source: Dalle Grave webinar]

Stage One: "Starting well" (20-session version: about 8 sessions, twice weekly for 4 weeks)

Goals: engage the patient in treatment and change. Jointly create the formulation. Start real-time self-monitoring and weekly collaborative weighing. Give personalised education. Establish regular eating. Involve significant others where helpful. For underweight patients, start the decision about weight regain. [source: Credo-Oxford; Dalle Grave webinar; CEBC; Murphy et al. 2010 outline, whose Stage One headings name these same procedures]
Why twice weekly: to build momentum, because early change matters. The manual's chapter is called "Achieving early change". [source: Guilford contents; Credo-Oxford]

Stage Two: "Taking stock" (about 2 sessions, weekly)

Goals: a systematic review of progress (re-administering the EDE-Q and CIA is the usual way to do this [uncertain]). Identify barriers to change and revise the formulation. Decide between focused and broad CBT-E. Design Stage Three. [source: Credo-Oxford; Dalle Grave webinar; CEBC]
Adolescent version: reviews happen one week after Step One and then every 4 weeks; for underweight adults, the review is also repeated about monthly. [source: CEBC; Dalle Grave webinar]

Stage Three: the main body (about 8 weekly sessions in the 20-session version; much longer in the 40-session version)

Goals: address the maintaining processes in the formulation, using these modules:
- Overvaluation of shape and weight (shape concern, shape checking, feeling fat, mindsets)
- Dietary restraint and dietary rules
- Events, moods and eating (in the 2008 version this includes mood intolerance)
- Underweight and undereating
- Setbacks and mindsets
- In the broad form only: clinical perfectionism, core low self-esteem and interpersonal difficulties
[source: Credo-Oxford; Guilford contents; CEBC; Murphy et al. 2010 outline, which lists the Stage Three sections as overevaluation of shape and weight, dietary rules, event-related changes in eating, and the three broad-form problems, with underweight patients covered in a separate section]
Order: start with the most powerful maintaining process, usually overvaluation. Dietary restraint and event-related eating usually run in parallel. [Fairburn 2008; uncertain; ordering by formulation is [synthesis]]

Stage Four: "Ending well" (20-session version: 3 sessions, about 2 weeks apart)

Goals: make sure progress is maintained and minimise the risk of relapse. Address concerns about ending. Phase out self-monitoring and in-session weighing. Set realistic expectations. Agree a personal maintenance plan, including how to handle setbacks and a long-term plan for weight maintenance. [source: CEBC; Credo-Oxford]

Post-treatment review.

Adults: one review session some months after treatment ends (about 20 weeks in the 20-session version [uncertain]). [source: Credo-Oxford]
Adolescents: reviews at about 4, 12 and 20 weeks after the end of treatment. [source: CEBC; Dalle Grave webinar]

Underweight version (40 sessions): three steps

Help the patient decide to regain weight rather than have it imposed.
Regain weight while addressing the eating-disorder psychopathology at the same time.
Become skilled at maintaining the new weight.

Sessions stay twice weekly until weight regain is under way. [source: Dalle Grave, Encyclopedia; CEBC]

Criteria for moving on:

Stage One to Two: after the planned number of Stage One sessions (about 4 weeks), whether or not change is complete. Stage Two is where non-response is examined. [source: Credo-Oxford stage descriptions; time-limited moving on is [synthesis] from the fixed session plan]
To the broad form: only when clinical perfectionism, core low self-esteem or interpersonal problems are marked, appear to maintain the eating disorder and may interfere with treatment. Focused is the default. In the 2008 version, mood intolerance does not on its own call for the broad form, because the focused form handles it. [source: CEBC; Dalle Grave webinar; Dalle Grave, Encyclopedia; Murphy et al. 2010 outline]
Extending treatment: a life crisis or clinical depression may justify a delay or an extension. [source: CEBC]
Into Stage Four: when the remaining sessions call for it. The calendar drives this, and the patient's readiness shapes its content. [synthesis]

Medical management. Low weight, frequent purging and laxative misuse carry medical risk. Arrange medical assessment and monitoring by a physician alongside therapy, and agree in advance the thresholds for a step-up to intensive care. [source: Fairburn 2008 ch. 4 title "…Medical Management"; detail is [synthesis]; NICE NG69 [uncertain]]

