Cognitive behavior therapy (CBT) is a highly effective psychological treatment approach. It’s considered the gold standard for treating eating disorders, depression, anxiety, PTSD, substance abuse, insomnia, and many other psychological conditions and illnesses. This discussion is about why CBT for eating disorders works well for Highly Sensitive People (HSPs).

Let’s start with the basics.

What is cognitive behavioral therapy (CBT)?

CBT is a form of psychotherapy, made up of techniques designed to identify how thoughts affect emotions and actions. The cognitive behavioral method teaches people how to notice patterns, change unhelpful thoughts and behaviors, and develop new coping strategies. I like to think of CBT as a triangle.

The CBT triangle

Meaning the way you think about something affects how you feel and what you do.

Let me back up. CBT talk is exciting. I don’t want to get ahead of myself.

The gist of CBT (and not just for eating disorders or HSPs):

The foundation

Our minds interpret the world around us and try to make sense of it.

Sometimes we see the world as it “really” is. In other words, our thoughts are accurate and objectively true, such as “there is a brown dog sitting on the lawn.” 

At other times our thoughts are biased, and we base our thoughts on assumptions, as in, “There’s a brown dog sitting on the lawn, ready to lunge and bite me.”

Both scenes are the same: A brown dog sitting on a lawn. 

Our thoughts – accurate or inaccurate – determine how we feel. The interpretation or appraisal are what create feelings. 

In the first example, feelings are likely to be neutral or positive (if we like dogs). 

In the second example, feelings are fear-based due to predicting that the dog is likely to attack.

How we interpret events, not the events themselves, determines how we feel. That’s why people going through the same event react differently.

Changing our thinking style causes changes in feelings and behaviors. Often the change takes the form of reframing inaccurate thoughts to more accurate ways of thinking.

Let’s take the dog example above. Someone who’s been bitten by a dog in the past, or who for some other reason dislikes dogs, is more likely to have an automatic negative thought, accurate or not.

Our minds often take short cuts. Automatic thoughts, often based on assumptions or past experiences, just pop up like a jack-in-the-box.

Thoughts over time become default, like a “repeat” cycle, to the point where we may not even know we’re having the thoughts.

Sometimes what we think actually is true and factual. Other times our thoughts are purely biased – they’re neither true nor factual. And sometimes they’re somewhere in between.

Even if terrible things did happen in the past, our suffering – what we want to relieve – happens in the present.

CBT treatment – for eating disorders or any other issue –  is NOT about simply swapping a negative thought for a positive one. In fact, neither Pollyanna nor Suzie Cheerleader is on CBT’s guest list (other than maybe for parody).

Cognitive distortions

Cognitive distortions are negative thinking patterns, aka thinking mistakes. In other words, they’re thoughts that aren’t based in fact. But they are taken as fact and assumed to be true.

Our internal dialogue (aka self-talk) can be riddled with inaccurate and problematic ways of viewing ourselves and the world.

Cognitive distortions lead to difficult emotions and problematic behaviors. CBT emphasizes the need and method to restructure distortions.

CBT helps us become more aware of our thoughts. We can then evaluate their validity and reframe them to be more accurate.

Thinking mistakes are based on our experience and interpretation of the world around us. 

Other than Dr. Spock perhaps, no one’s mind is completely logical. We all have cognitive distortions.

Core Beliefs

Core beliefs are the basis for what we think about ourselves, other people, and the world. 

These beliefs aren’t inborn. Rather, we learn them, usually during childhood or stressful times as an adult.

And they’re responsible for the automatic thoughts we have. 

Automatic thoughts are like plants that grow. Which plants grow depends on what type of soil we give them.

Examples of core beliefs:

  • “I am unlovable.”
  • “I will end up alone.”
  • “No one likes me.”
  • “I’m damaged.”
  • “I am worthless.”

Keep in mind:

  • Anything that contradicts core beliefs is often ignored.
  • Negative core beliefs feel true, even though they aren’t.
  • Core beliefs tend to be long-standing.

Why does CBT for eating disorders work well?

One of the most prominent features of eating disorders is cognitive in nature – the overvaluation of shape and weight.

Shape and weight among people with an eating disorder create the basis for a common cognitive distortion for just about everyone – with or without an eating disorder.

