

































COLUMBIA SOCIAL WORK REVIEW, VOL. XIX  |   65   

Enhanced Cognitive 
Behavioral Therapy 
(CBT-E) as an 
Intervention for 
BIPOC Adolescent 
Girls with Eating 
Disorders

YINAN CHEN, LILY GABAY, AND CATHERINE STAMPFLI



66  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

ENHANCED COGNITIVE BEHAVIORAL THERAPY (CBT-E) AS AN INTERVENTION FOR BIPOC  
ADOLESCENT GIRLS WITH EATING DISORDERS 

ABSTRACT

Eating disorders (ED) have some of the highest mortality rates of any 
mental health condition due to medical complications and high rates of 
suicidality. Black, Indigenous, and People of Color (BIPOC) adolescent 
girls and women are at especially high risk for developing EDs, which 
JHU�OH]L�U\TLYV\Z�ULNH[P]L�TLU[HS�HUK�WO`ZPJHS�OLHS[O�JVUZLX\LUJLZ��
Enhanced Cognitive Behavior Therapy (CBT-E) is a transdiagnostic 
cognitive behavioral treatment for EDs that, although originally designed 
[V�^VYR�^P[O�HK\S[Z��OHZ�ILLU�ZOV^U�[V�IL�LɈLJ[P]L�^P[O�HKVSLZJLU[Z��
+LZWP[L�*);�,»Z�WYV]LU�LɉJHJ`�HJYVZZ�HNL�WVW\SH[PVUZ��[OLYL�PZ�SPTP[LK�
YLZLHYJO�VU�P[Z�LɈLJ[P]LULZZ�^P[O�)076*�PUKP]PK\HSZ��>L�HYN\L�[OH[�^P[O�
culturally informed, competent, and sensitive clinicians, CBT-E can be 
used to treat underdiagnosed and undertreated BIPOC adolescent girls, 
whose EDs have been unjustly overlooked.



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   67   

YINAN CHEN, LILY GABAY, AND CATHERINE STAMPFLI

Eating disorders (EDs) are serious mental health diagnoses within 
the United States, warranting the attention of social workers 
and clinicians due to their high mortality rates (Arcelus et al., 
2011; Johnson et al., 2002; National Institute of Mental Health, 

2021; Striegel-Moore & Bulik, 2007). Many EDs begin in adolescence 
HUK�JHU�OH]L�ULNH[P]L�JVUZLX\LUJLZ�VU�TLU[HS�HUK�WO`ZPJHS�OLHS[O�
(Micali et al., 2014; Verschueren et al., 2020). Women and adolescent 
girls are especially at risk due to societal pressure to conform to the 
“thin ideal” (Striegel-Moore & Bulik, 2007). Black, Indigenous, and 
People of Color (BIPOC) women and girls are even more vulnerable 
because the existence of EDs among them has been ignored by 
researchers and practitioners alike, leading to a general lack of research 
and treatment (Gilbert, 2003; Rodgers et al., 2017; Sonneville & Lipson, 
2018; Striegel-Moore & Bulik, 2007; Talleyrand, 2015).

0[�PZ�]P[HS�[OH[�ZVJPHS�^VYRLYZ�OH]L�HU�HKLX\H[L��L]PKLUJLK�IHZLK�
intervention to address the gap in treatment for BIPOC adolescent girls. 
This paper proposes Enhanced Cognitive Behavioral Therapy (CBT-E) as 
HU�LɈLJ[P]L�PU[LY]LU[PVU�MVY�[YLH[PUN�)076*�HKVSLZJLU[Z�^P[O�,+Z��HZ�P[�
PZ�OPNOS`�HKHW[HISL�HUK�OHZ�ILLU�ZOV^U�[V�IL�LɈLJ[P]L�^P[O�HKVSLZJLU[Z�
(Fairburn, 2008; Cooper & Grave, 2017). Although there is little research 
VU�*);�,»Z�LɈLJ[P]LULZZ�^P[O�)076*�PUKP]PK\HSZ��^L�HYN\L�[OH[�[OL�
inclusion of culturally competent care will allow for accessible and 
LɈLJ[P]L�[YLH[TLU[�

EATING DISORDERS

Eating disorders (EDs) are a serious mental health concern globally 
and within the United States. About nine percent of all Americans will 
be diagnosed with an ED at some point in their life, and more than a 
X\HY[LY�VM�PUKP]PK\HSZ�^P[O�HU�,+�^PSS�H[[LTW[�Z\PJPKL��(YJLS\Z�L[�HS���
2011; Deloitte Access Economics, 2020). EDs are more prevalent among 
women than men, mostly due to societal pressures placed on them. 



68  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

Although men are also faced with pressure to conform to an ideal body 
type, women face constant exposure to society’s “thin ideal,” or the 
notion that worth and beauty are dependent upon body size and shape 
(Striegel-Moore & Bulik, 2007). This pressure can cause women mental 
distress about their current weight and body shape, which can lead 
to the development of extreme and unhealthy attitudes or behaviors 
around food and eating habits. There are multiple types of EDs, the 
three most common being binge eating disorder, anorexia nervosa, and 
bulimia nervosa (National Institute of Mental Health, n.d.).

EATING DISORDER TYPES

Of the multiple ED diagnoses in the DSM-5, anorexia nervosa and 
bulimia nervosa are most likely to begin in adolescence (Striegel-Moore 
& Bulik, 2007). Anorexia nervosa, which has the highest mortality rate of 
all EDs, is commonly characterized by extremely restrictive eating and 
MVVK�H]VPKHUJL��HU�VIZLZZPVU�^P[O�VUL»Z�^LPNO[��HUK�H�ZPNUPÄJHU[S`�SV^�
body weight (Arcelus et al., 2011; Johnson et al., 2002; National Institute 
of Mental Health, 2021; Striegel-Moore & Bulik, 2007). There are two 
Z\IJH[LNVYPLZ�VM�HUVYL_PH�ULY]VZH!�YLZ[YPJ[P]L�[`WL��^OPJO�PZ�KLZJYPILK�
HIV]L��HUK�IPUNL�LH[PUN�W\YNPUN�[`WL��^OPJO�PUJS\KLZ�LWPZVKLZ�VM�
binging—consumption of a large amount of food in a short amount of 
time—and purging through vomiting, laxatives, or diuretic use (National 
Institute of Mental Health, 2021). Bulimia nervosa is characterized 
by episodes of eating large amounts of food in a short period of time 
followed by purging through vomiting or use of laxatives or diuretics, 
fasting, or excessive exercise. Binge eating disorder, which is the most 
common ED in the United States, is characterized by an individual losing 
control and eating a large amount of food in an unusually short time, 
without any form of purging, fasting, or excessive exercising afterwards.

