Riccardo Dalle Grave
Director Department of Eating and Weight Disorders, Villa Garda Hospital, Garda (VR), Italy
Introduction: Why Engagement Is Everything
Eating disorders—such as anorexia nervosa, bulimia nervosa, and binge eating disorder—are among the most complex and concerning mental health challenges affecting adolescents. These conditions often come with serious psychosocial and medical complications, ranging from social isolation, anxiety, and depression to heart and bone problems and growth delays. The earlier they are treated, the better the chances for recovery. However, a major obstacle often gets in the way: many teens don’t want help.
In many cases, adolescents don’t see their behaviors—whether it’s extreme dieting, purging, or over-exercising—as harmful. Instead, they may view them as necessary or positive, helping them feel more in control or aligned with their self-image. This mindset, known as egosyntonic thinking, makes treatment hard to start and even harder to sustain. Many teens begin therapy only because they are pressured by parents or doctors, not because they want to change.
This is why patient engagement is crucial—the process of getting young people involved in and committed to their recovery. And it’s why Enhanced Cognitive Behavior Therapy (CBT-E), a treatment approach that puts adolescents at the center of their healing journey, is gaining attention.
What Is CBT-E, and How Is It Different?
CBT-E is an evidence-based, flexible form of psychotherapy developed initially for adults with eating disorders. It has since been adapted for adolescents and is recommended in cases where family-based therapy is not suitable or has not worked.
What sets CBT-E apart is its conceptualization: teens with eating disorders are not seen as passive recipients of care but as capable and active participants who can learn to understand, challenge, and change the thoughts and behaviors keeping their eating disorder alive.
This personalized and collaborative approach contrasts with more directive treatments that rely heavily on parental control or medical supervision. Instead, CBT-E aims to gradually hand back responsibility to the adolescent, helping them build insight and autonomy.
Understanding the Psychological Roots
One of the first things teens learn in CBT-E is that their eating disorder isn’t just about food or weight—it’s about how they evaluate themselves. Many adolescents base their self-worth almost entirely on their shape, weight, and control over eating. This leads to behaviors like extreme dieting or purging, which feel rewarding in the short term but are harmful in the long run.
Rather than labeling these behaviors as irrational or dangerous, CBT-E helps teens explore why they do what they do. Through real-time self-monitoring, collaborative discussions, and personalized visual tools (called “formulations”), they see how certain habits—like skipping meals or body checking—are connected to deeper beliefs and fears.
Understanding these patterns is the first step toward change.
Six Key Strategies to Engage Teens in CBT-E
- Adopt an engaging and collaborative approach
From the very first session, therapists adopt a warm and non-judgmental stance. Instead of lecturing or giving orders, they work with the teen to understand their experience. This helps build trust and reduces resistance.
The therapist listens actively, avoids confrontation early on, and shows genuine interest in the teen’s world beyond the eating disorder. This connection is the foundation of the therapeutic relationship—and it’s what makes everything else possible.
- Explain the difference between the disease model and the psychological CBT-E model
The therapist explains two key models behind persistent disordered eating behaviors in adolescents: the disease model and the CBT-E psychological model.
The disease model views eating disorders as illnesses characterized by uncontrollable behaviors, such as extreme dieting, binge eating, purging, concerns about shape, weight, and eating control, and the fear of weight gain as symptoms of a specific disease (e.g., anorexia nervosa, bulimia nervosa, and similar states). In this model, patients are seen as unable to manage their illness, requiring external control from parents or professionals. Treatment is directive, with the patient in a passive role, as seen in approaches like family-based therapy or medical stabilization.
In contrast, the CBT-E psychological model considers eating disorders as driven by a dysfunctional self-evaluation system focused on weight, shape, and control over eating. Here, patients actively work with therapists to understand the psychological processes of maintaining their disorder. They are empowered to identify problems, develop strategies, and take ownership of change. The aim is to build a healthier sense of self-worth, making sustainable recovery possible.
Explaining this difference helps teens see themselves as active agents of change rather than passive victims of an illness.
- Help Teens Understand Their Maintenance Processes
Once a teen is engaged, the next step is helping them map out the factors that maintain their disorder. For instance, for low weight teens, therapists first highlight the harmful physical and social effects of being underweight and explore the behaviors and thought patterns contributing to it—such as restrictive eating, excessive exercise, and overvaluation of weight and shape. They also explore reinforcing factors such as the sense of accomplishment associated with adhering to a strict diet and achieving a low weight, as well as physiological and psychological effects like delayed digestion, heightened preoccupation with food, and social withdrawal. Additional reinforcers may include social approval for weight loss, increased parental attention, and the avoidance of stressors related to school, sports, or interpersonal relationships.