3. Guiding principles

Transdiagnostic: treat the processes, not the diagnosis label. Use the same toolkit for AN, BN, BED and OSFED, and pick modules from the formulation. [source: Credo-Oxford; Dalle Grave, Encyclopedia]
Highly individualised ("like a glove"): the formulation, not a session-by-session script, decides which modules run and when. Revise the plan as the patient changes. [source: Credo-Oxford]
Focused is the default: add broad-form modules only when external problems are marked and maintaining the disorder. [source: Dalle Grave, Encyclopedia; CEBC]
Collaborative and never coercive: never ask the patient to do something they have not agreed to. Change, including weight regain, is chosen, not imposed. [source: Dalle Grave webinar; Dalle Grave, Encyclopedia]
Enhance control and autonomy: frame procedures as ways the patient regains control over eating, not as control taken from them. [source: Dalle Grave webinar]
Engagement and ambivalence are worked on from session one: treat ambivalence as expected material, not as a reason to wait. [source: Dalle Grave webinar]
Address the maintaining processes, not the origins: spend session time on what keeps the problem going now. Explore origins only briefly and late, when it helps loosen overvaluation. [source: CEBC ("explore origins" sits inside the overvaluation module); Credo-Oxford]
Early change is a priority: twice-weekly sessions in Stage One, with behaviour change starting at once. Early response matters. [source: Credo-Oxford; Guilford ch. 6 title]
Change behaviour, then study its effect on thinking: make gradual behavioural changes and analyse their effects on cognition, rather than relying on verbal challenging. [source: Dalle Grave webinar]
Real-time self-monitoring drives everything: the patient observes the formulation operating in daily life, and that observation is what produces cognitive change. [source: Dalle Grave webinar]
Homework is the treatment: the work between sessions largely determines outcome. Review it at every session. [source: CEBC; Oxford Health leaflet]
Weight is handled openly and jointly: weigh in session, and interpret the trend together. [source: CEBC; Springer EWD 2023]
Time-limited, with a fixed endpoint: the endpoint is stated at the start and keeps momentum. [source: Credo-Oxford session numbers; framing is [synthesis]]
Educate on the patient's own terms: education is personalised and tied to the patient's records and formulation. [source: Credo-Oxford ("personalised education")]
Plan for setbacks rather than promising cure: setbacks are expected. Teach the patient to spot them early and act. [source: CEBC; Dalle Grave webinar]
Medical safety comes first: physical risk sets the treatment setting. [source: Fairburn 2008 ch. 4 title; [synthesis]]

4. Intervention inventory

The named procedures and modules below are confirmed in the sources. The Stage One procedures (engaging the patient, jointly creating the formulation, real-time self-monitoring, collaborative weekly weighing, education, regular eating, involving significant others) and the Stage Three modules match the section headings of Murphy et al. (2010). The step detail within each one is partly reconstructed from the manual and tagged accordingly. Every example line is my own wording (illustrative). Session-by-session scripts and the record forms in Fairburn (2008) are copyrighted, so use the manual for the exact forms.

A. Stage One: Starting well

1. Engaging the patient and preparing for treatment

Purpose: turn an often ambivalent patient into an active partner, and set the treatment's frame. The frame is fixed length, twice-weekly sessions to begin with, homework, weighing, and treatment as a priority. Use it in the assessment and initial session. [source: Dalle Grave webinar; Credo-Oxford; Guilford ch. 4–5 titles]
Steps:
1. Invite the patient's own account of the problem and its costs.
2. Explain that CBT-E is personalised, collaborative and time-limited, and that most change happens between sessions.
3. Describe the main procedures (monitoring, weekly weighing, regular eating) and why each matters. Say clearly that nothing will be done without their agreement.
4. Check for barriers: life events, other commitments, and medical issues.
5. If the patient does not agree there is a problem, do not start. Revisit later. [source: Dalle Grave webinar]
Example language (illustrative): "This treatment works best if we treat the next few months as a priority. I won't ask you to do anything you haven't agreed to, but I will ask you to try things between sessions."
Watch for: passive agreement, or the patient presenting a family member's goals as their own. Engagement is working when the patient brings their own examples and questions.

2. Jointly creating the personal formulation

Purpose: a visual diagram, built from the patient's own experience, of the processes maintaining the problem. These processes become the treatment targets. Do this in the first session, and revise it at each review. [source: Dalle Grave webinar; CEBC; Credo-Oxford]
Steps:
1. Start where the patient is. Usually that is the behaviour that troubles them most, such as binge eating or the inability to gain weight.
2. Using their words, draw the links between the core overvaluation of shape, weight and eating control and strict dieting. Then link dieting to binge eating and compensation, or to low weight and starvation effects, and add events and moods. Possible targets include strict dieting, low weight, starvation symptoms, binge eating, purging, adverse events and moods, and overvaluation. [source: Dalle Grave webinar]
3. Include only elements that apply to this patient, and keep it simple.
4. Point out the vicious circles, and say that breaking them is what treatment does.
5. Present it as provisional, to be revised with information from the records. Give the patient a copy. [Fairburn 2008; steps 3–5 uncertain]
Example language (illustrative): "Let's draw what seems to keep this going for you. Tell me if any link doesn't fit."
Watch for: a formulation drawn by the therapist and accepted politely. It is working when the patient corrects it or adds to it, and later recognises the circles in their records.

3. Real-time self-monitoring

Purpose: the foundation of the whole treatment. It shows the formulation operating in daily life, and that observation produces cognitive change. Start it in session one and keep it going until Stage Four. [source: Dalle Grave webinar; CEBC]
Steps:
1. Give the monitoring record. Typical columns are the time, all food and drink (described, not in calories), place, a mark for episodes the patient regards as excessive or binges, and vomiting, laxatives or exercise. A comments column records thoughts, feelings, events and body checking. [source: Mental Health @ Home summary; CEBC ("eating, thoughts and behaviors"); column layout per Fairburn 2008, uncertain]
2. Ask the patient to record in real time, straight after eating, not from memory at the end of the day.
3. At every session, the patient talks you through the records. Look for patterns, and link what you see to the formulation.
4. Respond to gaps with curiosity, not criticism.
5. Phase it out in Stage Four. [source: CEBC]
Example language (illustrative): "Write it down as close to eating as you can. The record is for us to learn from, not to judge you by."
Watch for: calorie-counting creeping into the records, which feeds dietary checking; retrospective filling-in; and records withheld out of shame. It is working when records are complete and the patient starts to spot triggers themselves.