ADOLESCENTS

ED symptoms often begin to present in adolescence (Micali et al., 
2014; Verschueren et al., 2020). Adolescent girls experience the dual 
stressors of societal pressure to ascribe to the “thin ideal” and a natural 

ENHANCED COGNITIVE BEHAVIORAL THERAPY (CBT-E) AS AN INTERVENTION FOR BIPOC  
ADOLESCENT GIRLS WITH EATING DISORDERS



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   69   

increase in weight as they transition through puberty, which may lead 
to discontent with their body shape (Verschueren et al., 2020). Thus, 
ED symptoms such as body dissatisfaction, restrictive eating, and 
purging begin to appear. Adolescents are particularly at risk if they 
Z\ɈLY�MYVT�WLYMLJ[PVUPZT�VY�SV^�ZLSM�LZ[LLT��^OPJO�JHU�PUJYLHZL�[OL�
likelihood of internalizing the “thin ideal” due to an increased reliance 
on the opinions of others (Keel & Forney, 2013). Social media exposure 
HUK�WLLY�PUÅ\LUJLZ��UHTLS`�[OYV\NO�[OL�ZLSLJ[PVU�VM�WLLYZ�^P[O�ZOHYLK�
insecurities about weight and body shape, also work to perpetuate EDs 
by reinforcing these insecurities.

The onset of EDs in adolescence can have numerous negative 
JVUZLX\LUJLZ�VU�HU�PUKP]PK\HS»Z�TLU[HS�OLHS[O��4PJHSP�L[�HS�������"�
Johnson et al., 2002; Verschueren et al., 2020). For example, EDs are 
closely correlated with anxiety and depression in what appears to be a 
cyclical relationship, wherein one perpetuates the other (Verschueren et 
HS����������(KVSLZJLU[Z�^P[O�,+Z�HYL�HSZV�TVYL�SPRLS`�[V�OH]L�KPɉJ\S[`�
regulating their own behavior, as well as having a dysfunctional self-
evaluation caused by placing too much value on their body weight and 
shape. EDs are also related to feelings of being a burden to one’s family 
and can negatively impact one’s social relationships (Micali et al., 2014). 
Finally, EDs are associated with higher levels of suicidality and mortality 
(Johnson et al., 2002).

BIPOC CONSIDERATIONS

Historically, researchers have falsely believed that EDs are most 
common among White, upper-class women (Striegel-Moore & Bulik, 
�������;OPZ�ILSPLM�PZ�PU�WHY[�ILJH\ZL�,+�Z`TW[VTZ�JHU�KPɈLY�I`�YHJL�VY�
L[OUPJP[`"�ZVTL�YLZLHYJOLYZ�HYN\L�[OH[�[OPZ�WLYJLP]LK�KPɈLYLUJL�PU�[OL�
prevalence of EDs between White women and BIPOC women may be 
K\L�[V�J\S[\YHS�KPɈLYLUJLZ�PU�ILH\[`�Z[HUKHYKZ�HUK�PKLHS�IVK`�[`WLZ��
with White cultures placing more value on the “thin ideal,” resulting 
PU�KPɈLYLUJLZ�PU�IVK`�KPZZH[PZMHJ[PVU�HUK�PKLHS�IVK`�^LPNO[��.PSILY[��
2003; Striegel-Moore & Bulik, 2007; Talleyrand, 2015). Symptoms 
TH`�[OLYLMVYL�THUPMLZ[�KPɈLYLU[S`�MVY�)076*�^VTLU�[OHU�[OL`�KV�MVY�

YINAN CHEN, LILY GABAY, AND CATHERINE STAMPFLI



70  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

White women (Talleyrand, 2015). However, many experts posit that 
globalization and the spread of Western culture will cause the thin ideal 
[V�ILJVTL�TVYL�WYL]HSLU[��[OLYLI`�KPTPUPZOPUN�J\S[\YHS�KPɈLYLUJLZ�PU�
rates of EDs (Striegel-Moore & Bulik, 2007). 

The false belief that EDs exist only among White women has led to 
a lack of research on EDs in the BIPOC community (Striegel-Moore 
& Bulik, 2007). BIPOC women and girls are also less likely to seek or 
receive treatment for an ED for a variety of reasons, including clinician 
stereotyping or bias, limited resources, and mistrust of the health 
and mental health systems (Gilbert, 2003; Sonneville & Lipson, 2018; 
Striegel-Moore & Bulik, 2007; Talleyrand, 2015). In addition, Black and 
Latinx adults and children have the highest rates of obesity in the US 
and are therefore less likely to be diagnosed with EDs, as clinicians 
working with overweight women often focus on weight loss and 
therefore fail to recognize symptoms of EDs among this population 
(Stierman et al., 2021). 

