Cognitive Remediation for Eating Disorders

What is it?

Monday Musings: Cognitive Remediation for Rigidity and Fixations in Eating Disorders.

Many of you readers are not sure what we do to treat eating disorders and overweight. So, these musings are to give you a peep into the secrets of treatment.

Eating disorders are problems with behaviour. Therapists seek to know what lies beneath problem behaviour like purging, starving and binge eating. Some therapists say it is all about early experiences. Other therapists think it is all caused by trauma or not having better ways to self-soothe.

People get into eating disorders by one road only. For whatever reason, they want to change their weight to feel better about themselves. So, they stop eating what they want and begin eating what they think they should.   The unintended consequence for some people is getting into serious food restriction. For other people,   dieting or cutting out food groups leads to binge eating and a small number of people  end up purging to try and manage their binges.

A tangle of different “maintaining factors”.

Tangles of EDs

Very few people know what keeps people stuck inside the tangle of an eating disorder.  There are many different things and so we must UNPICK the eating disorder, one tangle at a time. One of these tangles is very stuck habits. Everything inside an eating disorder is a habit, what food you binge, how you binge or purge, how and when you exercise, how often and when you might weigh yourself.

Some people with eating disorders,  especially people with anorexia or ARFID are very rigid by nature and they are easily fixated by the small details of the food they eat and what they think it does to them.  Many show signs of Obsessive Compulsive Disorder. This is partly to do with how their brain works. If we ask a person with anorexia to describe a picture, they tend to focus on a great deal of detail.  A person who eats normally tends to tell us about the overview of a scene, such as “This is a picture of the countryside in autumn”.

To recover from eating distress,  a person needs to become more flexible – to allow them to make more helpful food choices, and to worry less about their eating.

Cognitive Remediation (CRT) is a therapy  that works directly with the brain. The therapist is trained to do tasks with their client like picture work, or use of symbols, so that the brain learns how do several useful things. Firstly, to stop focusing on small details like “the food I just ate for lunch” and secondly to stop obsessing about ideas and thoughts so that the sufferer develop better coping strategies.

Cognitive Remediation Therapy is not the only thing we use to help restore a client to health. This is simply addressing one of the tangles in which they are trapped. Most good eating disorder specialists, like ours,  will have done some training in CRT.  If you need help with an eating disorder, have a look at our counsellor list at

Young people at risk – test an App

stem4 Self Worth/Eating Disorders app Research Study – request for help in recruiting participants.

stem4 is a London-based teenage mental health charity that aims to develop positive mental health in teenagers through education and early intervention. stem4’s digital portfolio of award-winning evidence-based apps (Calm Harm, Clear Fear, Move Mood and Combined Minds) have been created by Consultant Clinical Psychologist Dr Nihara Krause in collaboration with young people, and are available free of charge on the App Store and Google Play.

This study is a preliminary evaluation of a new app called Worth Warrior for young people who experience early stage eating disorders. Like the other stem4 apps, this app, which will also be available free to users, has been developed by a Clinical Psychologist and stem4 Chief Executive Officer and Clinical Lead, Dr Nihara Krause and has been funded by the National Institute of Health Research (NiHR). The app uses techniques from a talking therapy called, Cognitive Behavioural Therapy for eating disorders to help tackle the symptoms of early eating disorders and low self-worth.

stem4 would like to know if the Worth Warrior app works well and if it can help young people manage their early symptoms of eating disorders by contributing to improving their self-worth. They will use a ‘before and after’ design to see if the Worth Warrior app is user friendly and can help to reduce symptoms in young people aged between 17-25 years.

The research will take place over a 7-week period and aims to include up to 30 young people. stem4 would like to collect information using online questionnaires at three time points, followed by a brief interview online. Young people will be recruited via stem4’s networks, social media, and their website. The project is divided into three stages:

Time 1: Introduction and familiarisation with the app.
Time 2: Post-app familiarisation (1 week).
Time 3: Follow-up after 6-weeks to see if the app was helpful.
Data will be collected via questionnaires at each time point. In order to collect more detailed feedback of using the app and its benefits (or qualitative data) participants will also be invited to take part in a brief online interview at Time 3. This qualitative part of the study will be jointly produced with young people.

As a thank you to the young people participating, stem4 will be offering a £30 Amazon voucher.

Participants can find out more and see if they are eligible for the study here:

Chewing & Spitting Adam Kay

Adam Kay the famous writer and broadcaster admits to a “serious eating disorder” where he chews large amounts of food (usually junk food) and spits it out.