4. Collaborative weekly in-session weighing

Purpose: to address the patient's fears and misreading of weight, and to replace both frequent checking and avoidance with one weekly, accurate data point. The data also show that changing the eating pattern does not produce the feared weight gain. Start it in Stage One. [source: CEBC; Springer EWD 2023; Credo-Oxford]
Steps:
1. Weigh the patient together at the start of each session. The patient sees the number.
2. The patient plots it on a personal weight graph.
3. Interpret the trend across several readings, not single readings. Teach that day-to-day fluctuations are expected. [source: CEBC ("interpret and cope with fluctuations")]
4. Ask the patient to stop weighing at home. Patients who avoid weighing are helped to face the weekly number instead. [source: Mental Health @ Home; avoidance part per Fairburn 2008, uncertain]
5. Withdraw it in Stage Four and agree a sustainable pattern for after treatment. [source: CEBC]
Example language (illustrative): "One reading tells us very little. We'll look at the last few together before deciding what anything means."
Watch for: distress spikes around the number. Plan time in the session for this. It is working when the patient's reaction to the number decreases and their interpretation becomes trend-based.

5. Personalised education

Purpose: to correct the beliefs that maintain the disorder. Give it in Stage One, linked to the patient's own records. [source: Credo-Oxford; CEBC]
Steps:
1. Cover these topics as they apply to the patient:
  - body weight regulation and natural fluctuation
  - the adverse effects of dieting, and how dieting promotes binge eating
  - the ineffectiveness and physical risks of self-induced vomiting and laxative misuse as weight control
  - the effects of being underweight, where relevant
  - the CBT maintenance model [source: CEBC; Dalle Grave webinar]
2. Use guided reading from a CBT-E-consistent self-help book (e.g. Fairburn's Overcoming Binge Eating, 2nd ed.). Discuss the chapters in session. [the use of reading is uncertain; book confirmed as CBT-E-based per Mental Health @ Home]
3. Ask what the patient makes of each point for themselves.
Example language (illustrative): "Let's check that idea against your own records from this week."
Watch for: intellectual agreement without any change in behaviour. Return the education to the behavioural tasks.

6. Establishing regular eating

Purpose: to displace both dieting and binge eating with a stable pattern of planned meals and snacks. This is the central early behavioural change. Introduce it in the first weeks. [source: Credo-Oxford; CEBC; Dalle Grave webinar]
Steps:
1. Agree a daily plan of three planned meals and two or three planned snacks, with no long gaps (no more than about four hours between eating episodes). [source: Mental Health @ Home summary; CEBC ("planned meals and snacks")]
2. Eat at the planned times, and try not to eat in between.
3. At first, the patient chooses what to eat. The pattern comes first, and what is eaten is addressed later in the dietary-restraint module. [Fairburn 2008; uncertain]
4. No compensatory vomiting or laxatives after planned eating.
5. Review adherence and any difficult times in the records. Problem-solve each sticking point.
6. Extend the pattern to social eating. [source: Mental Health @ Home]
Example language (illustrative): "For now, the goal is when you eat, not what. Let's plan this week's meal and snack times around your days."
Watch for: the plan being turned into a new diet with very small "snacks", and fear of weight gain (link this back to the weighing graph). It is working when the gaps shrink and binges fall in frequency.

7. Managing urges to binge or purge (alternative activities and urge management)

Purpose: to help the patient ride out urges while regular eating takes hold. Use it in Stage One with any patient who binges or purges. [source: Mental Health @ Home; Springer EWD 2023 ("urge management")]
Steps:
1. The patient lists activities that are incompatible with bingeing (e.g. going out for a walk) or that make it less likely (e.g. leaving the kitchen).
2. They write the list on a card, ready for use.
3. When an urge arises, the patient notes it in the record and starts an alternative activity.
4. They notice that the urge rises and then fades without being acted on (urge surfing).
5. Review what worked in session.
Example language (illustrative): "Urges peak and pass. Let's pick two things you can do for the next half hour when one hits."
Watch for: avoidance turning into new restriction. It is working when urges are recorded without a binge following.

8. Addressing purging and other compensatory behaviour

Purpose: to stop self-induced vomiting, laxative or diuretic misuse, and driven exercise. [source: CEBC (education on vomiting and laxatives); Mental Health @ Home (targets list)]
Steps:
1. Educate on how ineffective and risky these behaviours are.
2. Vomiting tied to binges usually falls as binges fall.
3. Address vomiting that is not tied to binges directly, through regular eating and weighing data.
4. Agree a plan to stop or reduce laxatives and diuretics, with medical input if use has been heavy.
5. Monitor all of these behaviours in the records. [steps 2–4 per Fairburn 2008, uncertain; medical input is [synthesis]]
Watch for: physical symptoms (dizziness, palpitations, fainting). Refer for urgent medical review. [synthesis]