Despite the fact that BIPOC women have comparable rates of EDs 
[V�>OP[L�^VTLU��THU`�YPZR�MHJ[VYZ�HYL�ZWLJPÄJ�[V�)076*�^VTLU�
(Talleyrand, 2015). These include level of acculturation, low levels of 
racial or ethnic identity, and experiences with racial oppression. High 
levels of acculturation appear to be a risk factor for Latina women, 
for example, because their culture of origin may place less value on 
thinness than mainstream White American culture, while the opposite 
appears to be true for Asian American women (Gilbert, 2003; Talleyrand, 
2015). High levels of racial and ethnic identity, on the other hand, 
may protect women from mainstream White beauty standards, while 
experiences of oppression can create feelings of powerlessness 
that may result in the development of EDs as a coping mechanism 
(Talleyrand, 2015). Thus, the presentation of EDs for BIPOC women 
TH`�KPɈLY�MYVT�[OL�J\YYLU[�JSPUPJHS�\UKLYZ[HUKPUN��^OPJO�JLU[LYZ�[OL�
experiences of White, upper-class women. More research is needed 
to understand the complexities of EDs and best treatments for BIPOC 
women.

ENHANCED COGNITIVE BEHAVIORAL THERAPY (CBT-E) AS AN INTERVENTION FOR BIPOC  
ADOLESCENT GIRLS WITH EATING DISORDERS



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   71   

RESEARCH LIMITATIONS

There is little research available regarding EDs among BIPOC adolescent 
girls. Rodgers et al. (2017) studied the prevalence and expression of 
EDs among overweight adolescent girls and found that overweight Asian 
American girls, compared to Black, Latina, and White girls, had the 
highest risk of overeating; White overweight girls had the second highest 
risk. Black overweight girls were most at risk for partaking in unhealthy 
behaviors such as fasting, purging, and food restriction to control their 
weight, and Latina and White overweight girls had the highest rates 
VM�KPL[PUN��0U[LYLZ[PUNS �̀�[OL�ÄUKPUNZ�Z\NNLZ[�[OH[�)SHJR�NPYSZ�TH`�IL�
at greater risk for binge eating in early adolescence, while risk among 
White girls increases with age. 

Overall, it appears that BIPOC women and adolescent girls experience 
EDs at similar rates to their White counterparts. Despite an increase 
in the number of studies that are beginning to demonstrate this fact, 
BIPOC women are still underdiagnosed and undertreated, due to a 
variety of factors (Gilbert, 2003; Sonneville & Lipson, 2018; Striegel-
Moore & Bulik, 2007; Talleyrand, 2015). It is vital to understand the 
KPɈLYLU[�^H`Z�,+Z�KL]LSVW�HUK�WYLZLU[�IHZLK�VU�HU�PUKP]PK\HS»Z�
J\S[\YL��YHJL��VY�L[OUPJP[`�PU�VYKLY�[V�TVYL�LɈLJ[P]LS`�[YLH[�[OL�KP]LYZL�
women and girls who experience EDs. This is especially important for 
adolescent girls, who are in a highly vulnerable developmental period 
at the age that EDs often begin (Micali et al., 2013; Verschueren et 
HS����������:[\KPLZ�Z\NNLZ[�[OH[�HKVSLZJLU[�NPYSZ�HYL�H[�LX\HS��PM�UV[�
higher, risk for developing such disorders compared with adult women 
(Rodgers et al., 2017).

ENHANCED COGNITIVE BEHAVIORAL THERAPY (CBT-E)
Enhanced Cognitive Behavior Therapy (CBT-E) is a leading empirically 
supported transdiagnostic cognitive behavioral treatment for EDs 
(Fairburn, 2008). The transdiagnostic theory of EDs is based on the 
ÄUKPUN�[OH[�[OL�WYPTHY`�THPU[HPUPUN�WYVJLZZLZ�MVY�LHJO�,+�KPHNUVZPZ�
largely overlap (Atwood & Friedman, 2020). Because of this, CBT-E 

YINAN CHEN, LILY GABAY, AND CATHERINE STAMPFLI



72  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

was developed to address the psychopathology of EDs as a whole. It 
is a treatment for all forms of EDs, including anorexia nervosa, bulimia 
nervosa, and binge eating disorder (Fairburn, 2008). CBT-E also 
allows patients with EDs to learn how their disorder functions, how it 
is maintained, and how to disrupt the self-reinforcing cycle of the ED 
(Murphy et al., 2010). 

CBT-E was initially developed for individuals in outpatient treatment 
settings, but there are also guidelines for implementation as an intensive 
form of day treatment, inpatient treatment, or group therapy (Fairburn, 
2008). According to the Centers for Disease Control and Prevention 
�*+*���HK\S[Z����`LHYZ�VSK�HUK�VSKLY�^P[O�H�)40�\UKLY������RN�T��
are considered underweight (CDC, 2022). Individuals with a BMI of 
�����RN�T��VY�TVYL��^OV�HYL�UV[�ZPNUPÄJHU[S`�\UKLY^LPNO[��4\YWO`�L[�
al., 2010), are advised to attend twenty therapy sessions over twenty 
^LLRZ��-VY�PUKP]PK\HSZ�^P[O�H�)40�IL[^LLU������HUK������RN�T���^OV�
HYL�ZPNUPÄJHU[S`�\UKLY^LPNO[�HUK�HYL�Z\IQLJ[�[V�THYRLK�WO`ZPJHS�HUK�
WZ`JOVZVJPHS�LɈLJ[Z��-HPYI\YU���������^LPNO[�YLZ[VYH[PVU�PZ�[OL�THPU�
treatment aim, and forty sessions over forty weeks are advised. Similar 
to other evidence-based CBT treatments, CBT-E is highly individualized, 
^OPJO�YLX\PYLZ�WH[PLU[Z�HUK�JSPUPJPHUZ�[V�^VYR�[VNL[OLY�[V�KL]LSVW�H�
personalized treatment plan based on an individual’s symptoms, core 
pathology, and triggers. The psychoeducation component of CBT-E 
addresses the distorted beliefs that contribute to patients’ EDs.