He became painfully aware of his size after a sexual encounter where his partner said that he had done well despite being “a big guy”.

He took the comment to heart and he decided to lose weight the quick way, by starving. Unsurprisingly he developed extreme hunger and began to crave food. Having failed to throw up, he decided to spit food out as a way to lose weight. He began to spit out more and more, to the extent that he kept a bin bag full of spat out food in his room until one day he was “found out”.

For a while, this strategy to lose weight worked. He lost a lot of weight and people began to be concerned about his appearance.

We have an article about chewing and spitting on our information pages. Some people have written in; they are annoyed about the things I have written. They are annoyed about me writing that we can take in a lot of calories when we spit out food, because a lot of energy is inadvertently swallowed.

The psychology of spitting

Spitting can become a major addictive behaviour because of the dopamine hits it gives. But the psychology of spitting is complicated.

For a short time, chewing food and spitting it out will calm the hunger drives. But this doesn’t work well in the long term. When the mouth receives food that the stomach doesn’t get, the brain is not fooled. Chewing palatable tasty and forbidden food will give us a dopamine “hit” that feels gratifying, but there are other physiological processes going on that could make it more likely that we will gain weight in the long term – one month, one year down the line. That is personal. The quick fix of spitting has a cost.

One reader wrote to me that the psychology of spitting food out is simple. He says it is simply about getting the taste without the calories. I do NOT agree.

Why people might chew and spit

What is the person REALLY spitting out? Who is the person REALLY spitting out?

I have found out that most people who chew and spit are very anxious, and this is a way of calming themselves down.

What is the underlying deep sense low self-worth that causes someone to believe that they do not deserve to eat real food. It is not just fear of getting fat.

What is the source of the pain that is being expressed by a behaviour that would be generally seen as shameful?

Does this person really believe that this is the only method of weight control available to them?

What is the cost of doing this, and what is stopping them from getting help?

How to get help

I wish that I had worked with Dr Kay, to find out what led him to take the comment about his size so much to heart, and to be the victim of someone else’s unguarded opinions about him. Maybe it is this fragility that lay behind so many of his other problems with life, work and relationships.

If you need help with chewing and spitting, we understand. Contact 0845 838 2040 and explore your options

Guided Self Help for Young People with Eating Disorders:

Request for participants

I am a PhD student at UCL Great Ormond Street Institute of Child Health, working under the supervision of Professor Roz Shafran. The aim of my PhD is to develop and evaluate a guided self-help treatment for children and young people with eating disorders.

I am currently running focus groups to better understand stakeholders views on guided self-help interventions for children and young people with eating disorders. We will then use these findings to inform the development of the treatment to ensure that it is sensitive to the needs of children and young people with eating disorders, their families and the clinicians that work with them.

We are looking to recruit young people (aged 11-17) with eating disorders and parents/carers of young people (aged up to 17) with eating disorders for the focus groups. The focus group will be online and will last approximately 1.5 hours. Participants will receive a £40 Amazon or Love2Shop voucher for their time. The study has received ethical approval from the UCL Research Ethics Committee.

If you are interested please email

Eating Disorders in Pregnancy

Pregnancy can be a difficult time for people with eating disorders.

In normal circumstances, hormones lead to weight gain and eating changes to support the additional 80,000 calories needed for the pregnancy and ongoing breastfeeding.

Regular weighing takes place to check the health of the mother and child, and to ensure that the baby is getting adequate nutrition for central nervous system health at the least. Weighing helps to against gestational diabetes and alert about dangerous conditions like pre eclampsia. Weighing can be traumatic for people with body image issues.

Sadly, there is a great deal of pressure on social media for women to gain as little weight as possible during pregnancy as a “badge of pride,” ignoring the effects that this might have on a child’s future mental and physical wellbeing.

For people with eating and body image issues, pregnancy can be very difficult.

Here are some of the dangers associated with different types of ED in pregnancy.


Binge eating and purging during pregnancy is dangerous, for example loss of potassium as a result of purging including laxative abuse might impair development of the central nervous system of the developing baby. Nutritional support to help prevent cravings is needed alongside urgent help to manage their eating disorder.


Some people living with AN give themselves a holiday from the ED and permit themselves to eat only to begin restricting after childbirth. Others continue to restrict and may not cope with looking pregnant. The risks to mother and child in such situations are critical and the person with AN during pregnancy needs a great deal of compassionate help.

