CBT Intervention Modules for Eating and Feeding

When became the senior program director of Western Psychiatric Hospital of UPMC's inpatient eating disorders program, the patient's requested alternatives to DBT treatment. One of the modalities we developed was a group therapy manual for the inpatient setting, and included modules for less acute settings as well. This manual can also be used in other settings including outpatient individual therapy (see below for access to purchase).

CBT-ARE ARFID and Eating Disorders Treatment Manual

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We developed this manual referencing the CBT-E treatment guide and an Italian inpatient group manual, adapting it to the US (higher acuity in the patient setting than the Italian manual was designed for, and of course English language), applying our take on the interventions and adding ARFID (Avoidant-Restrictive Food Intake Disorder) interventions. There is now a CBT-E workbook available as well.

What is ARFID and Why Include It?

ARFID is a feeding disorder and distinct from an eating disorder most notably in the underlying fear. Anorexia requires a fear (or phobia) of gaining weight while ARFID is a fear (phobia) of consequences of eating such as nausea, choking, or sensory sensitivity like discomfort with certain textures. It is quite common for people with Anorexia to meet criteria for ARFID, and treating those phobias will help unlock the door to treating other aspects of the illness - we sort of assume this is part of treatment but consequently may overlook it or de-emphasize the importance of stepwise exposure, using a fear ladder, to address these concerns. Additionally, while insurance (in Pennsylvania, at least during this epoch) would not cover ARFID at the inpatient eating disorder treatment, we did occasionally see ARFID patients who either were admitted despite this diagnosis or at the emergency department, their presentation was mistaken for Anorexia. Regardless, offering structured treatment is beneficial.

We want to provide psychoeducation, identify the specific phobias or feeding challenges of the client, and collaborate on a fear ladder. I refer to the Yerkes-Dodson scale to hone in one the peak-performance range (4-6 out of 10, 10 being panic attack, 1 being falling asleep bored). What foods are in the 4-6 range? Many clients can create lists for each number on the scale (1-3 are safe foods, 4-6 are current challenge foods, and 7-10 are currently off-limits), and often categorize them somehow such as food type (veggies) or the reason they are challenging (texture). We work through based upon opportunity (like family plans to go to a certain restaurant), and interest and motivation ("I'd really like to be able to eat salad - let's challenge 1 veggie a week!"). Often, we start with single ingredients, like lettuce, then another ingredient before combining them into simple recipes, then more complex recipes.

Many clients are highly motivated and relieved to have a clear, structured way to address a life-hurdle. The sense of progress is self-reinforcing, and foods quickly move down the fear ladder in terms of their rating. We have to remember to keep new foods on the menu and try them multiple times or the original exposure will lose it's impact and the client can become phobic to that food item again.

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CBT-E Interventions

I won't review the entirety of the modules here as it is available via the links above (either my version or the ones I linked to in Amazon). Part of the goal is understanding the individual client conceptualization which should be a live document over the course of treatment, updated as we gain insight in various modules, but also used as a guiding-light through the course of treatment. I tend to individualize the course of the modules for each outpatient client. Modules I find particularly helpful include:

• Differentiating slip-ups from relapse as to not "throw in the towel"

• Identifying our head-space or mindset and early interventions when the eating disorder voice is taking over

• Interpersonal difficulties

• Self-esteem

• Perfectionism

Additionally, clients who are overweight and have overeating concerns frequently request therapy support, and aspects of the binge-eating module can apply even if there is not technically binge behavior. However, having said that, my experience has been that there is a barrier of shame of which clients lack insight prior to treatment that prevents changing overeating behaviors that is not addressed in this manual. This is often something along the lines of fearing other's reactions if they a) see a change in eating or other lifestyle behaviors and b) the lifestyle changes aren't maintained. The former is experienced as embarrassment or shame simply of the change being acknowledged, that something needed to change, and that they are trying to take care of themselves. The latter, not maintaining the change, is fear of feeling like a failure in others' eyes. My experience has been that many clients presenting for self-described overeating (sometimes they call it bingeing) are pre-contemplative about this change and we have to gain insight into the fear of shame, then determine if now is the time to engage behavior change (considering stages of change model and motivational interviewing skills).

Conclusion

Despite having working with eating disorder clients for many years now, I frequently appreciate having the structure of modules available. While I don't use this in all of my work or with all clients, I do use it with some who require more structure, are earlier in treatment, are having a hiccup in recovery, or if I'm feeling stuck and want to reference the array of approaches in the repertoire. I'll draw an analogy between eating disorders and addiction in therapy: we can take on a client for any presenting concern, but it is common that eventually we will find that eating or addiction are also part of the picture. Even if we don't consider ourselves a specialist, or even if we typically refer out addiction and eat cases, we will eventually come across these concerns with an active client who wants to remain under our care. I'd recommend picking a resource, familiarizing yourself with it, and having it available ahead of time in the likely case this comes up, and don't hesitate to consult!