TREATMENT STEPS OF CBT-E

According to Fairburn (2008), CBT-E usually starts with a one-and-a-half 
[V�[^V�OV\Y�L]HS\H[PVU�ZLZZPVU��MVSSV^LK�I`�[^LU[`�ÄM[`�TPU\[L�[OLYHW`�
ZLZZPVUZ�V]LY�[OL�JV\YZL�VM�[^LU[`�^LLRZ��;OL�ÄYZ[�LPNO[�ZLZZPVUZ��
including the evaluation session, are held twice a week, followed by ten 
^LLRS`�ZLZZPVUZ�HUK�[OYLL�ÄUHS�ZLZZPVUZ�L]LY`�V[OLY�^LLR�

There are four stages associated with CBT-E (Fairburn, 2008). Stage 
one is the intensive initial stage, called “starting well.” During this stage, 
patients meet clinicians twice a week for four weeks. They spend 

ENHANCED COGNITIVE BEHAVIORAL THERAPY (CBT-E) AS AN INTERVENTION FOR BIPOC  
ADOLESCENT GIRLS WITH EATING DISORDERS



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   73   

[OL�ÄYZ[�ML^�^LLRZ�VM�[OL�[YLH[TLU[�NH[OLYPUN�PUMVYTH[PVU�HIV\[�[OL�
disorders and carefully considering the reasons for and against change. 
Then an individualized treatment plan is developed, and patients are 
informed of its utility, structure, and homework. Research on EDs has 
ZOV^U�[OL�THNUP[\KL�VM�JOHUNL�PU�[OL�ÄYZ[�ML^�^LLRZ�VM�[YLH[TLU[�PZ�
a strong predictor of treatment outcomes, so these initial weeks are 
especially crucial. 

Sessions in stage one include weekly weigh-ins to help patients 
\UKLYZ[HUK�UH[\YHS�Å\J[\H[PVUZ�PU�^LPNO["�[OPZ�KH[H�PZ�WSV[[LK�VU�H�
graph to give individuals a better understanding of weight trends. 
Patients may not weigh themselves outside of these sessions (Fairburn, 
2008). Homework between sessions includes self-monitoring forms to 
record everything consumed, cognitions and emotions while eating, 
any excessive eating or drinking, use of laxatives or diuretics, bouts 
of purging, and any compensatory actions in response to eating. Self-
monitoring forms not only increase patients’ self-awareness around 
eating behaviors, but also provide a structured log for practicing skills 
so they can address any barriers. Clinicians also introduce regular eating 
to patients, which entails eating three meals and three snacks per day in 
regular intervals, not exceeding four hours without eating. 

Stage two of the treatment, the transitional stage, is called “taking 
stock” (Fairburn, 2008). In these sessions, clinicians review progress 
and help patients identify and address any barriers they encountered 
between sessions, such as resistance to change, not prioritizing the 
treatment, depression, poor planning, and low self-esteem. Then, 
clinicians and patients review and modify the initial formulation of the 
disorder based on the information collected over several weeks of self-
monitoring. For example, if patients are not able to follow their dietary 
plan when they are angry or anxious, they would need to add mood 
changes as a trigger for binge eating to their existing formulation.

After modifying the initial formulation, clinicians and patients must 
decide whether to use a broad or focused version of CBT-E for the 
remainder of the treatment (Fairburn, 2008). The focused version 

YINAN CHEN, LILY GABAY, AND CATHERINE STAMPFLI



74  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

exclusively addresses ED psychopathology, while the broad version 
is only recommended if one or more external mechanisms, such as 
clinical perfectionism, core low self-esteem, or marked interpersonal 
KPɉJ\S[PLZ��HYL�PKLU[PÄLK�[V�IL�THPU[HPUPUN�[OL�KPZVYKLY�HUK�WYL]LU[PUN�
change (Cooper & Grave, 2017). Normally, the focused form is the 
KLMH\S[�ILJH\ZL�P[�PZ�TVYL�LɈLJ[P]L�HUK�LHZPLY�[V�PTWSLTLU["�P[�PZ�\ZLK�
with most patients who can be safely managed as outpatients. Once 
clinicians and patients determine which mechanisms to address and in 
what order, based on the patient’s needs and presentation, they develop 
a treatment plan (Fairburn, 2008).

In stage three, the intensive treatment stage which comprises eight 
weekly sessions, clinicians and patients address key mechanisms 
[OH[�THPU[HPU�[OL�,+!�IVK`�PTHNL"�KPL[HY`�YLZ[YHPU["�HUK�L]LU[Z��
moods, and eating (Fairburn, 2008). The clinician addresses patients’ 
overvaluation of body shape and weight by providing psychoeducation 
HIV\[�V]LY]HS\H[PVU�HUK�P[Z�JVUZLX\LUJLZ��;OPZ�OLSWZ�[V�KL]LSVW�
formerly ignored domains of self-evaluation; reduce unhelpful body 
checking and avoidance (e.g., mirror checking and comparing bodies); 
relabel unhelpful thoughts (e.g., feeling fat); examine the origins of the 
overvaluation; and learn to identify and modify the mindset surrounding 
the ED (Cooper & Grave, 2017). Additionally, clinicians help patients 
JOHUNL�YPNPK�KPL[HY`�Y\SLZ�PU[V�ÅL_PISL�N\PKLSPULZ�MVY�LH[PUN��PU[YVK\JL�
previously avoided foods, and develop problem-solving and mood-
regulation skills. If clinicians decide to use the broad version mentioned 
in stage two of the treatment, they address the external mechanism in 
addition to the general psychopathology. 