Binge & compulsive eating

Binge eating is not just taking in a lot of food. Because binge eating is usually highly processed sugar rich food that provides emotional comfort, there are profound metabolic effects. These in turn can switch on epigenetic changes that predict future weight struggles in the developing child. People who enter pregnancy with pre existing struggles to control eating and weight need informed help to manage their relationship with food from the get-go.

They do NOT need being shamed by health professionals about size or weight gain and they do NOT need well-meaning advice about how to eat a healthier diet.

Every single pregnant woman with runaway weight gain during pregnancy will benefit from compassionate help from someone who can talk to them without blame about their relationship with food.

Pregnant women do not respond well to midwives and doctors telling them what they should do for the good of their baby. The best way to protect the baby is to look after the mother and the people who support her.


Kings College London has a Video to support women in Pregnancy

Here is another perinatal support website

The British Journal of Midwifery has an article to support midwives – hope they read this

Susie Orbach talks about the needs of eating disordered women during pregnancy. See her podcast Life After Diets with Susie Orbach,

If you are expecting a child, and need compassionate help with your eating disorder, call us now
0845 838 2040

Research into Anorexia Treatment

Sophie is writing to you about the research project that she is conducting as part of the Doctorate in Clinical Psychology at UCL. My project aims to explore how Externalisation of Anorexia Nervosa can Help and Hinder Recovery from this Eating Disorder.

She says

We are carrying out this research because although externalisation (viewing and talking about anorexia as a separate entity that is external to the individual receiving treatment) is a widely used therapeutic technique within therapies for anorexia, research exploring how externalisation helps and hinders people’s recovery from an eating disorder is very sparse. Our research aims to further our understanding of people’s experiences of externalisation in treatment for anorexia in order to learn how this approach may or may not support recovery from an eating disorder. We hope that by exploring a common strategy used in therapies for AN, this project will help to inform and improve treatments for anorexia. To help increase people’s chances of recovering fully from an eating disorder, it is important that we understand the views of individuals who have received treatment for anorexia. Therefore, we aim to obtain people’s views through semi-structured interviews which I will be conducting online.  

We are looking for people aged 16 and above who have received at least one or more NICE recommended therapies for anorexia, who may or may not have reached a point of recovery from an eating disorder, and who are familiar with the notion of externalisation in treatment for anorexia.

To recruit participants, I have posted on my linked in, twitter and facebook accounts. However, I would be enormously grateful for any support that NCFED may be able to give to raise awareness of the study among the target population which NCFED have greater access to. I would be happy for you to post about the study or alternatively you can share / retweet my posts. Below I list my accounts on social media, however, please do let me know if there are alternative or additional methods of raising awareness that NCFED may be able to support with. I attach my leaflet for your reference.



Linked  in:

Bikini Body Outrage

A Brummie Mummy has has invented a wooden bikini into which you can insert coins for every pound of weight you lose to get into a bikini body.

To get summer bikini body ready.

There is a WEDDING DRESS version for women to get sized down for their big day. I wonder how many men “fit-up-slim-down for their big day?

is this what women are supposed to eat so that they can have fun at the beach?

There is not an equivalent wooden weight loss “trunks” for men. We have to put an end to this kind of nonsense

Children with ARFID Family Support Group

A monthly family support group with Jenny Phaure

Family Skills for Autism and Disordered Eating Monthly Psycho-Education and Coaching Group.  

This group is now open for referrals and bookings from Charities, Mental Health Teams, Eating Disorder Services, Social Care, Allied Health Professionals, GP’s, Therapists and independent providers.  

Why is there a need for this group?

Up to 70% of Autistic Children may experience atypical eating behaviours, many have issues with food or eating. Whilst research indicates that between 25-30% of those with Anorexia Nervosa also meet the diagnostic criteria for Autism there is a much larger number of autistic children, young people and adults who experience avoidant, restricted and disordered eating patterns.

Avoidant, Restricted and Disordered Eating patterns may be a precursor to Anorexia Nervosa or may exist alongside other Eating Disorders such as Bulimia Nervosa or Binge Eating Disorder.   This group is the only Family Skills for Autism and Disordered Eating Group in the United Kingdom and has been set up due to the need to provide more immediate support to families living with Autism and Eating Disorders.   With limited recourse to local or national autism specific services it is vital that parents/families are given access to essential psycho-education, tools and strategies to support their loved ones at home or in the community. Families are often the most important resource.

A Monthly Psycho-education and Coaching Group   with Jenny Phaure (Child and Adolescent Psychotherapist)  
2 hours on line via zoom   Wednesday 20th July (10.00am – 12.00pm)    

Family Skills for Autism and Eating Disorders  

Using positive psychological approaches to improve mood and food regulation.    

