Types of Psychotherapy

Reviewed by Douglas Bunnell, Ph.D, FAED, CEDS

Perhaps one of the most important considerations when selecting a psychotherapist is the type of therapy they provide. There are several types of psychotherapy for eating disorders and research suggests that some of them may be more effective than others for certain individuals and for certain types of eating disorders. But the decision about which type of therapy is best made in collaboration with you, the therapist and, as appropriate, with your family. The choice of therapy should also consider factors such as individual choice and preferences and prior treatment history. The goals for treatment should prioritize ensuring that the person with the eating disorder is medically safe. While these various types of psychotherapy will emphasize different clinical factors, all of them will address the thoughts, feelings, behaviors, and relationship factors that are influencing the eating disorder symptoms.

Recommendations about any particular type of psychotherapy should include an explanation of how the treatment will address food behaviors, family and social factors, and the influence of other medical or psychiatric symptoms such as depression or anxiety. The psychotherapist should also be able to describe how the proposed treatment might deal with issues related to cultural and gender related issues. It is also essential that the recommendation include specific goals regarding progress and should include an estimate of how long the treatment will take.

Evidenced-Based Treatment1


It is important to note that while all of these therapies are frequently used to treat individuals with eating disorders, they have varying levels of research supporting their efficacy and effectiveness. Many professionals now recommend the use of evidence-based treatment, which is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”2 In eating disorder therapies, evidence-based treatment usually means that the therapy has been used in a research study and found to be effective in reducing eating disorder symptoms, encouraging weight restoration in underweight patients, and decreasing eating disorder thoughts.

Classifying a therapy as “evidence-based” doesn’t mean that it automatically works for everyone; just that it works for many patients. Do some research and evaluate which types of treatments would best target relevant symptoms and psychological concerns. Also keep in mind that not all therapists who say they utilize a type of treatment actually use it in all of their sessions. Some cognitive-behavioral (CBT) therapists, for example, might have a primarily psychodynamic approach and only occasionally use CBT principles. Ask about how strictly the therapist adheres to treatment guidelines, what a typical session might consist of, how much training the therapist has received in this particular treatment modality, the rough percentage of patients who they treat using this form of psychotherapy, and how current their eating disorders knowledge base is.

The following is an alphabetical list of the most widely-known psychotherapies that have the strongest research supporting their effectiveness. Some of these treatments may be more effective for specific types of eating disorders.

Acceptance and Commitment Therapy (ACT)


The goal of ACT is focusing on changing your actions rather than your thoughts and feelings. Patients are taught to identify core values and commit to creating goals that fulfill these values. ACT also encourages patients to detach themselves from emotions and learn that pain and anxiety are a normal part of life. The goal isn’t to feel good, but to live an authentic life. Through living a good life, people often find they do start to feel better and feel more confident about resisting the urge to engage in eating disorder behaviors.3

Cognitive Behavioral Therapy (CBT) and Enhanced Cognitive Behavioral Therapy (CBT-E)


The goal of ACT is focusing on changing your actions rather than your thoughts and feelings. Patients are taught to identify core values and commit to creating goals that fulfill these values. ACT also encourages patients to detach themselves from emotions and learn that pain and anxiety are a normal part of life. The goal isn’t to feel good, but to live an authentic life. Through living a good life, people often find they do start to feel better and feel more confident about resisting the urge to engage in eating disorder behaviors.4

Integrated Cognitive Affective Therapy (ICAT)


ICAT is a form of short-term psychotherapy that combines a focus on the cognitive issues addressed in CBT-E and a variety of emotional and interpersonal factors. ICAT may help patients develop a deeper understanding of how their moment to moment emotional reactions can influence their eating disorder urges and behaviors. It also incorporates meal planning and self-monitoring of eating behaviors and emotions.5,6

Cognitive Remediation Therapy (CRT)


CRT may be a useful addition to other types of psychotherapy. It is not designed to be a stand-alone treatment. CRT targets rigid thinking processes considered a core component of anorexia nervosa through simple exercises, reflection, and guided supervision. As of 2023, CRT is being studied to test effectiveness in improving treatment adherence in adults with anorexia; it has not been tested in other eating disorders.7,8