9. Involving significant others (adults) and parents (adolescents)

Purpose: to make the home environment help rather than hinder. For adults, use it when others can help or are interfering. For adolescents it is standard. [source: Credo-Oxford; Dalle Grave webinar; CEBC]
Adolescent steps:
1. Two short joint sessions during assessment.
2. One 50-minute parent-only session in the first week. It covers:
  - education on the disorder, the CBT model and the parents' role
  - instilling hope
  - building a supportive home: no restrictive dieting at home, no comments on the young person's eating or on thinness, and a calm atmosphere
  - assessing barriers, such as practical problems, cultural factors, disagreement about the need for treatment, and parental mental illness
3. About 8–10 joint segments of 15–20 minutes at the end of individual sessions. These update parents and, with the young person's prior agreement, plan how they can help with procedures such as meals.
4. Extra joint sessions for family crises, severe mealtime difficulties or high parental criticism.
[source: Dalle Grave webinar; CEBC]
Adults: with consent, one or more sessions with a partner or family member to explain the treatment and agree how they can help. [Fairburn 2008; number of sessions uncertain]
Example language (illustrative), to parents: "Comments about how much she is eating, even kind ones, tend to backfire. What helps most is a calm table and sticking to the plan she's agreed."
Watch for: parents taking over the treatment, or the young person's confidentiality being breached. Agree what will be shared before each joint segment.

10. Stage Two review (and later reviews)

Purpose: a systematic stock-take. It identifies barriers, revises the formulation, decides focused versus broad, and designs Stage Three. [source: Credo-Oxford; Dalle Grave webinar; CEBC]
Steps:
1. Re-administer the outcome measures (EDE-Q, CIA) [uncertain], and review the records and the weight graph together.
2. List what has changed and what has not.
3. Identify general barriers (e.g. work or school pressure) and barriers specific to the eating disorder (e.g. difficulty regaining weight, persistent restraint). [source: CEBC]
4. Update the formulation.
5. Assess whether clinical perfectionism, core low self-esteem or interpersonal problems are marked and maintaining the disorder. If they are, plan the broad form. If mood intolerance is prominent, plan the mood-intolerance work inside the focused form (intervention 25). [source: Murphy et al. 2010 outline]
6. Agree the Stage Three plan and its order.
Example language (illustrative): "Let's look honestly at what has shifted and what hasn't, and use that to plan the rest of treatment."
Watch for: poor early progress. This predicts outcome, so the review should change the plan rather than continue unchanged. [synthesis]

B. Underweight and undereating module (40-session version)

11. Deciding to change: weighing up weight regain

Purpose: to help the underweight patient choose to regain weight rather than have it imposed. This takes up the first weeks of the underweight version. [source: Dalle Grave, Encyclopedia; Dalle Grave webinar; CEBC ("pros and cons of weight regain" as homework)]
Steps:
1. Educate about the effects of being underweight, linking each one to the patient's own experience: preoccupation with food, rigidity, low mood, poor sleep, social withdrawal and physical effects. [effects list per Fairburn 2008, uncertain]
2. Ask the patient to list the pros and cons of change, both now and imagined some years ahead, as homework. [source: CEBC]
3. Discuss the list in session, helping the patient see which points are driven by the disorder.
4. Bring them to a decision to start regaining weight. If they are not ready, revisit regularly; do not move on by force. [source: Dalle Grave webinar ("never coercive")]
Example language (illustrative): "You've written that being thin makes you feel in control. Looking at your records, how much control do you have over thinking about food?"
Watch for: a decision on paper with no change in eating. It is working when the patient starts to own the reasons for change.

12. Regaining and then maintaining weight

Purpose: to restore a healthy weight while the eating-disorder psychopathology is worked on in parallel, and then to build the skills to maintain it. [source: Dalle Grave, Encyclopedia; CEBC]
Steps:
1. Agree a gradual eating plan that creates a steady daily energy surplus, built on the regular eating pattern. [source: CEBC] The manual specifies quantities and an expected average weekly rate of gain; take these from the manual and the medical team, not from this guide.
2. Monitor progress on the weekly graph, and review it about monthly.
3. Address the fears that arise using the overvaluation and restraint procedures.
4. Address driven exercise as part of this module. [uncertain]
5. Once the patient is in the healthy range, shift to maintenance: learning to eat flexibly, interpreting fluctuations, and setting a weight-range plan for after treatment. [source: CEBC ("long-term weight maintenance plan")]
Example language (illustrative): "This week the graph is going the way you decided you wanted it to. What thoughts came up when you saw it?"
Watch for: stalls, hidden restriction or compensatory activity, and medical warning signs. Liaise with the physician. [synthesis]

C. Overvaluation of shape and weight module

13. Identifying overvaluation and its consequences (the pie chart)

Purpose: to make the core problem visible: self-evaluation that depends largely on shape, weight or the control of eating. This is usually the first Stage Three module. [source: CEBC ("educate on overvaluation"); Mental Health @ Home (pie chart credited to Murphy et al. 2010)]
Steps:
1. Ask the patient to list the domains of life they use to judge themselves, such as relationships, work or study, sport and appearance.
2. Ask them to rate how important each domain is to them.
3. Draw these as slices of a pie chart, sized by importance. The shape-and-weight slice is typically very large.
4. Discuss the problems with this scheme: it is risky ("all eggs in one basket"), self-defeating, and it squeezes out the other domains.
5. Draw an extended formulation of how overvaluation shows itself, through body checking, avoidance, feeling fat, preoccupation and the marginalising of other areas.
6. Repeat the pie chart later to show change. [steps 1–6 per Fairburn 2008 and Murphy et al. 2010; uncertain]
Example language (illustrative): "If this slice is most of the pie, then every bad body day becomes a bad day about you as a person."
Watch for: the patient defending the importance of appearance. That is fine. The aim is a larger set of domains, not denial.

