Dr Amy Wicksteed outlines some key ideas and references relating to the use of Cognitive Analytic Therapy with people experiencing eating distress or diagnosed with an eating disorder.
Currently there are few research studies that specifically look at how CAT can help with eating disorders. However there have been two small RCTs looking at the value of CAT for anorexia nervosa (Treasure et al 1995; Dare et al 2001), plus an encouraging audit of a 100 therapies for people with a range of eating disorder presentations (Tanner and Carolan 2009*). More recent publications include accounts of single case studies (eg see Holt 2017; Beckford 2021). Simmonds et al., 2020 also highlights the therapeutic value of Goodbye letters in CAT with eating disorder presentations.
Further research, including those supported by treatment protocols, would help to expand the evidence base for CAT in this area. Recent literature which more actively includes the voices and perspectives of experts-by-experience is much welcomed. As Taylor et al (2024) suggest, different types of research design and evidence, including co-produced research, will help to enhance CAT’s evidence base and build on its collaborative values.
While no treatment manuals exist for CAT in this area, a couple of summary chapters (Newell, 2012; Wicksteed, 2016) provide suggestions on how the approach can be adapted. Newell outlines his observations on how the majority of reciprocal roles map onto three distinct groups of states. These can include idealised states (eg admiring/admired), and avoided states (eg critical and demanding/failure, abandoned or rejected). A third variety, fortress states (eg thin/special) might help a person avoid connecting with feared states. However because approval through achieving them is so conditional, it can be hard for the person to ever feel contented. Instead, they may continue to strive towards an ideal state, with some sense of control, but one which is very fragile. The standards required to feel in this desired ideal position can be very hard to sustain. As a result, the person’s sense of control can be challenged repeatedly.
Coleby et al (2024) build on this using both professional and expert-by-experience perspectives. Drawing on this range of experience, they set out the value of relational understanding in various forms of eating distress. They highlight how non-specific relational work can foster a relationship base with both self and others. This in turn can build a foundation for interventions that support change.
Johnson (2022) illustrates this powerfully in her article reflecting on her recovery journey. She acknowledges the importance of the relational aspects of CAT in rebuilding a more fair and attuned way of relating to herself. She has very kindly given permission for a short extract from her piece to be included in this summary:
‘Throughout therapy, having my letter to refer to, and revisiting my formulation or ‘map’ regularly helped me to build a sense that someone could be with me, see some of the things I struggled with, and that had led me to struggle, without turning away or becoming overwhelmed…..I began to see how the harsh, rigid rules and critical internal narrative mirrored some of my life experiences. I began to recognise a pattern of striving as an attempt to manage feeling not good enough, and how this pattern of high standards and relentless ‘following of the rules’ left me feeling worn out, inadequate and uncertain. I began to see how my eating disorder mirrored this in my attitude towards food and my body, and to question where such harsh rules and standards came from. ‘Do these rules really fit? What if I risk taking a different position towards myself?’ ‘How does being a low weight reinforce this, and what would happen if I began to let go of that?’
My therapist and I discussed how feeling undeserving might lead to being unaware of the things I needed, and that perhaps this prevented me from making full use of the support available to me. It was difficult to begin to turn towards other people, even those I trusted and invite them in to journey with me. I began to see how being self-sufficient might create a barrier to receiving validation and encouragement that could be helpful, if unfamiliar and uncomfortable. I found myself gradually articulating new perspectives, first to myself, and then to my therapist, ‘maybe it is reasonable to allow myself things, maybe I am not so different to other people, maybe it is OK for things to feel messy sometimes.’
Johnson highlights the benefits of the relationally-informed formulation that CAT offers. This can help to build a greater capacity for reflection on how standards, rules and judgements can play out ‘self-to-self’, and also with other people. Alongside this, CAT‘s concept of target problems, specifically around aspects of the eating disorder, is helpful to include from the start of therapy. As the extract highlights, the procedural patterns (TPPs) identified as maintaining problems can also be used to understand and address broader interpersonal issues. This is particularly important where such patterns increase emotional distress and serve as obstacles to emotional regulation.
CAT emphasises how previous relationships and experiences can shape a person’s repertoire of reciprocal roles. CAT uses shared letters and jointly developed diagrams to help identify and make sense of these links. This collaborative and narrative approach can be valuable in helping individuals understand how unhelpful cognitions associated with an eating disorder mindset developed. For example harsh and critical thoughts about body image may resonate with previous life experiences when a person felt “not good enough.” The relationship between such reciprocal roles and procedural patterns such as avoidance can then be drawn out using the CAT diagram.