Dialectical Behavioral Therapy (DBT)


A behavioral treatment supported by empirical evidence for treatment of binge eating disorder, bulimia nervosa, and anorexia nervosa. DBT assumes that the most effective place to begin treatment is with changing behaviors. Treatment focuses on developing skills to replace maladaptive eating disorder behaviors. Skills focus on building mindfulness, becoming more effective in interpersonal relationships, emotion regulation, and distress tolerance. Although DBT was initially developed to treat borderline personality disorder, it is currently being used to treat eating disorders as well as substance use. 9,10

Radically Open DBT (R/O DBT) is a newer adaptation of DBT that addresses factors such as social anxiety, perfectionism, and emotional restriction. It may be particularly helpful for people with anorexia nervosa.11

Exposure and Response Prevention (ERP)


ERP is a highly structured treatment that has been used for the treatment of people with obsessive compulsive disorder. This approach has been modified for the treatment of eating disorders and may be particularly useful for people dealing with ARFID. ERP therapists will help the patient map out a list of foods and situations that are anxiety provoking. Starting with the easier challenges the patient and therapist practice skills and explore cognitions related to the feared challenge. These exposures and exploration help patients confront their fears and to develop more helpful responses.12

Family Therapy


Family therapy is a broad term for a variety of different therapeutic approaches that seek to help families coping with an eating disorder. Most types of family therapy focus on communication patterns between family members but will often address issues related to parenting styles, family secrets and family patterns that may influence recovery from an eating disorder. Recent research indicates that multi-family therapy may be an effective treatment for teens with anorexia nervosa. Emotionally Focused Family Therapy (EFFT) has been shown to be an effective way to address some of the common communication struggles that can develop as families navigate recovery.13,14,16,17

Family-Based Treatment (FBT)

Also known as the Maudsley Method or Maudsley Approach, this is a home-based treatment approach that has been shown to be effective for adolescents with anorexia and bulimia. FBT doesn’t focus on the cause of the eating disorder but instead places initial focus on refeeding and full weight restoration to promote recovery. All family members, including chosen family,  are considered an essential part of treatment, which consists of re-establishing healthy eating, restoring weight and interrupting compensatory behaviors; returning control of eating back to the adolescent; and focusing on remaining issues.18

Adolescent Focused Individual Therapy is an individually based psychotherapy approach that may be recommended by your FBT therapist towards the end of the family-based work. This treatment helps the adolescent patient to establish their own independent focus on their ongoing recovery.19   

Interpersonal Psychotherapy (IPT)


Interpersonal psychotherapy (IPT) is an evidence-based treatment for bulimia nervosa and binge eating disorder. IPT sees eating disorder symptoms as occurring and being maintained within social and interpersonal relationships. IPT is associated with specific tasks and strategies linked to the resolution of a specified interpersonal problem area. IPT helps clients improve relationships and communication and resolve interpersonal issues in the identified problem area(s), which in turn results in a reduction of eating disorder symptoms.20

Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA)


MANTRA is a structured and manualized approach that may be particularly helpful for adults with anorexia nervosa. The MANTRA manual lays out a series of specific worksheets and exercises that address four key general factors that may both spark and maintain an individual’s anorexia nervosa. These factors include emotional and social issues, the degree to which a patient defines themselves as having anorexia nervosa, their thinking styles, and their family and personal relationships. MANTRA has been used in both individual and group formats.21

Psychodynamic Psychotherapy/Focal Psychodynamic Therapy


The psychodynamic approach holds that recovery from an eating disorder requires understanding how the eating disorder symptoms and behaviors help the individual manage psychological development, internal conflict, relationships and emotions. Psychodynamic psychotherapists view behaviors as the result of internal conflicts, motives and unconscious forces, and if behaviors are discontinued without addressing the underlying motives that are driving them, then relapse will occur. Symptoms are viewed as expressions of the patient’s underlying needs and issues and are thought to be resolved with the completion of working through these issues. Most psychodynamic therapists working with patients with eating disorders will also directly address food and eating behaviors.22,23

To learn more about the types of psychotherapy for eating disorders visit the National Institute for Health and Care Excellence.