14. Enhancing the importance of other domains

Purpose: to shrink the shape-and-weight slice by growing the others. This is the most direct way to reduce overvaluation. Use it with the pie chart. [source: CEBC ("restore neglected self-evaluation domains"); Oxford Health leaflet]
Steps:
1. Identify activities the patient used to value or would like to try.
2. Choose one or two, and schedule them as homework.
3. Use problem solving (intervention 24) for the practical obstacles.
4. Review each week, and build on what works. [steps per Fairburn 2008; uncertain]
Example language (illustrative): "What did you care about before the eating disorder took up so much room? Which of those could you restart this week?"
Watch for: new activities being chosen for their calorie burn. It is working when the patient's time and attention spread more widely.

15. Addressing body checking

Purpose: to reduce body checking, which maintains dissatisfaction by magnifying perceived flaws. Examples are repeated weighing, mirror scrutiny, pinching, measuring, checking how clothes fit and comparing oneself with others. In an experiment by Fairburn's group, repeated critical mirror checking increased body dissatisfaction and feelings of fatness, while a neutral look at the whole body reduced feelings of fatness. [source: CEBC ("reduce body checking"); Springer EWD 2023 ("reducing shape checking"); Shafran, Lee, Payne & Fairburn 2007 abstract; Dudek et al. 2014 (comparison as a form of checking)]
Steps:
1. Ask the patient to record body checking in real time on one weekday and one weekend day, to reveal how often and in what ways they check.
2. Educate on how selective attention and scrutiny magnify what is seen.
3. Agree which checks to stop outright (e.g. pinching or measuring) and which to modify (e.g. mirror use).
4. For mirror use, help the patient work out what they are trying to find out and whether a mirror can really tell them. Keep mirrors for ordinary purposes (e.g. hair, make-up), and avoid prolonged critical scrutiny of particular body parts, which in the 2007 experiment raised feelings of fatness. [mirror guidance per Fairburn 2008, uncertain; the experimental link is from Shafran et al. 2007]
5. Monitor checking as it falls. [steps per Fairburn 2008; uncertain]
Example language (illustrative): "If you study any part of anyone's body for long enough, it starts to look wrong. What happens to how you feel after you check?"
Watch for: checking that has moved underground or into reassurance-seeking. It is working when checking is less frequent and the patient is less preoccupied.

16. Addressing comparison making

Purpose: to correct biased comparisons with other people. Comparison is treated as a form of shape checking. Patients typically compare themselves with thin or attractive people, judge them superficially, and judge themselves critically. [comparison as checking: Dudek et al. 2014, citing Fairburn's group; the description of the bias per Fairburn 2008 ch. 8; uncertain]
Steps:
1. Record comparisons for a few days: who the patient compared with, and how.
2. Review the bias in who is chosen and in how each side is judged.
3. As a behavioural exercise, observe a range of people, for example every third person of similar age in a public place, to recalibrate.
4. Discuss what the patient notices. [uncertain]
Example language (illustrative): "Notice who you pick to compare with. What happens if the comparison group is everyone, not just the slimmest person in the room?"
Watch for: the exercise turning into more checking. Keep it brief and structured.

17. Addressing body avoidance

Purpose: to reverse avoidance of seeing or feeling one's body, such as covering up or avoiding mirrors, swimming pools or trying on clothes; never weighing is the weight equivalent. Avoidance maintains fears in the same way checking does. [source: CEBC ("reduce body checking and avoidance"); Dudek et al. 2014 (these avoidance examples as maintaining mechanisms, citing Fairburn's group); Shafran et al. 2007 (neutral whole-body observation reduced feelings of fatness)]
Steps:
1. Identify the avoided situations.
2. Grade them by difficulty.
3. Help the patient get used to their own body step by step, through planned exposure (e.g. wearing more fitted clothes, or looking at their body in a neutral, descriptive way). [grading per Fairburn 2008; uncertain]
4. Review what they predicted and what actually happened.
Safety and consent: this is exposure. Agree each step explicitly. Avoid it during acute distress or acute self-harm risk. Keep it descriptive and non-critical. Stop and review if distress rises without settling. [synthesis]
Example language (illustrative): "What do you predict will happen if you wear that top for an hour? Let's test it."

18. Addressing "feeling fat"

Purpose: to relabel the experience of "feeling fat", which patients equate with being fat. It is triggered by other emotions or body sensations, and body checking can intensify it. [source: CEBC ("relabel 'feeling fat'"); Dudek et al. 2014 (misreading sensations as fatness as a maintaining mechanism); Shafran et al. 2007 (checking increased feelings of fatness)]
Steps:
1. Record times of intense feeling fat in real time.
2. For each, identify what else was happening: specific emotions (boredom, sadness, feeling unattractive) or sensations (feeling full, bloated, sweaty, clothes tight).
3. Teach the patient to ask, when it occurs, what they are actually feeling, and to relabel it.
4. Address the real trigger, through problem solving or mood strategies. [steps per Fairburn 2008; uncertain]
Example language (illustrative): "Fat isn't a feeling. When it hit yesterday, what else was going on?"
Watch for: fewer, briefer episodes. It is working when the patient can name the underlying state themselves.

