1. CBT-E Assisted Eating at HFU

2. Aims of assisted eating/meals
To apply cognitive behavioural strategies during meals
Exactly what assisted eating addresses depends on the nature of the patient’s difficulties/their formulation
Help the patient to eat ‘actively’, not ‘passively’
Help the patient recognise unhelpful thoughts and decentre from these
Help the patient to distance behaviour from thoughts, choosing instead to behave within a ‘recovery mindset’
Address ritualistic eating behaviour
As with all CBTE procedures, the structure is to
identify the problem,
educate about the problem, and then
address the maintaining mechanisms.
‘Mechanical eating’: - Patients encouraged to eat regardless of feelings of fullness or hunger – view food as ‘medication’

3. General open questions such as:
Before meal: Any initial thoughts or worries? How did you manage your anxiety?
Looking at the food presented: Talk me through what you’re thinking. Thoughts on portion size? What made you choose that meal for your lunch choice – is it something you’ve had at home/‘safe food’? Which part are you going to start with and why? Are you tempted to try to use any dietary rules?
During meal: I noticed you have divided the vegetables, carbs and main meal up and wondered why that was? I was wondering what made you start with the smallest slice of toast? How are you doing for time? Try to complete your self-monitoring sheets to record your thoughts, feelings and behaviours in real-time.
After meal: How are you going to manage your anxiety/urges to purge or body-check on supervision?

4. 1. Identify the problem Socialise the patient to take an active role
Self monitor in real time
First meal for assessment
Notice ED mindset; patterns in thoughts, behaviours, feelings
Review other monitoring forms to identify rules / behaviours to tackle, and plan
The patient’s role is active
Not just eating, but also applying cognitive behavioural strategies to handle your ED mindset
If you eat passively (just because we tell you to), when you come to eat meals by yourself it will still be difficult to manage your ED mindset
By practising now, you skill yourself up to be your own therapist and be able to manage your own eating after discharge.
Assessment & understanding
Discuss with the YP which meal they would like to start with and why? Which meal do they struggle with the most? Are they avoiding choosing a certain meal/foods?
The ‘assessment’ can take place over more than one meal – depends on the YP
This meal is about listening, building engagement/ rapport and developing an understanding of the YP’s difficulties, thoughts, feelings, behaviours, rituals etc.
Be on the look out for idiosyncratic dietary rules, such as avoiding eating more than others
Bring paper for yourself and the YP – offer them the opportunity to make their own notes or use their CBT-E self-monitoring record sheets
Depending on the YP, prompting may be needed if they are struggling to voice their thoughts and feelings
No challenging yet (this comes later)
Not giving feedback to change their eating behaviour (smearing, crumbing etc. – this comes later)
Think about what information you may wish to gather for future meals
Ensure the YP understands the difference between thoughts and feelings
Record their thoughts, feelings and behaviours, using direct quotes where possible. These act as a baseline when comparing to future meals and noticing patterns of thoughts/behaviours
Can be a bit flexible with the time limit – takes longer to talk and eat! Staff discretion how much time allocated before thinking about Ensure replacement
Notice ED mindset
Cognitions are elicited for the purpose of decentring / challenging / acting opposite. Balance carefully.
Elicit cognitions with the aim of change; be aware of increasing rumination, or the young person persuading themselves in favour of the ED mindset.
Review monitoring forms
Some behaviours may have become so automatic, the YP may not even realise they are engaging in them (body-checking, rituals, dietary rules, small mouthfuls etc.) – this is the chance to un-pick some of these behaviours, draw their attention to it and get them to question it/reflect on whether this may be a result of their ED (distance the behaviour) and offer them the chance to act on the thought in a different way
Ask YP to practice self-monitoring in real-time during meals and offer the time to review the records together later
Reviewing recorded sheets and make a plan with what to tackle first

5. 2. Explore / educate
Examples
‘Have you noticed yourself doing…?’
‘How do you think you’re doing for time…?’
‘What happens if you…?’
‘Is that something you have always done…?’
‘Does it keep you stuck in the ED mindset or help you move into recovery mindset?’
Be curious, not judgemental or authoritative Question thoughts and behaviours
Notice/acknowledge thoughts associated with ED mindset, and identify patterns
Focus on the effect on preoccupation
Link to formulation and Life Design
Be curious, not judgemental or authoritative – get the YP to question themselves
Question thoughts and behaviours
Notice/acknowledge thoughts associated with ED mindset, and as with other CBT approaches, identify patterns such as
black and white thinking, mindreading, predicting the future, catastrophising, jumping to conclusions, etc.
Focus on effect on preoccupation
whether the thoughts and behaviours help them to manage the meal or keep them feeling anxious about eating.
Link to Life Design
young people want to be able to eat in restaurants with their friends, go on dates, eat at school, etc etc. this is a chance to experiment, rehearse coping, etc to build confidence.

6. 3. Practice alternative mindset
“Try to adopt the mindset of an athlete before high jumping. They concentrate on the technique to use and not on the fear of falling or on how high the bar may be”
Directly challenge the ED mindset
Distance and decentre from the ED mindset
Eat all the planned food
… without being influenced by internal signs of hunger/ fullness
… without being influenced by preoccupations of eating and food
… without rituals
Utilise general CBT skills to question thoughts, referring to previous psychoed
Directly tackle dietary rules
Set homework to continue practising these outside 1:1 sessions, e.g. skills to practise or further challenges to set
Some young people may engage well with directly challenging their thoughts, e.g. alternative statements using flashcards or visual reminders (e.g “I don’t want to have it as I don’t want to enjoy it” -> It is a normal biological response to enjoy certain foods, this does not make me greedy)
Others will benefit from distancing from the thoughts; rather than engaging with them, just recognise that it is the ED mindset, and focus on changing mindset (skills such as opposite emotion action, imagery and behaviour to get self into recovery mindset, distraction, reviewing pros and cons if motivation is wobbly)
Plan meals that directly tackle rules, such as eating more than others, in addition to increasing the range of food eaten.
Eating all the planned food
“Sticking to the meal plan will help you to feel in control during the weight restoration phase; this way you can predict the rate of weight regain.”
Eating without being influenced by internal signs of hunger and fullness
“Try to eat without being influenced by feelings of hunger or fullness because they are altered by your physical state” (refer to starvation syndrome and changes to gut and transit)
Eating without being influenced by preoccupations of eating and food
“Say to yourself that these are the expressions of the eating problem mindset that you want to change”
Utilise general CBT skills to gently question thoughts, including referring to previous psychoeducation
shades of grey thinking, focussing on facts not feelings, moving attention away from the food / internal states to the room, people, conversation, etc.
Distancing the behaviour from thoughts and preoccupations on eating and food
“Do not follow the thoughts of your eating problem mindset, do the opposite”
Avoiding rituals at the table
Dissuade the patient from unusual habits or any rituals that attempt to control eating or make food unpalatable.
Using the self-monitoring record in real time “

7. Points to remember:
Not to say they are wrong/silly or shouldn’t think that way
Not to tell them what to think or ways of challenging thoughts, but to lead and support
Therapy sessions occur on 1:1 basis alongside meals
Speed of progression for assisted meals are flexible and adaptable to each individual – there is no specific time frame
Link in with individual therapist regarding dietary rules, avoided foods, etc.