:[HNL�MV\Y��JHSSLK�¸LUKPUN�^LSS�¹�PZ�[OL�ÄUHS�Z[HNL�VM�*);�,��-HPYI\YU��
2008). It consists of three sessions that take place every other week. 
+\YPUN�[OL�ÄUHS�WHY[�VM�Z[HNL�[OYLL�HUK�PU�Z[HNL�MV\Y��[OL�LTWOHZPZ�
shifts from treating the existing problem to looking toward the future. In 
this stage, patients work with clinicians to address their reactions and 
JVUJLYUZ�HIV\[�LUKPUN�[YLH[TLU[�HUK�ÄUK�^H`Z�[V�THPU[HPU�WYVNYLZZ��
The goal is for patients to be able to apply learned skills independently, 

ENHANCED COGNITIVE BEHAVIORAL THERAPY (CBT-E) AS AN INTERVENTION FOR BIPOC  
ADOLESCENT GIRLS WITH EATING DISORDERS



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   75   

so as to handle setbacks and maintain the changes that have already 
been made in order to minimize the risk of relapse. Together they devise 
a short-term maintenance plan for patients to utilize until their review 
HWWVPU[TLU[��^OPJO�VJJ\YZ�[^LU[`�^LLRZ�HM[LY�[OL�ÄUHS�ZLZZPVU��

In stage four, clinicians help patients phase out treatment procedures 
and homework (Fairburn, 2008). For example, patients stop self-
monitoring records and in-session weighing in week eighteen. Patients 
learn to be aware of what they eat, what happens throughout the day, 
and their urges to engage in ED behaviors without the aid of self-
monitoring forms. Patients also start to weigh themselves at home 
with an open mind about their weight and identify strategies to prevent 
relapse, including listening to joyful music, reaching out to friends and 
family for support, exercising (CBT-E, n.d.), and engaging in relaxation 
[LJOUPX\LZ��Z\JO�HZ�KLLW�IYLH[OPUN�HUK�TPUKM\SULZZ�WYHJ[PJLZ��;OL`�
may also identify helpful preventive strategies such as avoiding certain 
people, places, or stimuli when they experience urges to binge eat. 
-PUHSS �̀�K\YPUN�[OPZ�ÄUHS�Z[HNL��JSPUPJPHUZ�LK\JH[L�WH[PLU[Z�HIV\[�YLHSPZ[PJ�
expectations for recovery, devise a long-term maintenance plan to deal 
with setbacks, and encourage patients to seek help from professionals 
to address these issues (Fairburn, 2008).

Twenty weeks after the conclusion of treatment, patients are asked to 
return for a post-treatment review session (Cooper & Grave, 2017). A 
X\LZ[PVUUHPYL�PZ�\ZLK�[V�HZZLZZ�[OL�WYLZLU[�Z[H[L�VM�[OL�,+�HUK�^OL[OLY�
daily function is impaired by the ED (Fairburn & Beglin, 1994; Bohn & 
Fairburn, 2008). In addition to the assessment, the review also includes 
a recap of patients’ progress throughout the entire treatment, a short-
term plan for how patients can continue to address the remaining 
symptoms, and strategies to handle setbacks. Clinicians also review 
the long-term maintenance plan with patients to see if any necessary 
changes are needed (Fairburn, 2008).

YINAN CHEN, LILY GABAY, AND CATHERINE STAMPFLI



76  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

EVALUATION AND MEASUREMENT IN CBT-E

In CBT-E, patient outcomes are observed through pre- and post-
assessments as well as session-by-session symptom measurements. 
These measures include the Eating Disorder Examination (EDE), with 
versions available for both children and adults (Cooper & Fairburn, 1987; 
Hilbert et al., 2013); the Eating Disorder Examination Questionnaire 
(EDE-Q; Fairburn, 2008); the Clinical Impairment Assessment (CIA; 
Bohn & Fairburn, 2008); the Clinical Perfectionism Questionnaire (CPQ; 
Fairburn et al., 2003); the Eating Problem Checklist (EPCL; Dalle Grave 
et al., 2019); and the Starvation Symptoms Inventory (SSI; Calugi et al., 
2017).

CBT-E WITH ADOLESCENTS

The content of CBT-E for adolescents is similar to that of adults, 
although it tends to be shorter because adolescents are typically 
capable of changing their behaviors faster than adults (Cooper & 
Grave, 2017). For example, underweight adolescent patients may only 
need thirty sessions to complete the treatment, instead of the typical 
MVY[`�ZLZZPVUZ��(�THQVY�TVKPÄJH[PVU�VM�[OL�[YLH[TLU[�MVY�HKVSLZJLU[Z�
PZ�WHYLU[HS�PU]VS]LTLU[��)LJH\ZL�H�ZPNUPÄJHU[�U\TILY�VM�HKVSLZJLU[Z�
receiving treatment are younger than eighteen, parental involvement 
PZ�ULJLZZHY �̀�0U�[OL�ÄYZ[�[^V�^LLRZ�VM�[OL�[YLH[TLU[��[OL�JSPUPJPHU�OHZ�
HZZLZZTLU[�ZLZZPVUZ�HSVUL�^P[O�[OL�WHYLU[Z��(M[LY^HYK��ÄM[LLU��[V�
twenty-minute joint sessions with the adolescent and parents are 
conducted throughout the course of treatment to update parents on 
treatment progress. The joint sessions also educate parents about 
the nature of their child’s ED, the rationale of treatment interventions, 
and how they can help their child during the treatment process. The 
U\TILY�HUK�MYLX\LUJ`�VM�[OLZL�QVPU[�ZLZZPVUZ�KLWLUK�VU�LHJO�WH[PLU[»Z�
situation. 

ENHANCED COGNITIVE BEHAVIORAL THERAPY (CBT-E) AS AN INTERVENTION FOR BIPOC  
ADOLESCENT GIRLS WITH EATING DISORDERS



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   77   

EFFECTIVENESS AND LIMITATIONS OF CBT-E

There are many reasons CBT-E is useful in both clinical and social work 
WYHJ[PJL!�P[�JHU�IL�\ZLK�PU�IV[O�PUWH[PLU[�HUK�V\[WH[PLU[�ZL[[PUNZ��OHZ�H�
Ä_LK�SLUN[O��HUK�\ZLZ�ZWLJPÄLK�Z[YH[LNPLZ�HUK�WYVJLK\YLZ�[V�HKKYLZZ�
,+�WZ`JOVWH[OVSVN`�[OYV\NO�MV\Y�^LSS�KLÄULK�Z[HNLZ��-HPYI\YU��
2008). Additionally, it encourages the establishment of "therapeutic 
momentum" that is needed early in treatment to make inroads in 
addressing the ED, helps ensure clinicians and patients keep working to 
achieve change, and increases the likelihood that treatment will have a 
formal ending.