19. Exploring the origins of overvaluation

Purpose: to help the patient see overvaluation as a historical development that once served a purpose, which weakens its hold now. Use it late in the module. [source: CEBC ("explore origins")]
Steps:
1. Build a timeline of when shape and weight became so important, and the events around that time.
2. Discuss how the overvaluation may once have helped, and whether it does now. [uncertain]
Example language (illustrative): "Looking back, what was happening when weight started to matter this much? Does that reason still apply?"
Watch for: sessions drifting into extended exploration of the past. Keep it brief and linked to the present. [synthesis]

20. Learning about and controlling the eating-disorder mindset

Purpose: to help the patient recognise the eating-disorder "frame of mind", which can switch back on, and to learn to displace it. Use it at the end of the overvaluation module and throughout Stage Four. [source: CEBC; Dalle Grave webinar]
Steps:
1. Describe the mindset as a state that filters experience through shape, weight and eating.
2. Identify its triggers and early warning signs (e.g. weighing more often, cutting a snack, or a rise in checking).
3. Plan concrete actions that displace it when it switches on. For example, get back on track with regular eating, do something absorbing, or talk to someone. [source: CEBC ("displace the mindset"); Dalle Grave webinar ("decentring" from it quickly)]
Example language (illustrative): "When you notice the old mindset switching on, that's the signal to act, not to wait and see."
Watch for: the patient's ability to name the mindset and act early. This is the core relapse-prevention skill.

D. Dietary restraint module

21. Identifying and breaking dietary rules (behavioural experiments)

Purpose: to turn rigid dietary rules into flexible guidelines. Examples are not eating before a set time, keeping under a set amount, or never eating certain foods. Breaking these rules tests the patient's feared outcomes and removes a key binge trigger. [source: CEBC ("turn rigid food rules into flexible guidelines"); Springer EWD 2023 ("dietary rule breaking experiments" testing feared outcomes); Dalle Grave webinar]
Steps:
1. Help the patient recognise that their dieting is a problem, not a solution. [source: Dalle Grave webinar]
2. List the rules, using the records and questioning.
3. For each rule, identify the belief behind it and the feared consequence of breaking it.
4. Plan a specific, agreed experiment to break the rule. Predict the outcome beforehand, and record what actually happened.
5. Review the result, and repeat until the rule loosens.
6. Address related "food checking" behaviours, such as calorie counting or scrutinising labels, in the same way. [step 6 uncertain]
Example language (illustrative): "Your rule says if you eat before noon you'll lose control. Shall we test that on Tuesday and write down what happens?"
Watch for: the patient replacing one rule with another. It is working when experiments disconfirm the patient's predictions and rigidity falls.

22. Reintroducing avoided foods

Purpose: to address food avoidance, a core form of restraint and a frequent binge trigger. [source: CEBC ("reintroduce avoided foods")]
Steps:
1. Build a list of avoided foods. One option is a supermarket or online browse, noting foods the patient avoids or would be anxious to eat. [uncertain]
2. Group the foods by difficulty.
3. Introduce them progressively, starting with the easier ones, in planned amounts within regular meals and snacks. Choose days when the patient feels able. [grading per Fairburn 2008; uncertain]
4. Continue until the foods can be eaten without undue anxiety.
5. Review each introduction against the patient's prediction, and record it.
Safety and consent: this is exposure to feared foods. Agree each step. For patients who binge, plan introductions at times and places where the risk of a binge is low. [synthesis]
Example language (illustrative): "Let's start with the food on your list you're least worried about, as part of a planned snack."

E. Events, moods and eating module

23. Analysing triggers of binge eating and other episodes

Purpose: to identify the four typical precipitants of binges: breaking a dietary rule, undereating or low weight, adverse events or moods, and alcohol or other disinhibition. Each one points to a different module. [source: Mental Health @ Home summary (four triggers); Fairburn 2008 ch. 10; uncertain]
Steps:
1. For each episode, review the record for what came before it.
2. Assign it to one or more triggers.
3. Match each trigger to a response: regular eating, rule-breaking work, problem solving or mood work.
Example language (illustrative): "Look back at the three hours before the binge. Which of the usual triggers do you see?"

24. Proactive problem solving

Purpose: to deal with the events that set off eating changes before they do so. Use it when the records link episodes to external triggers. [source: CEBC ("proactive problem-solving for triggering events"); Credo-Oxford ("coping with day-to-day events")]
Steps:
1. Spot a problem early, and note it in the records.
2. Specify it exactly.
3. Brainstorm several solutions without judging them.
4. Consider the likely effects of each one.
5. Choose one, or a combination.
6. Act on it.
7. The next day, review both the solution and how well the problem-solving went. [the standard stepwise sequence used in CBT-E per Fairburn 2008; exact steps uncertain]
Example language (illustrative): "Let's catch Friday's problem now, before it turns into an eating problem. What exactly is the difficulty?"
Watch for: solving the problem in your head rather than on paper, especially early on. It is working when the patient does it unprompted.