Wicksteed (2016) outlines how the Psychotherapy File can be useful in identifying procedural patterns maintaining aspects of the eating disorder.
Traps are patterns of thinking and acting that start as ways to escape or protect oneself from fears, but act as “vicious circles” that ultimately end up confirming these fears. In the case of eating disorders, it’s helpful to consider avoidance behaviours such as avoiding certain sorts of food, eating in company, looking in mirrors or other forms of body exposure. Once a CAT client is better able to recognise these traps, therapy might focus on exits such as gradually reintroducing avoided foods, or other avoided situations. Starting to experiment with changes in behaviours like these, with therapeutic support, can help the person address fears and beliefs relating to them.
Dilemmas are patterns where choices are viewed in a polarised way such as “either/or” or “if/then”. A person viewing choices in this limited manner can end up acting in one way because the only other ways they can imagine seem just as bad or worse. One of the dilemmas described in the Psychotherapy File is: “Either I keep things in perfect order, or I fear a terrible mess.” This pattern can be helpful to reflect on with a range of concerns about food and eating. An example of this is rigidly adhering to food plans or a daily calorie intake.
By recognising such patterns, the thinking that drives the eating disorder can be easier to spot. An example is a binge-purge cycle triggered by eating food with no specified calorific value, or breaking a self-imposed dietary ‘rule’. Again, therapy aims might focus on identifying and practising “exits” which expand the range of possible responses. This could involve, for example, exploring principles which help guide more flexible food choices.
Snags are patterns where a way of thinking prevents someone from making more helpful choices or accepting positive opportunities. Believing oneself to be undeserving, for example can mean dismissing or declining other forms of care or comfort, or limiting life choices in other ways. This sort of belief could both relate how an eating disorder develops, and also to how easy it is to access treatment or maintain a process of recovery. Revision could include challenging this belief through attention to cognitive aspects of this patterns, alongside experimenting with self-care focussed acts or other behaviours that help to promote self-value.
The Psychotherapy File also asks how respondents might limit their own life because of concern about the response of others. Examples it gives include the belief that changes a person makes may deprive others, or that others may envy them, or perhaps that there are not enough good things to go around. It can be helpful in therapy to explore other snag possibilities specific to the client and their circumstances. The potential for withdrawal of support, or greater expectations, from others may cause a person concern and anxiety about steps towards recovery. Together, a therapist and client can notice when these patterns might play out between them in therapy. When exploring options for change outside of the therapy room, therapy may involve testing out some of these feared consequences in other relationships.
Psychotherapy File also includes a focus on “difficult and unstable states of mind”. This section is especially useful when a person’s mood state is closely tied in to aspects of eating disorder behaviour. Reviewing this section together can be a good opportunity to explore and share information about ways in which lack of nutrition can affect mood. This section may also clarify where eating difficulties present within a broader context of other difficulties.
As an integrative approach CAT embraces using tools and interventions grounded in other therapy models. Behavioural change can be supported by techniques which have been shown to be effective, such as monitoring weight and food intake, and exposure work. However for some clients these can link powerfully to existing reciprocal roles and evoke strong reactions. For example, the idea of monitoring food intake or being weighed might trigger connection with a reciprocal role like critical-to-criticised. A result may be that the client shifts into a pattern which helps to avoid a previously-encountered and painful sense of judgement or scrutiny. Being able to make links and reflect on this within an active, attuned and collaborative therapeutic relationship can help to address such barriers. Unaddressed, such patterns may otherwise leave clients, therapists and services in a more ‘stuck’ position.
CAT tools like the SDR diagram can help to track, think and talk about this type of enactment. The diagram can be used by both client and therapist as a live tool, visible between them in sessions, with a copy retained for day-to-day use by the client if desired. Reference to the map can at times aid uncomfortable or challenging moments. Being able to describe and talk about the process can, in itself, make possible a shift allowing things to move forward. Once the client is better able to recognise such enactments, a therapist can help provide the right sort of scaffolding to support them to explore alternative ways of responding. Therapists can also employ the SDR diagram to support their own self-reflection and supervision.
Teams working in the eating disorders area may encounter struggles in maintaining a consistent therapeutic approach with a person. Consultation using CAT can help to contain such difficulties and promote a shared way forward. CAT reflective practice, consultation or team formulation drawing on the shared language of CAT may help team members stay aware of patterns they may be drawn in to, and find ways to manage these to the benefit of both their clients and the well-being of the team.