For a teen with binge eating, therapy focuses on understanding the binge episodes, their emotional and behavioral triggers, and the role of rigid dietary rules.
Therapists use visual diagrams and self-monitoring logs to help teens connect the dots. This insight builds motivation and creates a shared understanding of what needs to change.
- Empower Teens to Decide When and How to Change
Unlike some approaches that begin with a demand for immediate weight restoration or behavior change, a key strategy of CBT-E is to actively involve adolescents in their treatment decisions, fostering a sense of control and commitment throughout the process. The treatment is structured in three main steps:
- Step One – Starting Well and Deciding to Change: This step aims to build engagement and encourage patients—especially those who are low weight —to actively choose to address weight regain. It also applies to individuals with binge-eating symptoms who may not initially see some of their behaviors (e.g., strict dieting or excessive exercising) as problematic.
- Step Two – Addressing the Change: Treatment is customized to each patient’s needs. Goals include weight restoration (if needed), tackling disordered eating behaviors, and overcoming psychological barriers, suce as the overvaluation of shape and weight, events and associated mood changes influencing eating, and in some patients also one or more of general psychological issues such as low self-esteem, perfectionism or interpersonal difficulties. Patients play an active role in interpreting their weight trends, planning their eating to create a positive energy balance, and understanding strategies to address barriers to progress. For example, they collaborate with their therapist to establish a plan for achieving a steady weight increase of 0.5 kg per week while addressing psychological obstacles that may arise.
- Step Three – Ending Well: Patients develop a personalized maintenance plan, learning to identify and manage relapse risks. They are taught to recognize early warning signs and apply problem-solving strategies, promoting long-term self-efficacy and recovery.
The CBT-E strategy respects the teen’s autonomy and reduces defensiveness. Therapists might suggest “trying out” the change as an experiment, allowing the adolescent to stay in control while gently nudging them toward change.
As therapy progresses, teens are guided to set goals, choose which behaviors to address, and evaluate their progress.
- Use Personalized Homework Assignments
CBT-E includes between-session tasks designed to reinforce learning and encourage reflection. These range from monitor records and behavioral experiments to cognitive exercises and exposure tasks (like eating a feared food).
Importantly, these tasks are not imposed. They are chosen collaboratively and tailored to each teen’s stage of readiness. This promotes a sense of ownership and helps teens see that real progress often happens outside the therapy room.
- Involve Parents as Supportive Helpers
Although CBT-E is an individual therapy, parents still have an important role. Rather than being controllers or enforcers, they act as helpers—providing emotional support, encouragement, and a stable environment at home.
Parents are invited to attend occasional joint sessions, where progress is reviewed, and supportive strategies are discussed. All topics are agreed upon with the teen to protect their autonomy.
When family dynamics are challenging, therapists work with parents to improve communication, reduce conflict, and build trust—all of which can strengthen the teen’s engagement.
Why Teens Respond Well to CBT-E
CBT-E is particularly well-suited to adolescents for several reasons:
- It values autonomy. Many teens are fiercely independent and dislike being told what to do. CBT-E respects this by putting them in the driver’s seat.
- It’s flexible. The therapy can be adjusted to suit the teen’s developmental stage, cultural background, and specific symptoms.
- It addresses the whole person. Rather than focusing only on weight or food, CBT-E helps teens explore the emotional, social, and cognitive aspects of their disorder.
- It builds self-efficacy. By encouraging small, achievable steps, CBT-E helps teens develop confidence in their ability to change.
Evidence and Outcomes
While more research is still needed—primarily randomized controlled trials—the existing evidence for CBT-E in adolescents is promising. Studies show that teens who complete CBT-E often gain weight (if needed), reduce eating disorder symptoms, and experience improved mood and functioning.
In one study involving teens with anorexia nervosa, about 66–70% of those who completed CBT-E maintained their gains at follow-up. Another study comparing CBT-E to family-based therapy (FBT) found similar results in symptom reduction and recovery, with some teens preferring the greater independence offered by CBT-E.
Even in complex or severe cases, CBT-E has been shown to help teens make meaningful progress—especially when engagement strategies are used consistently.
Conclusion: Healing Through Partnership
Eating disorders in adolescence are not just clinical conditions to be “managed”—they are deeply personal struggles that often tie into identity, self-worth, and emotional regulation. Treating them effectively requires more than just medical monitoring or strict parental control.
CBT-E offers a different path that begins with empathy, builds on collaboration, and leads to empowerment. By helping teens understand their disorder, take responsibility for change, and develop confidence in their abilities, CBT-E makes lasting recovery not just possible—but achievable.