(KKP[PVUHSS �̀�HS[OV\NO�[OLYL�PZ�SPTP[LK�YLZLHYJO�VU�[OL�LɈLJ[P]LULZZ�
of CBT-E among younger patients, many considerations support the 
proposal that CBT-E might be especially suitable for them (Cooper & 
Grave, 2017). CBT-E is designed to increase patients’ self-control, which 
JHU�ILULÄ[�TVZ[�HKVSLZJLU[Z��HUK�LUOHUJL�TV[P]H[PVU��H�NVHS�[OH[�PZ�
particularly relevant for underweight adolescent patients. CBT-E also 
HKVW[Z�H�ÅL_PISL�HUK�PUKP]PK\HSPaLK�HWWYVHJO�[OH[�PZ�LHZPS`�HKHW[HISL�
to the needs of adolescents’ cognitive development; moreover, it 
promotes autonomy, which is particularly relevant to adolescents, who 
respond favorably to collaborative treatment. Finally, CBT-E has been 
adapted for adolescents in a way that takes their physical health into 
account because the prevalence of medical complications associated 
with EDs is particularly severe for adolescents. As a result, there is a 
SV^LY�MYLX\LUJ`�VM�OVZWP[HS�HKTPZZPVUZ�HTVUN�HKVSLZJLU[Z�PU�*);�,�
treatment. 

:[\KPLZ�VU�*);�,�^P[O�HKVSLZJLU[Z�OH]L�ZOV^U�H�ZPNUPÄJHU[�
improvement in the BMI in adolescent participants with anorexia 
nervosa, as well as decreases in their clinical impairment scores, ED 
psychopathology, and general psychopathology scores (Dalle Grave 
et al., 2013; Dalle Grave et al., 2020; de Jong et al., 2020). They have 
also demonstrated that patients are able to maintain improvements 
even after treatment is completed (Signorini et al., 2018). Although this 

YINAN CHEN, LILY GABAY, AND CATHERINE STAMPFLI



78  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

research is primarily focused on anorexia nervosa, the transdiagnostic 
MLH[\YL�VM�*);�,�Z\NNLZ[Z�P[Z�LɈLJ[P]LULZZ�^P[O�HSS�,+Z�

,]LU�^P[O�[OL�THU`�ILULÄ[Z�VM�*);�,��ZVTL�SPTP[H[PVUZ�ULLK�[V�IL�
addressed through additional research. Despite a low remission rate 
for individuals who participate in CBT-E, it does not work for everyone. 
Around 50% of individuals do not fully recover using CBT-E, with 
some showing no improvements at all (Linardon et al., 2018). Similarly, 
around 25% of individuals drop out of treatment prematurely due to 
KPZZH[PZMHJ[PVU��;OL�J\YYLU[�YLZLHYJO�KVLZ�UV[�ZWLJPÄJHSS`�HKKYLZZ�
multiple comorbidities that individuals with EDs may experience and 
does not address other relevant factors to the disorder, such as shame 
or trauma. More importantly, there is a lack of evidence that CBT-E 
treatment works across ethnic, racial, and socioeconomic groups. 

+LZWP[L�[OL�SHJR�VM�YLZLHYJO�VU�[OL�LɈLJ[P]LULZZ�VM�*);�,�^P[O�)076*�
individuals, we argue that the individualized and cooperative nature 
of the treatment allows clinicians to assist  individuals in constructing 
culturally appropriate treatments. As such, we suggest adding a 
component during the initial planning stage that addresses patients’ 
culture and beliefs around mental health and EDs. This addition would 
HSSV^�WH[PLU[Z�[V�IYPUN�\W�HU`�J\S[\YHSS`�ZWLJPÄJ�JVUJLYUZ��IHYYPLYZ��
or accommodations they would like to include in their treatment. In 
the case of BIPOC adolescents, this component would involve parent 
and caregiver input as well. It is also vital for all clinicians working with 
BIPOC individuals to receive cultural competency training and speak the 
same language as those they are working with, preferably the client’s 
ÄYZ[�SHUN\HNL��[V�TH_PTPaL�LɈLJ[P]LULZZ�

CONCLUSION 

Evidence-based treatments such as CBT-E are crucial for addressing 
,+Z�HUK�[OLPY�Z`TW[VTZ��^OPJO�JHU�SLHK�[V�MH[HS�JVUZLX\LUJLZ��>L�
HYN\L�[OH[�*);�,�PZ�LɉJHJPV\Z�PU�[YLH[PUN�HKVSLZJLU[Z�ILJH\ZL�P[�PZ�
highly individualized and promotes engagement in order to produce 
change. We believe our recommendations would aid in improving 

ENHANCED COGNITIVE BEHAVIORAL THERAPY (CBT-E) AS AN INTERVENTION FOR BIPOC  
ADOLESCENT GIRLS WITH EATING DISORDERS



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   79   

[OL�X\HSP[`�VM�JHYL�MVY�)076*�HKVSLZJLU[�NPYSZ�HUK�\S[PTH[LS`�YLK\JL�
further negative outcomes. However, due to a lack of evidence on the 
LɈLJ[P]LULZZ�VM�*);�,�MVY�)076*�HKVSLZJLU[�NPYSZ�PU�WHY[PJ\SHY��M\Y[OLY�
YLZLHYJO�PZ�ULLKLK�[V�L_HTPUL�[OL�LɉJHJ`�VM�[OL�[YLH[TLU[�HUK�[V�
develop CBT-E to be more culturally competent.

REFERENCES

Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with 
HUVYL_PH�ULY]VZH�HUK�V[OLY�LH[PUN�KPZVYKLYZ!�(�TL[H�HUHS`ZPZ�VM����Z[\KPLZ��Archives of 
General Psychiatry,�����������¶�����O[[WZ!��KVP�VYN���������HYJONLUWZ`JOPH[Y �̀��������

Atwood, M. E., & Friedman, A. (2020). A systematic review of enhanced cognitive 
behavioral therapy (CBT-E) for eating disorders. International Journal of Eating 
Disorders������������¶�����O[[WZ!��KVP�VYN���������LH[�������

)VOU��2���
�-HPYI\YU��*��.����������;OL�JSPUPJHS�PTWHPYTLU[�HZZLZZTLU[�X\LZ[PVUUHPYL��*0(���
In C. G. Fairburn (Ed.), Cognitive behavioral therapy for eating disorders (pp. 315-317). 
Guilford Publications.