25. Addressing mood intolerance

Purpose: to help patients who cannot tolerate intense moods and use binge eating, vomiting, intense exercise or self-harm to modulate them. They learn to accept and regulate moods instead. In Fairburn (2008) this belongs to the focused form's events, moods and eating work, not to the broad-form modules. [source: CEBC; Dalle Grave webinar; placement per Murphy et al. 2010 outline, whose broad-form section omits mood intolerance; how the adolescent book places it is [uncertain]]
Steps:
1. Help the patient recognise the pattern of mood, then dysfunctional mood modulation, then relief and later regret.
2. Monitor mood changes and the responses to them in real time.
3. Identify the triggers of mood shifts, and address them through problem solving.
4. Practise accepting a mood without acting on it.
5. Practise adaptive modulation instead, such as calming or distracting activity or talking to someone.
6. Reduce any mood-altering substances. [steps 2–6 uncertain]
Example language (illustrative): "The feeling will peak and fall even if you do nothing about it. What could you do in the meantime that you won't regret later?"
Watch for: self-harm. Assess risk using standard practice and act on it (see Section 5).

F. Broad-form modules

Use these only when the problem is marked, is maintaining the disorder and is likely to block progress. In the 2008 version there are three: clinical perfectionism, core low self-esteem and interpersonal difficulties. Mood intolerance is not among them (see intervention 25). [source: CEBC; Dalle Grave webinar; Murphy et al. 2010 outline]

26. Clinical perfectionism

Purpose: to address self-evaluation based on striving for, and achieving, demanding standards. It shows as preoccupation with performance, checking for deficiencies and a sense of repeated failure. [source: Mental Health @ Home (targets); Guilford ch. 13 title]
Steps:
1. Map perfectionism as a second overvaluation, using the same pie-chart and formulation approach.
2. Reduce performance checking and avoidance.
3. Use behavioural experiments with adjusted standards.
4. Address self-criticism and overgeneralising from single "failures".
5. Broaden the patient's domains of self-evaluation. [steps per Fairburn 2008 ch. 13; uncertain]
Example language (illustrative): "What would happen if this piece of work were good enough rather than perfect? Let's test it."

27. Core low self-esteem

Purpose: to address unconditional, pervasive negative self-evaluation that is independent of performance and that blocks change. [source: Guilford ch. 13 title; CEBC]
Steps:
1. Explain the negative view of self as long-standing, and as distinct from the patient's real qualities.
2. Identify the cognitive biases that keep it going: discounting positives and overgeneralising.
3. Collect and log evidence of positive qualities.
4. Re-evaluate the patient's overall view of themselves. [uncertain]
Example language (illustrative): "You notice every mistake and file away every success as luck. Let's keep a different kind of record this week."

28. Interpersonal difficulties

Purpose: to address interpersonal problems that maintain the eating disorder. Fairburn uses an interpersonal psychotherapy (IPT)-style approach, delivered within the same sessions. [source: Guilford ch. 13 title; CEBC; IPT method per Fairburn 2008; uncertain]
Steps:
1. Identify the current interpersonal problem area (e.g. a role dispute, a role transition or interpersonal deficits).
2. Agree goals.
3. Work on them with IPT methods, alongside the eating-disorder work in the same sessions. [uncertain]
Example language (illustrative): "It looks like the binges cluster after arguments with your sister. Let's make that relationship one of our targets."

G. Stage Four and after

29. Ending well: maintenance plan and setbacks

Purpose: to maintain progress and minimise relapse. [source: CEBC; Credo-Oxford; Dalle Grave webinar]
Steps:
1. Discuss the patient's concerns about ending.
2. Plan short-term work to continue until the review.
3. Phase out self-monitoring and in-session weighing, and agree a sustainable weighing habit for afterwards.
4. Set realistic expectations: residual concerns are common, and setbacks are likely.
5. Write a personal maintenance plan together. It should cover early warning signs, triggers, and the steps to take when a setback occurs, such as restarting monitoring, regular eating and problem solving. For formerly underweight patients, include long-term weight maintenance.
6. Frame setbacks as "setbacks" to be acted on promptly, not as relapse. [source: CEBC; Dalle Grave webinar; "setback" framing per Fairburn 2008]
Example language (illustrative): "A slip is information, not failure. What will you do on the first day you notice the old patterns?"

30. Post-treatment review session(s)

Purpose: to check that the maintenance plan is being used, and to address residual or new problems. [source: Credo-Oxford; CEBC]
Steps:
1. Review the patient's progress since treatment ended.
2. Weigh with the patient if they agree.
3. Revise the maintenance plan.
4. Refer onward if a full relapse has occurred.
Timing: adults, one review some months after the end of treatment. Adolescents, reviews at about 4, 12 and 20 weeks after the end. [source: Credo-Oxford; CEBC]

5. Handling problems

The sources name some of these responses (tagged). The rest is my own synthesis from CBT-E's principles, tagged [synthesis].

Patient does not see a problem or is not ready.

CBT-E does not start, and is suspended, if the patient does not agree there is a problem to address. [source: Dalle Grave webinar]
Use engagement work and education. For underweight patients, use the pros-and-cons work in intervention 11 over several sessions.
Offer a planned return date rather than a discharge that feels like rejection. [synthesis]
With minors, safety and family-based alternatives take precedence when engagement fails. [synthesis]

Ambivalence about weight regain.

Expect it. Treat it as material for the pros-and-cons work, not a reason to impose change. [source: Dalle Grave webinar; Dalle Grave, Encyclopedia]
If weight keeps falling or the patient becomes medically unstable, step up to intensive CBT-E or other higher-level care. Make this agreement in advance. [synthesis]

Stuck: little change by the Stage Two review.