Sources


[1] Crone, C., Anzia, D. J., Fochtmann, L. J., & Dahl, D. (2023). The American Psychiatric Association practice guideline for the treatment of patients with eating disorders. American Psychiatric Association. Available at: https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424865. Accessed on 8/3/23.

[2] Sackett D. L. (1997). Evidence-based medicine. Seminars in perinatology, 21(1), 3–5. https://doi.org/10.1016/s0146-0005(97)80013-4

[3] Onnink, C. M., Konstantinidou, Y., Moskovich, A. A., Karekla, M. K., & Merwin, R. M. (2022). Acceptance and commitment therapy (ACT) for eating disorders: A systematic review of Intervention Studies and call to action. Journal of Contextual Behavioral Science, 26, 11–28. https://doi.org/10.1016/j.jcbs.2022.08.005

[4] Kaidesoja, M., Cooper, Z., & Fordham, B. (2023). Cognitive behavioral therapy for eating disorders: A map of the systematic review evidence base. The International journal of eating disorders, 56(2), 295–313. https://doi.org/10.1002/eat.23831

[5] Lebow, J., Sim, L., Wonderlich, S., & Peterson, C. B. (2023). Adapting integrative cognitive-affective therapy for adolescents with full and subthreshold bulimia nervosa: A feasibility study. European eating disorders review : the journal of the Eating Disorders Association, 31(1), 178–187. https://doi.org/10.1002/erv.2946

[6] Wonderlich, S. A., Peterson, C. B., Crosby, R. D., Smith, T. L., Klein, M. H., Mitchell, J. E., & Crow, S. J. (2014). A randomized controlled comparison of integrative cognitive-affective therapy (ICAT) and enhanced cognitive-behavioral therapy (CBT-E) for bulimia nervosa. Psychological medicine, 44(3), 543–553. https://doi.org/10.1017/S0033291713001098

[7] Tchanturia, K., Giombini, L., Leppanen, J., & Kinnaird, E. (2017). Evidence for Cognitive Remediation Therapy in Young People with Anorexia Nervosa: Systematic Review and Meta-analysis of the Literature. European eating disorders review : the journal of the Eating Disorders Association, 25(4), 227–236. https://doi.org/10.1002/erv.2522

[8] Rhind, C., Mahdi, M., Simic, M., Espie, J., & Tchanturia, K. (2022). Group cognitive remediation therapy for children and adolescents in intensive day-patient treatment for anorexia nervosa: a feasibility study. Kognitive Gruppen-Remediationstherapie für Kinder und Jugendliche in intensiver teilstationärer Behandlung von Anorexia nervosa: eine Machbarkeitsstudie. Neuropsychiatrie : Klinik, Diagnostik, Therapie und Rehabilitation : Organ der Gesellschaft Osterreichischer Nervenarzte und Psychiater, 36(3), 125–135. https://doi.org/10.1007/s40211-022-00420-5

[9] Brown, T. A., Wisniewski, L., & Anderson, L. K. (2020). Dialectical Behavior Therapy for Eating Disorders: State of the Research and New Directions. Eating disorders, 28(2), 97–100. https://doi.org/10.1080/10640266.2020.1728204

[10] Reilly, E. E., Orloff, N. C., Luo, T., Berner, L. A., Brown, T. A., Claudat, K., Kaye, W. H., & Anderson, L. K. (2020). Dialectical behavioral therapy for the treatment of adolescent eating disorders: a review of existing work and proposed future directions. Eating disorders, 28(2), 122–141. https://doi.org/10.1080/10640266.2020.1743098

[11] Gilbert, K., Hall, K., & Codd, R. T. (2020). Radically Open Dialectical Behavior Therapy: Social Signaling, Transdiagnostic Utility and Current Evidence. Psychology research and behavior management, 13, 19–28. https://doi.org/10.2147/PRBM.S201848

