Typically this is combined with medication, and people can expect to see improvements in inhibition control and how to handle mood fluctuations (4). There is no set limit on how many sessions or for how long it takes for DBT to be effective. Some institutions encourage a 24-week program, but note that some people require regular, ongoing therapy, as relapse can be common.
Cognitive-behavioral therapy (CBT) helps to identify someone’s unhealthy thought patterns (cognitive distortions) that can contribute to unhelpful behavior. CBT teaches individuals to reframe their cognitive distortions, cope, and react to situations in a healthy way. It takes practice and consistency, as no one can change their behavior overnight, but studies show this is much more effective than a psychodynamic approach alone. Best results are seen when someone undergoes CBT at least once a week for around 20 sessions (1,2).
Dialectical behavior therapy (DBT) is a type of psychotherapy that uses the principles of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Utilization of DBT skills help manage mood reactivity, minimize unhelpful behavior, and improve communication with others (3).
Interpersonal therapy addresses issues like social isolation, unresolved grief, and difficult life transitions like retirement, divorce, or moving. This type of therapy is recommended when someone struggles with the conflict between friends and/or family (5). Studies show that this can be helpful for bulimia nervosa, but CBT has shown far superior results (6).
Acceptance and commitment therapy (ACT) was developed in the 1980s as a way to help people stop avoiding, denying, and struggling with their emotions. ACT helps people to accept that even distressing feelings are an appropriate response to some situations and should not prevent them from living fulfilling lives (7). While this can certainly be helpful, studies also show, similar to interpersonal therapy, that CBT is the most effective at treating bulimia (8).
Family therapy addresses the health and functioning of a family unit. When someone suffers from disordered eating, such as bulimia nervosa, it can have a negative impact on other family members. They may not understand how to help the person suffering from BN. Family therapy helps to equip them with the right actions and words to encourage them without enabling or making their symptoms worse. This is especially effective in those who suffer from anorexia nervosa. Studies show that FT improves self-esteem, quality of life, and the experience of caregiving for family members (9). Timelines for family therapy have not been formally decided, and are left up to the discretion of the therapist.
The Maudsley family-based treatment approach was developed in 1987 by psychiatrists and psychologists at the Maudsley Hospital in London as a treatment cure primarily for anorexia nervosa. This type of therapy has several goals (10,11):
- To prevent hospitalization of adolescents who struggle with disordered eating by recruiting the help of his or her parents.
- To help the person return to normal life unencumbered by the symptoms of an eating disorder.
- Help the adolescent control their eating disorder behaviors
Treatment involves three phases, with studies showing that people have the most benefit if families participate and commit to a minimum of 12 months of therapy. Persons with disordered eating undergo 15-20 treatment sessions over the course of one year.
Based on clinical studies, those who benefited the most from the Maudsley Approach had the following criteria (11):
- Developed disordered eating before the age of 18.
- Have only struggled with symptoms for less than three years.
- The Maudsley Approach usually starts with around ten weeks of inpatient care.
- The adolescents’ had strong nuclear families and friendships that also participated in treatment.
Having a strong, supportive family is critical for the Maudsley approach to be effective.
Other Effective Therapies
In recent years, art therapy has gained traction as a treatment modality, especially for teens, as some tend not to respond positively to verbal therapy. Clinical trials evaluating the efficacy of art therapy are frequently criticized for having too small of a study population, or following a faulty design. More studies are definitely needed before making blanket recommendations, but people who have undergone art therapy report great improvements in quality of life and mental health.
Art therapy supports expression, awareness, new perspectives, pride, and distraction, which can be helpful tools for healing from BN (12). Types of art therapy include drawing, painting, sculpting, listening to music, playing musical instruments, and dancing, to name a few (13).
Equine-assisted therapy (EAT) and equine-assisted learning (EAL) aim for the person to develop a therapeutic relationship with a horse, as opposed to simply with a therapist. This type of therapy typically occurs on a farm, or equine-related environment, as opposed to a doctor’s office. Many find this much more approachable and comforting.
Equine therapy can be used for physical, occupational, and speech-language pathology, which is especially effective for those with autism spectrum disorders, as well as those that struggle with disordered eating. Therapeutic riding is an excellent way to use horses to sharpen mindful body skills and accomplish emotional goals. (14,15,16).
Nutritional therapy involves working with dieticians to establish a healthy relationship with food again. Those who struggle with bulimia nervosa often eat in restricted patterns, engage in puring or other compensatory behaviors, and develop a fear of gaining weight. Nutrition therapy helps rededucate about food and nutrition, since bulimia can engrain inaccurate beliefs about food and nutrition. A dietician can help develop meal plans, and teaches the Health At Every Size (HAES) curriculum.
Dieticians almost always work on a multidisciplinary team to teach people about the psycho-socio-cultural aspects of eating. Some specialize in certain illnesses, like diabetes, dementia, or kidney failure. If possible, try to locate someone who specializes in eating disorders and has undergone trauma-sensitization training. They can provide skills that promote behavior change and teach about the physiology behind disordered eating (18).
How Do I Know Which Treatment Is Best for Me?
This is an incredibly important question that has no one-size-fits-all answer. Clinically, the best treatments for bulimia nervosa entail medication and cognitive behavioral therapy. Some, however, may not enjoy talk therapy at all, and prefer more intimate expressions of emotions that can be found in art and music therapy. If someone has suffered significant trauma, working with a horse in equine therapy can feel much safer. Studies do show that having a strong, supportive friend or family group is invaluable to recover from disordered eating.