Use the review to identify general and eating-disorder-specific barriers, revise the formulation, and consider the broad form. [source: CEBC; Dalle Grave webinar]
Check the basics first: Are records being done in real time? Is regular eating actually in place? Is the therapist covering too many topics at once? [synthesis]
Re-focus on the single most powerful maintaining process. [synthesis]

Non-adherence to homework or monitoring.

Homework largely determines outcome, so treat incomplete homework as a priority agenda item. [source: CEBC]
Explore the obstacles without criticism: shame, perfectionistic standards for the records, practical barriers. Then simplify the task and problem-solve it. [synthesis]

Weighing distress.

Allow session time for it.
Interpret the trend, not single readings.
Link the graph back to the patient's decision to change.
Never weigh covertly. [source: CEBC (interpreting fluctuations); covert-weighing point is [synthesis] from the "never coercive" principle]

Overwhelm or distress during exposure work (body avoidance, avoided foods, rule-breaking).

Use smaller steps, and get explicit agreement for each one.
Debrief each step against the prediction.
Pause exposure if acute risk or severe depression is present. [synthesis]

Clinical depression. Clinical depression may justify delaying or extending treatment. [source: CEBC] Assess severity, and arrange treatment of the depression (psychological, or medical via the prescriber) before or alongside CBT-E when it blocks engagement. [synthesis; Fairburn 2008 ch. 16 "Complex cases and comorbidity"]

Suicide and self-harm risk.

Assess risk at the start and whenever mood worsens, following standard practice. Cover ideation, intent, plans, history and protective factors.
Agree a safety plan, and include lethal-means counselling (secure storage or removal of medications and other means).
Escalate to crisis services when risk is high. [synthesis]
Self-harm used to regulate mood is targeted in the mood-intolerance work (intervention 25). [source: CEBC]

Medical deterioration.

Signs include fainting, chest pain, rapid weight loss, frequent vomiting with symptoms, and very low intake.
Pause the session agenda and arrange urgent medical review.
Agree physical-monitoring arrangements with a physician from the outset. [synthesis; Fairburn 2008 ch. 4 "Medical Management"]

Ruptures (e.g. the patient feels criticised over the records or the weight).

Name the rupture, acknowledge your contribution to it, and restate that the work is collaborative and agreed.
Return to the formulation as the shared reference point. [synthesis]

Parents undermining treatment (adolescents).

Address it with education, a supportive home environment and barrier assessment in the parent session.
Hold extra joint sessions for crises, severe meal difficulties or high criticism.
Assess parental mental illness, and signpost support. [source: Dalle Grave webinar; CEBC]

Setbacks late in treatment or after it.

Use the maintenance plan.
Spot setbacks early, then reinstate monitoring and regular eating, and displace the mindset. [source: CEBC; Dalle Grave webinar]

Breaks in treatment (holidays, illness).

Plan them in advance, with a self-guided plan for the gap.
Avoid breaks in Stage One, which depends on momentum. [synthesis]

Higher BMI or binge eating disorder with a wish to lose weight.

Explain that CBT-E targets the eating disorder, not weight loss, and that dieting is a binge trigger.
Defer any weight-management decisions until after treatment. [synthesis; the targeting of dieting is from CEBC and Credo-Oxford]

Not covered in the sources [uncertain]:

the exact Stage One session-by-session content
the exact layout of the record form
guidance on remote delivery (one trial delivered modified CBT-E by videoconference without reported problems [source: Springer EWD 2023])

Sources

Sources:

Further reading (not drawn on) [uncertain]: Murphy et al. 2010 on PubMed Central (PMC2928448); the Guilford sample-chapter PDF (fairburn4.pdf); a Scinapse PDF link; the Reading repository copy of Shafran et al. 2007.

Attempted but not readable [uncertain]:

NICE NG69 recommendations: the page content did not render.
The job's trial paper (PMC3489167).
Murphy et al. (2010) via Europe PMC.
The Guilford sample-chapter PDF: access was not permitted.

Books and papers cited (not drawn on unless listed above):

Fairburn, C. G. (2008). Cognitive Behavior Therapy and Eating Disorders. Guilford Press. The treatment manual: chapters 5–12 cover the core protocol and chapter 13 the broad-form modules.
Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: a "transdiagnostic" theory and treatment. Behaviour Research and Therapy, 41, 509–528.
Murphy, R., Straebler, S., Cooper, Z., & Fairburn, C. G. (2010). Cognitive behavioral therapy for eating disorders. Psychiatric Clinics of North America, 33, 611–627.
Cooper, Z., & Fairburn, C. G. (2011). The evolution of "enhanced" cognitive behavior therapy for eating disorders: learning from treatment nonresponse. Cognitive and Behavioral Practice, 18, 394–402.
Fairburn, C. G. (2013). Overcoming Binge Eating (2nd ed.). Guilford Press.
Dalle Grave, R. (2012). Intensive Cognitive Behaviour Therapy for Eating Disorders. Nova.
Dalle Grave, R., & Calugi, S. (2020). Cognitive Behavior Therapy for Adolescents with Eating Disorders. Guilford Press.
Dalle Grave, R., & el Khazen, C. (2022). Cognitive Behaviour Therapy for Eating Disorders in Young People: Parents' Guide. Routledge.
NICE (2017). Eating disorders: recognition and treatment (NG69).

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