Cost: £45 per person     Bookings via service contracts or block bookings are available for those referred via a service provider. Please call: 07545 190915 for more information.  

Your facilitator Jenny Phaure

Can an Eating Disorder Service also offer Obesity Treatment

Yes, if the service is specified as two -sided and clear about the distinction between eating disorder treatment and weight loss coaching.

At the National Centre for Eating Disorders we do a holistic assessment of a person to ensure that no significant eating disorder is present; if it is present we make it clear that there are to be no weight loss attempts during treatment for the eating disorder and such a person might not in the future be suitable for intentional weight loss.

It is incorrect to assume that all people wanting weight change have an eating disorder.

If we agree after assessment to support a client in their weight change intentions, we will engage in a manner consistent with good practice and we have transformed many lives. Some of our clients have had a history of binge eating / bulimic disorders and have gained weight throughout the years because they have not had timely treatment for their eating disorder. We empathise with their desire to change weight if the time is right.

In such a case we would not do anything that would reactivate their eating disorder.

Weight loss “guidance / therapy”, does not imply dieting or food rules or boot-camping nor does it have goal weights. Nor does it require endless searching into childhood adversity. Nor is it HAES although they have some but not all, very good points.  The service includes bariatric counselling. Some people, with our help, decide that they are happy as they are. The ultimate outcome is flourishing.

We market obesity treatment because of the numbers of desperate people INCLUDING therapists who seek our help. It must mean something that over the course of 40 years no one entering our service has complained about stigma.  No therapist training with us over the same period has raised a complaint about anti-fat bias.

Activists who have not done our training are pitching against us with total ignorance about what we do. It interests us that while they are intolerant of the word “obesity” they bandy the term “fat” as if it means something different. Really?

What worries us at NCFED is the number of activists who actively try to deny people from having access to good weight change help; who wish to prevent therapists from learning about strategies that might work, and who wish to withhold from the public factual information about some health risks of living in a larger body. On top of this, no activist is able to come up with a single client or psychotherapist trained by NCFED who has been “traumatised” by weight stigma.

The NCFED has no need to make a big deal about inclusivity. We have therapists of all genders, races, religions, tribes and colours. We treat people without needing labels. Inclusivity is woven into our trainings and the first thing we do is delve into the history, generational issues, declared identity and value systems, of each individual in a place of complete acceptance.

I will not give the litmus of attention to angry people. Certainly, it is right to question the old “sacred cows” and reflect on their meaning and purpose. Having reflected, we feel good about what we do and we will not kowtow to aggression. People in the community who do not have a clinically significant eating disorder, who desire intentional weight change, deserve far better help than the traditional diet and lifestyle methods that do not work. They can come to us for that help, given by people we trust.

Meanwhile, Our amazing course, Essential Obesity: Psychological Interventions, next date June 2022

BACP advertising unethical Weight Loss Plan

I and my colleagues are angry and disappointed that a weight loss consultancy company advertised for “weight loss counsellors” in Therapy Today, the main journal from the British Association of Counselling and Psychotherapy (BACP).  This Company is selling Very Low Calorie diets based on milk shakes and “treat” such as “protein bars” to help people supplement the boring shakes with tid-bits that will help “keep them on track”.

Weight loss counsellors are paid according to their success in motivating clients to stick to the programme and to buy the Company Products. So, the counsellors are invested in tricking, or persuading or coercing people to stick to the programme.  Why wouldn’t they?  After all there is money in it for everyone except for the poor client who will be led to think that what they are doing is good for them.

As for the company (Cambridge) – having a “trained counsellor” on board means that their diet is legitimised.  The “trained counsellor” can deal with the psychology while the diet helps with the fat. Win-win all round for everyone concerned.

Can you see what is going on? It is horrible. Extreme weight loss plans like Cambridge can be dangerous, can lead to eating disorder behaviour, and liver damage. They are guaranteed to cause runaway weight regain in most people who embark on programmes like this in hope and desperation. There is a high risk that a person will end up fatter than they were before they invested their hard-earned money on a quick fix solution to their weight issue.  I know that most of you don’t want to read this, but diets like this don’t work.  Extreme calorie restriction teaches the brain that there are famines to come and your weight thermostat tends to rise. There are other ways to bring the thermostat down but this deserves another blog.
So, you might argue, would a counsellor help someone to avoid that kind of risk and somehow help a client stick to the diet and maintain the weight they have lost?  Perhaps they will tweak your emotional life or do some work on your early adverse experiences.  Perhaps a compassionate buddy will help you to be the 1 in 100 success case from a milkshake diet.