Overvaluation of shape and weight links with these eating disorder behaviors:

  • binge eating
  • compensatory behaviors (e.g. self-induced purging, laxative use, overexercising)
  • changes in body weight
  • dieting (e.g. skipping meals, eating small amounts, and avoiding certain foods)

Particular types of unhelpful, inaccurate thinking styles and eating disorders are linked.

Polarized or dichotomous thinking is a common cognitive distortion for just about everyone – with or without an eating disorder.

However, it’s especially common among people with an eating disorder.

Some common categories of all-or-nothing thinking in people with eating disorders:

  • dichotomy of “good” versus “bad” foods
  • avoidance of “bad” foods
  • defining eating behavior as either good or bad
  • strict adherence to self-imposed rules and unrealistic standards

Types of all-or-none thinking among people with eating disorders:

  • “Baked goods are bad. Vegetables are good.”
  • “I ate (fill in the blank), so now the whole day is ruined.”
  • “If I’m not the thinnest person at the party, I’m leaving.”
  • “Feelings are bad. They always get me in trouble.”

Challenging all-or-nothing thinking can be tough, but is essential to recovery. And CBT is a helpful way to go about it.

CBT for eating disorders may address other types of cognitive distortions, such as:

  • emotional reasoning (when emotions are taken as evidence of truth)
  • “shoulding” (directing “should” statements towards others tends to lead to anger or frustration. When “should” statements are directed at ourselves, we tend to feel shame or guilt.)
  • mental filtering (taking one small detail or event and focusing on it, filtering out anything else)
  • Overgeneralization (taking one incident or detail and exaggerating its frequency or impact.)

Let’s add the HSP component to the equation:

Highly Sensitive People (HSPs) are born with a trait called sensory processing sensitivity. As a result, they think deeply, are skilled at looking at situations from different perspectives, have a lot of empathy, and value consistency and structure.

CBT incorporates all of these typical HSP features. CBT is based on a person’s internal dialogue. HSPs have active self-talk and are often curious about their own thoughts. Their natural strong empathy facilitates looking at situations from different vantage points. CBT also appeals to HSPs because of its structure as well. 

CBT for HSPs is an ideal match!

Here are some CBT techniques for eating disorder treatment, for both HSPs and non-HSPs:

  • SMART goals. Set goals that are Specific, Measurable, Achievable, Realistic, and Time-limited.
  • Challenging self-talk. By questioning assumptions, you learn to challenge thoughts and consider other points of view.
  • Self-monitoring. You might jot down automatic negative beliefs and the more accurate ones to replace them with.
  • Self-talk. Ask what you tell yourself about a certain situation. Then say to yourself what you would say to a friend.
  • Cognitive restructuring. Identify cognitive distortions — such as black-and-white thinking — and reframe them.
  • Record keeping. Record thoughts and feelings from a specific situation. Then come up with unbiased evidence supporting your negative belief and evidence against it. Use this evidence to develop a more realistic thought.

Cognitive restructuring is about challenging the content of automatic thoughts to make them more accurate.

Here is an example:

Sara felt a ton of academic pressure from her parents and didn’t want to let anyone down. Her sister excelled academically, and, as a result, Sara felt extra down on herself.  Especially for some of her HSP traits, such as deep thinking and anxiety tendencies.

Through her chronic self-criticism, she developed the core belief “I’m a loser” and the assumption “but as long as I am skinnier than everyone else, I’m ok.”

Whenever she got a grade lower than an A, she had the automatic thought, “I’m a complete failure, but at least I’m thin.”

In CBT, Sara learned she is an HSP. She also became more aware of how to identify core beliefs and how to recognize how those beliefs lead to eating disorder behaviors.

HSPs with eating disorders benefit from CBT – as does everyone, really, HSP or not, eating disordered or not..

Henry Ford was correct:

“Whether you think you can, or you think you can’t–you’re right.”

Please reach out here if you’d like more information – about CBT, EDs, or HSPs!

Dr Elayne Daniels, a Boston-based coach and psychologist, is passionate about helping HSPs live their best lives. She also specializes in body image and eating disorder recovery. Read more of her blog articles here.