Calugi, S., Miniati, M., Milanese, C., Sartirana, M., El Ghoch, M., & Dalle Grave, R. 
��������;OL�Z[HY]H[PVU�Z`TW[VT�PU]LU[VY`!�+L]LSVWTLU[�HUK�WZ`JOVTL[YPJ�WYVWLY[PLZ��
Nutrients�� � ��� ����O[[WZ!��KVP�VYN������ ��U\ � � ���

CBT-E: How it works & what to expect. (n.d.). Choosing Therapy. Retrieved November 27, 
������MYVT�O[[WZ!��^^ �̂JOVVZPUN[OLYHW �̀JVT�JI[�L��

CDC. (2022, June 3). All About Adult BMI. Centers for Disease Control and Prevention. 
O[[WZ!��^^ �̂JKJ�NV]�OLHS[O`^LPNO[�HZZLZZPUN�ITP�HK\S[FITP�PUKL_�O[TS

*VVWLY��A���
�-HPYI\YU��*���� �����;OL�LH[PUN�KPZVYKLY�L_HTPUH[PVU!�(�ZLTPɫZ[Y\J[\YLK�
PU[LY]PL^�MVY�[OL�HZZLZZTLU[�VM�[OL�ZWLJPÄJ�WZ`JOVWH[OVSVN`�VM�LH[PUN�KPZVYKLYZ��
International Journal Of Eating Disorders,������������O[[WZ!��KVP�VYN����������� ��
���?�� ������!�#�!!(0+�,(;����������%����*6"�� �

*VVWLY��A���
�.YH]L��9��+����������,H[PUN�KPZVYKLYZ!�;YHUZKPHNUVZ[PJ�[OLVY`�HUK�[YLH[TLU[��
In S. G. Hofmann & G. J. G. Asmundson (Eds.), The Science of Cognitive Behavioral 
Therapy��WW�����¶������(JHKLTPJ�7YLZZ��O[[WZ!��KVP�VYN���������) ���������������
6.00014-3 

Dalle Grave, R., Calugi, S., Doll, H. A., & Fairburn, C. G. (2013). Enhanced cognitive 
ILOH]PV\Y�[OLYHW`�MVY�HKVSLZJLU[Z�^P[O�HUVYL_PH�ULY]VZH!�(U�HS[LYUH[P]L�[V�MHTPS`�
therapy? Behaviour Research And Therapy,��������9 �9����O[[WZ!��KVP�VYN���������Q�
brat.2012.09.008 

YINAN CHEN, LILY GABAY, AND CATHERINE STAMPFLI



80  |  COLUMBIA SOCIAL WORK REVIEW, VOL. XXI 

+HSSL�.YH]L��9���*VU[P��4���
�*HS\NP��:����������,ɈLJ[P]LULZZ�VM�PU[LUZP]L�JVNUP[P]L�
behavioral therapy in adolescents and adults with anorexia nervosa. International 
Journal of Eating Disorders����� ��������������O[[WZ!��KVP�VYN����������:0*0��� ��
���?��  ����� !�#� �!!(0+�,(;�%����*6"��.�

Dalle Grave, R., Sartirana, M., Milanese, C., El Ghoch, M., Brocco, C., Pellicone, C., 
& Calugi, S. (2019). Validity and reliability of the Eating Problem Checklist. Eating 
Disorders��������������  ��O[[WZ!��KVP�VYN�������������������������������

de Jong, M., Spinhoven, P., Korrelboom, K., Deen, M., van der Meer, I., Danner, U. N., van 
KLY�:JO\\Y��:���:JOVVYS��4���
�/VLR��/��>����������,ɈLJ[P]LULZZ�VM�LUOHUJLK�JVNUP[P]L�
ILOH]PVY�[OLYHW`�MVY�LH[PUN�KPZVYKLYZ!�(�YHUKVTPaLK�JVU[YVSSLK�[YPHS��International 
Journal of Eating Disorders������������������O[[WZ!��KVP�VYN���������LH[����� �

Deloitte Access Economics. (2020). The social and economic cost of eating disorders 
in the United States of America: A report for the strategic training initiative for the 
prevention of eating disorders and the Academy for Eating Disorders.�O[[WZ!��^^ �̂OZWO�
OHY]HYK�LK\�Z[YPWLK�YLWVY[�LJVUVTPJ�JVZ[Z�VM�LH[PUN�KPZVYKLYZ��

-HPYI\YU��*��.���
�)LNSPU��:��1����  ����(ZZLZZTLU[�VM�LH[PUN�KPZVYKLYZ!�0U[LY]PL^�VY�ZLSMɫ
YLWVY[�X\LZ[PVUUHPYL&�International Journal Of Eating Disorders, 16(4), 363-370.

-HPYI\YU��*��.���*VVWLY��A���
�:OHMYHU��9����������*SPUPJHS�WLYMLJ[PVUPZT�X\LZ[PVUUHPYL��
Behavioural and Cognitive Psychotherapy.

Fairburn, C. G. (2008). Cognitive Behavior Therapy and Eating Disorders. Guilford Press.

