Riccardo Dalle Grave, MD
Eating disorders are among the most misunderstood mental health conditions. Despite decades of research and advancements in treatment, myths continue to shape care and influence patients’ experiences. A new paper in The Cognitive Behaviour Therapist sheds light on enhanced cognitive behavior therapy (CBT-E), one of the most effective therapies for eating disorders. It explores the misconceptions that hinder its wider use.
The authors highlight ten common misunderstandings about CBT-E. Their aim is not to criticize clinicians or patients but to encourage open conversations, flexibility, and confidence in a therapy that has helped many people recover.
What is CBT-E?
CBT-E is an evidence-based psychological treatment designed specifically for eating disorders. Unlike therapies tied to a single diagnosis, it takes a “transdiagnostic” approach, meaning it works across anorexia nervosa, bulimia nervosa, binge eating disorder, and related conditions.
Rather than being a rigid manual, CBT-E is guided by a formulation — a personalized diagram of the psychological mechanisms that keep the eating disorder going. Therapists and patients use this map to identify and address maintaining mechanisms, replacing them with healthier, more flexible ways of thinking, coping, and eating.
The 10 Misconceptions on CBT-E
The paper highlights ten misconceptions that can discourage clinicians from offering CBT-E or make patients less likely to start this effective treatment. Let’s explore them in everyday language.
- “CBT-E is rigid and requires strict adherence to a fixed protocol.” Not true. While CBT-E has a structure, it is designed to be tailored to each person’s needs, addressing their individual maintaining psychological mechanisms. Think of it as a flexible roadmap: the landmarks are the same, but the exact route changes for each traveler.
- “CBT-E is simply standard CBT applied to eating disorders.” CBT-E is not generic CBT. It was created specifically to target the unique thinking, emotional, and behavioral patterns of eating disorders, which are different from those in depression or anxiety.
- “CBT-E only addresses observable behaviors without tackling underlying issues.” Another myth. CBT-E addresses thoughts, feelings, and the meaning and function of eating disorders. It also includes space for understanding past experiences.
- “CBT-E has limited applicability in real-world clinical settings, where it often fails to achieve positive outcomes.” Studies across countries have shown that CBT-E is effective in everyday clinical settings, ranging from community services to day-hospital and residential settings. The challenge isn’t whether it works, but how to ensure people can access it in a timely manner and adhere to it.
- “CBT-E is unsuitable for ‘complex’ patients, particularly those with co-occurring conditions.” Complexity is the rule, not the exception, in eating disorders. Most patients have other challenges, such as depression or anxiety. CBT-E has been shown to be effective even in these situations, and its modular design enables therapists to adapt treatment as needed.
- “CBT-E is only suitable for outpatients and not applicable to intensive treatment settings.” Initially developed for outpatient care, CBT-E has been successfully adapted for use in day hospital and inpatient settings.
- “CBT-E is a lengthy and resource-intensive treatment, making it impractical for widespread use.” CBT-E can be delivered in as few as 20 sessions for some patients, while others may benefit from longer treatment. It has even been adapted into digital and guided self-help formats to expand access.
- “CBT-E is designed for adults and is not suitable for treating young people with eating disorders.” CBT-E has been adapted for adolescents and shows promising results. It involves parents as helpers while respecting young people’s growing independence.
- “CBT-E is inherently weight-stigmatizing, reinforcing negative views about higher weight.” On the contrary, CBT-E is explicitly anti-diet and works to reduce the importance placed on weight and shape in self-evaluation. The authors acknowledge that past practices sometimes unintentionally echoed weight-stigmatizing language; however, guidance has now been updated to ensure a weight-inclusive and compassionate approach.
- “CBT-E is not appropriate for individuals in larger bodies, as it may not address their specific needs.” Eating disorders affect people of all sizes, and CBT-E can help across the weight spectrum. Notably, the therapy now directly addresses the harmful effects of diet culture and internalized weight stigma, encouraging patients to build a sense of self-evaluation beyond body size.
Why These Myths Matter
These misconceptions are significant because they impact access to care. If clinicians assume CBT-E won’t work for a “complex” patient, opportunities for recovery are lost. Misbeliefs can discourage both sides from engaging in a therapy that could make a difference.
Clarifying what CBT-E really is makes treatment more accessible and effective. It encourages clinicians to use it with confidence and patients to approach it with hope.
A Therapy that Evolves with Patients
One of CBT-E’s strengths is that it evolves as understanding of eating disorders deepens. Some important updates include:
- Moving away from BMI as a health marker. CBT-E recognizes BMI as a limited and misleading measure, focusing instead on overall well-being.
- Using compassionate, weight-neutral language. This reduces stigma and helps patients feel understood.
- Developing digital and modular adaptations. Online delivery, self-help formats, and modules for trauma or cultural diversity expand CBT-E’s reach.
This adaptability makes CBT-E more than a static treatment; it is a living approach that grows with research and clinical experience.
The Bigger Picture
Eating disorders can be devastating, but recovery is possible with the proper support. The authors’ message is hopeful: CBT-E, when used as intended, can help many people regain their lives.
Replacing myths with accurate information fosters flexibility, collaboration, and compassion in treatment. Therapists are encouraged to view misconceptions as chances for reflection and learning, while patients can be reassured that CBT-E is not about dieting or shame but about building a broader, kinder sense of self.
Conclusion
CBT-E is not a miracle cure, and it is not suitable for every person. But when applied with understanding, flexibility, and respect, it can transform lives.
Misunderstandings can block recovery, but clear communication and evidence can open doors. For anyone touched by eating disorders — whether patient, family member, or clinician — the message is worth sharing: CBT-E offers a path out of the prison of an eating disorder and into a fuller, freer life.
Reference
Murphy R, Bailey-Straebler S, Dalle Grave R, Calugi S, Osborne EL, Cooper Z. Evolving perspectives on CBT-E for eating disorders: clarifying ten key points – misconceptions and communication gaps explored. The Cognitive Behaviour Therapist. 2025;18:1–19. doi: 10.1017/s1754470x25100299. Full Text