[12] Butler, R. M., & Heimberg, R. G. (2020). Exposure therapy for eating disorders: A systematic review. Clinical psychology review, 78, 101851. https://doi.org/10.1016/j.cpr.2020.101851

[13] Jewell, T., Blessitt, E., Stewart, C., Simic, M., & Eisler, I. (2016). Family Therapy for Child and Adolescent Eating Disorders: A Critical Review. Family process, 55(3), 577–594. https://doi.org/10.1111/famp.12242

[14] Simic, M., Baudinet, J., Blessitt, E., Wallis, A., & Eisler, I. (2022). Multi-family therapy for anorexia nervosa: A treatment manual. Routledge/Taylor & Francis Group.

[15] Zinser, J., O’Donnell, N., Hale, L., & Jones, C. J. (2022). Multi-family therapy for eating disorders across the lifespan: A systematic review and meta-analysis. European eating disorders review : the journal of the Eating Disorders Association, 30(6), 723–745. https://doi.org/10.1002/erv.2919

[16] Lafrance, A., Henderson, K. A., & Mayman, S. (2020). Emotion-Focused Family Therapy: A Transdiagnostic Model for Caregiver-Focused Interventions. American Psychological Association. http://www.jstor.org/stable/j.ctv1chrvb2

[17] Osoro, A., Villalobos, D., & Tamayo, J. A. (2021). Efficacy of emotion‐focused therapy in the treatment of Eating disorders: A systematic review. Clinical Psychology & Psychotherapy, 29(3), 815–836. https://doi.org/10.1002/cpp.2690

[18] Gorrell, S., Loeb, K. L., & Le Grange, D. (2019). Family-based Treatment of Eating Disorders: A Narrative Review. The Psychiatric clinics of North America, 42(2), 193–204. https://doi.org/10.1016/j.psc.2019.01.004

[19] Datta, N., Matheson, B. E., Citron, K., Van Wye, E. M., & Lock, J. D. (2023). Evidence Based Update on Psychosocial Treatments for Eating Disorders in Children and Adolescents. Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 52(2), 159–170. https://doi.org/10.1080/15374416.2022.2109650

[20] Miniati, M., Callari, A., Maglio, A., & Calugi, S. (2018). Interpersonal psychotherapy for eating disorders: current perspectives. Psychology research and behavior management, 11, 353–369. https://doi.org/10.2147/PRBM.S120584

[21] Wittek, T., Truttmann, S., Zeiler, M., Philipp, J., Auer-Welsbach, E., Koubek, D., Ohmann, S., Werneck-Rohrer, S., Sackl-Pammer, P., Schöfbeck, G., Mairhofer, D., Kahlenberg, L., Schmidt, U., Karwautz, A. F. K., & Wagner, G. (2021). The Maudsley model of anorexia nervosa treatment for adolescents and young adults (MANTRa): a study protocol for a multi-center cohort study. Journal of eating disorders, 9(1), 33. https://doi.org/10.1186/s40337-021-00387-8

[22] Abbate-Daga, G., Marzola, E., Amianto, F., & Fassino, S. (2016). A comprehensive review of psychodynamic treatments for eating disorders. Eating and weight disorders : EWD, 21(4), 553–580. https://doi.org/10.1007/s40519-016-0265-9

[23] Herzog, W., Wild, B., Giel, K. E., Junne, F., Friederich, H. C., Resmark, G., Teufel, M., Schellberg, D., de Zwaan, M., Dinkel, A., Herpertz, S., Burgmer, M., Löwe, B., Zeeck, A., von Wietersheim, J., Tagay, S., Schade-Brittinger, C., Schauenburg, H., Schmidt, U., & Zipfel, S. (2022). Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in female outpatients with anorexia nervosa (ANTOP study): 5-year follow-up of a randomised controlled trial in Germany. The lancet. Psychiatry, 9(4), 280–290. https://doi.org/10.1016/S2215-0366(22)00028-1