Gilbert, S. C. (2003). Eating disorders in women of color. Clinical Psychology: Science and 
Practice������������¶�����O[[WZ!��KVP�VYN������ ��JSPWZ �̀IWN����

Hilbert, A., Buerger, A., Hartmann, A. S., Spenner, K., Czaja, J., & Warschburger, P. (2013). 
Psychometric evaluation of the eating disorder examination adapted for children. 
European Eating Disorders Review��������������� ��O[[WZ!��KVP�VYN���������LY]������

Johnson, J. G., Cohen, P., Kasen, S., & Brook, J.S. (2002). Eating disorders 
during adolescence and the risk for physical and mental disorders during early 
adulthood. Archives of General Psychiatry��� ��������¶�����O[[WZ!��KVP�VYN���������
archpsyc.59.6.545 

Keel, P. K., & Forney, K. J. (2013). Psychosocial risk factors for eating disorders. 
International Journal of Eating Disorders������������ ��O[[WZ!��KVP�VYN���������LH[���� ��

3PUHYKVU��1���-HPYI\YU��*��.���-P[aZPTTVUZ�*YHM[��,��,���>PSÅL �̀�+��,���
�)YLUUHU��3����������
The empirical status of the third-wave behaviour therapies for the treatment of eating 
KPZVYKLYZ!�(�Z`Z[LTH[PJ�YL]PL �̂�Clinical Psychology Review�������������O[[WZ!��KVP�
VYN���������Q�JWY������������

Murphy, R., Straebler, S., Cooper, Z., & Fairburn, C. G. (2010). Cognitive behavioral therapy 
for eating disorders. The Psychiatric Clinics of North America������������¶�����O[[WZ!��
KVP�VYN���������Q�WZJ������������

ENHANCED COGNITIVE BEHAVIORAL THERAPY (CBT-E) AS AN INTERVENTION FOR BIPOC  
ADOLESCENT GIRLS WITH EATING DISORDERS



COLUMBIA SOCIAL WORK REVIEW, VOL. XXI  |   81   

4PJHSP��5���7SV\IPKPZ��.���+L�:[H]VSH��)���:PTVUVɈ��,���
�;YLHZ\YL��1����������-YLX\LUJ`�
and patterns of eating disorder symptoms in early adolescence. Journal of Adolescent 
Health������������������O[[WZ!��KVP�VYN���������Q�QHKVOLHS[O�������������

National Institute of Mental Health. (n.d.-a). Statistics: Eating disorders��O[[WZ!��^^ �̂UPTO�
UPO�NV]�OLHS[O�Z[H[PZ[PJZ�LH[PUN�KPZVYKLYZ
WHY[F�����

National Eating Disorders Association. (n.d.-b). Warning signs and symptoms��O[[WZ!��^^ �̂
UH[PVUHSLH[PUNKPZVYKLYZ�VYN�^HYUPUN�ZPNUZ�HUK�Z`TW[VTZ��

National Institute of Mental Health. (2021, December). Health topics: Eating disorders. 
O[[WZ!��^^ �̂UPTO�UPO�NV]�OLHS[O�[VWPJZ�LH[PUN�KPZVYKLYZ�

Rodgers, R. F., Watts, A. W., Austin, S. B., Haines, J., & Neumark-Sztainer, D. (2017). 
Disordered eating in ethnic minority adolescents with overweight. International Journal 
of Eating Disorders���������¶������O[[WZ!��KVP�VYN���������LH[�������

:PNUVYPUP��9���:OLɉLSK��1���9OVKLZ��5���-SLTPUN��*���
�>HYK��>����������;OL�LɈLJ[P]LULZZ�
VM�LUOHUJLK�JVNUP[P]L�ILOH]PV\YHS�[OLYHW`��*);�,�!�(�UH[\YHSPZ[PJ�Z[\K`�^P[OPU�HU�V\[�
patient eating disorder service. Behavioural and Cognitive Psychotherapy, 46(1), 21-34. 
O[[WZ!��KVP�VYN���������:�����������������

Sonneville, K. R., & Lipson, S. K. (2018). Disparities in eating disorder diagnosis and 
[YLH[TLU[�HJJVYKPUN�[V�^LPNO[�Z[H[\Z��YHJL�L[OUPJP[ �̀�ZVJPVLJVUVTPJ�IHJRNYV\UK��HUK�
sex among college students. International Journal of Eating Disorders, 51, 518– 526. 
O[[WZ!��KVP�VYN���������LH[�������

:[PLYTHU��)���(Ɉ\S��1���*HYYVSS��4��+���*OLU��;�*���+H] �̀�6���-PUR��:���-Y`HY��*��+���.\��8���
Hales, C. M., Hughes, J. P., Ostchega, Y., Storandt, R. J., & Akinbami, L. J. (2021). 
National health and nutrition examination survey: 2017–March 2020 prepandemic data 
-PSLZ·+L]LSVWTLU[�VM�ÄSLZ�HUK�WYL]HSLUJL�LZ[PTH[LZ�MVY�ZLSLJ[LK�OLHS[O�V\[JVTLZ�
�5/:9�5V��������5H[PVUHS�*LU[LY�MVY�/LHS[O�:[H[PZ[PJZ��<�:����O[[WZ!��Z[HJRZ�JKJ�NV]�
]PL^�JKJ���������

Striegel-Moore, R. H., & Bulik, C. M. (2007). Risk factors for eating disorders. American 
Psychologist,�����������¶� ���O[[WZ!��KVP�VYN�����������������?����������

;HSSL`YHUK��9��4����������*SPLU[Z�VM�JVSVY�HUK�LH[PUN�KPZVYKLYZ!�*\S[\YHS�JVUZPKLYH[PVUZ��
In L. H. Choate (Ed.), Eating disorders and obesity (pp. 45-68). American Counseling 
(ZZVJPH[PVU��O[[WZ!��KVP�VYN��������� ����� �������JO��

Verschueren, M., Claes, L., Palmeroni, N., Bogaerts, A., Gandhi, A., Moons, P., & Luyckx, 
2����������,H[PUN�KPZVYKLY�Z`TW[VTH[VSVN`�PU�HKVSLZJLU[�IV`Z�HUK�NPYSZ!�0KLU[PM`PUN�
distinct developmental trajectory classes. Journal of Youth and Adolescence, 49, 
���¶�����O[[WZ!��KVP�VYN���������Z�� ����� ��������

YINAN CHEN, LILY GABAY, AND CATHERINE STAMPFLI