Think again.

I train many fully trained counsellors to work with eating disorders and obesity.  Up to half have serious eating disorders themselves, regularly go on and off diets and are struggling to control their own weight. Weight and eating issues simply do not form a good-enough part of the general counselling curriculum.  So, after they qualify, many counsellors stick eating disorders and obesity on their marketing material, but do not (yet) know what they are doing.  Some of them think (wrongly) that obesity and disordered eating is all about trauma. It is not.

I don’t want here to argue a case against all diets, because many people who control their weight do adjust their eating habits and manage their weight reasonably well. There is a difference between lifestyle change and the thousands of weight loss plans out there. However, a weight loss plan that relies on calorie restriction, fasting, or carving macronutrients out of your life though, works in the short term but makes things worse long-term. The only people who might be suited to a short term fix like this is someone suffering from Diabetes Type 2 – and only then under medical supervision. To impose this kind of diet on the public is harmful. Liver damage, gallstones, reactive binge eating, bulimia nervosa are common side effects, not to mention the stress of having to eat differently from the people you love.

For a counsellor to understand the psychology, the neuroscience and the physiology of eating and weight problems requires a large amount of additional specialist training. If you don’t use a counsellor with this training is like asking a GP to conduct brain surgery. You just wouldn’t let him or her loose on you.  And, to harness counsellors to sell diet Milkshakes for weight loss is not only wrong, it is wicked. For counsellor to engage with this  is also unethical unless they can prove their appropriate qualifications.

For one thing, agreeing with a client that they “need to lose weight” contributes to the weight stigma that may have led to their problems in the first place. People exposed to stigma find it harder to motivate themselves to eat well, and to engage in activity. They engage in more emotional eating and are likely to be black and white in their thinking. They divide food into good and bad, if they eat a good food, they are worthy people and if they eat a bad food they call themselves weak-willed and greedy. Restrictive diets plus stigma forces a client into a very all-or-nothing relationship with food and with themselves.

 I and my colleagues from the NCFED have spoken several times to the BACP advertising department and their Ethics team to express our opinions. We have also dredged up evidence to demonstrate to the BACP some of the dangers of extreme liquid diets.

The advertising department has ignored us, and as for the Ethics Team, we have had nothing other than an undertaking, since disappeared, to alert counsellors to the ethics of promoting themselves as weight loss consultants without appropriate training.  It seems that counsellors have to promise to regulate themselves and they do not. On a counselling forum recently that clients do not read, one counsellor confessed to having a binge eating client. She wrote “I will deal with all the other things and leave the binge eating alone”. I was horrified – the binge eating was probably causing all the emotional fallout that this poor client was experiencing. The counsellor should have referred the client straight to an eating disorder specialist but thought that it was not important. Maybe she just needed the money.

On another Facebook page peopled by counsellors, it was suggested that obesity was caused by trauma, and most of the members agreed that this was so. When I tried to explain that there are alternative explanations of why people gain weight, I was shouted down. There are a lot of charlatans out there and some of them may be the Cambridge counsellor consultants.

If you want to work with a proper weight change counsellor, you need to find a person who is properly trained to work with body image and the psychology of eating. You will need someone who understands the effects of weight stigma including the stigma that a rises in the counselling space, and to understand the physical and mental health effects of engaging in dieting practices.  Obesity is a very complex condition and its association with mental health is also complex and bi-directional. A Counsellor more than anyone should be aware of fostering the belief that weight loss is desirable and will bring happiness and success in life.  While it is true that weight change can greatly improve QOL, there are good and bad ways to achieve this and it is not a quick fix.

As part of their ongoing training, the counsellor will have done a great deal of work on their own relationship with food.   Quoting an eating disorder advocate – “there’s a sad irony to advertising weight loss consultancy to the very people who are key in helping others with their mental health”.

By encouraging this KIND of dieting, especially restrictive diets like the Cambridge one, Therapy Today/ the BACP are contributing to the harm caused by the diet industry and are encouraging eating disorders. This is unacceptable and unethical.

My plea to counsellors is this. Please do not associate yourself with the Cambridge Weight Loss plan. If you really want to help people who struggle with their relationship with food and their weight, without implying stigma about their size and shape, get proper training.  I am certain that you will never again want to promote a milkshake diet. And let the BACP know how you feel about their behaviour and their failure to rise to the concerns of people who work on the coalface with eating and weight.