Having a strong, supportive friend or family is very beneficial when recovering from an eating disorder.
It’s important to also consider the goodness of fit with each therapist. Someone may find that DBT feels helpful, for example, but they do not mesh well with a particular therapist. It is perfectly acceptable and common to ask for a different therapist, or change practices. Many people feel more comfortable seeing a therapist, who reflects one of all of their intersecting identities. For example gender, sexuality, race, ethnicity and religion.
Some find that augmenting therapy with practices like light therapy, acupuncture, meditation, hydrotherapy (floating), and relaxation therapy can help. These should not be practiced alone however, only in conjunction with formal therapy and medication (17).
- American Psychological Association. (n.d.). What is cognitive behavioral therapy? American Psychological Association. Retrieved June 27, 2022, from https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral
- Poulsen S, Lunn S, Daniel SI, Folke S, Mathiesen BB, Katznelson H, Fairburn CG. A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa. Am J Psychiatry. 2014 Jan;171(1):109-16. doi: 10.1176/appi.ajp.2013.12121511. PMID: 24275909.
- Sussex Publishers. (n.d.). Dialectical behavior therapy. Psychology Today. Retrieved June 27, 2022, from https://www.psychologytoday.com/us/therapy-types/dialectical-behavior-therapy
- Berner LA, Reilly EE, Yu X, Krueger A, Trunko ME, Anderson LK, Chen J, Simmons AN, Kaye WH. Changes in cognitive and behavioral control after lamotrigine and intensive dialectical behavioral therapy for severe, multi-impulsive bulimia nervosa: an fMRI case study. Eat Weight Disord. 2022 Jun;27(5):1919-1928. doi: 10.1007/s40519-021-01308-z. Epub 2021 Oct 18. PMID: 34661882; PMCID: PMC9122851.
- Sussex Publishers. (n.d.). Interpersonal psychotherapy. Psychology Today. Retrieved June 27, 2022, from https://www.psychologytoday.com/us/therapy-types/interpersonal-psychotherapy
- Agras WS, Walsh T, Fairburn CG, Wilson GT, Kraemer HC. A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa. Arch Gen Psychiatry. 2000 May;57(5):459-66. doi: 10.1001/archpsyc.57.5.459. PMID: 10807486.
- Sussex Publishers. (n.d.). Acceptance and commitment therapy. Psychology Today. Retrieved June 27, 2022, from https://www.psychologytoday.com/us/therapy-types/acceptance-and-commitment-therapy
- Pisetsky EM, Schaefer LM, Wonderlich SA, Peterson CB. Emerging Psychological Treatments in Eating Disorders. Psychiatr Clin North Am. 2019 Jun;42(2):219-229. doi: 10.1016/j.psc.2019.01.005. Epub 2019 Apr 3.
- Baudinet J, Eisler I, Dawson L, Simic M, Schmidt U. Multi-family therapy for eating disorders: A systematic scoping review of the quantitative and qualitative findings. Int J Eat Disord. 2021 Dec;54(12):2095-2120. doi: 10.1002/eat.23616. Epub 2021 Oct 20. PMID: 34672007.
- Grange, D., Lock, J. (2005) Family-based Treatment of Adolescent Anorexia Nervosa: The Maudsley Approach. MaudsleyParents.org.
- LE Grange D. (2005). The Maudsley family-based treatment for adolescent anorexia nervosa. World psychiatry: official journal of the World Psychiatric Association (WPA), 4(3), 142–146.
- Diamond-Raab L, Orrell-Valente JK. Art therapy, psychodrama, and verbal therapy. An integrative model of group therapy in the treatment of adolescents with anorexia nervosa and bulimia nervosa. Child Adolesc Psychiatr Clin N Am. 2002 Apr;11(2):343-64. doi: 10.1016/s1056-4993(01)00008-6. PMID: 12109325.
- Pratt RR. Art, dance, and music therapy. Phys Med Rehabil Clin N Am. 2004 Nov;15(4):827-41, vi-vii. doi: 10.1016/j.pmr.2004.03.004. PMID: 15458755.
- Cumella EJ. Is equine therapy useful in the treatment of eating disorders? Eat Disord. 2003 Summer;11(2):143-7. doi: 10.1080/10640260390199325. PMID: 16864516.
- Dezutti JE. Eating disorders and equine therapy: a nurse’s perspective on connecting through the recovery process. J Psychosoc Nurs Ment Health Serv. 2013 Sep;51(9):24-31. doi: 10.3928/02793695-20130612-01. Epub 2013 Jun 21. PMID: 23786240.
- Treating an eating disorder through equine therapy. Eating Disorder Hope. (2022, February 8). Retrieved June 27, 2022, from https://www.eatingdisorderhope.com/treatment-for-eating-disorders/types-of-treatments/horse-equine-therapy
- Fogarty S, Smith CA, Hay P. The role of complementary and alternative medicine in the treatment of eating disorders: A systematic review. Eat Behav. 2016 Apr;21:179-88. doi: 10.1016/j.eatbeh.2016.03.002. Epub 2016 Mar 6. PMID: 26970732.
- Reiter CS, Graves L. Nutrition therapy for eating disorders. Nutr Clin Pract. 2010 Apr;25(2):122-36. doi: 10.1177/0884533610361606. PMID: 20413693.