Eating Disorders Program

At CBTTexas™, we provide compassionate, evidence-based care for individuals struggling with eating disorders, including anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorder (ARFID), and other disordered eating patterns. We work with children, adolescents, adults, and families, offering both weekly outpatient treatment and higher-frequency, intensives when needed or desired.

Children and Adolescents

For younger patients with anorexia and bulimia nervosa, treatment follows the FBT-Anchored Modular (FAM) Model, developed by Dr. Zach Appenzeller during his tenure as Founding Director of the UTHealth Houston Center for Eating Disorders.

• In this model, FBT serves as the foundation of all child and adolescent eating disorder treatment.
• Additional treatments (CBT-E, ERP, MED-DBT, or RO DBT) are integrated as needed to allow for concurrent individual therapy that targets core eating disorder pathology, comorbid anxiety, OCD, or temperament-based patterns that interfere with recovery.
• Our approach does NOT sideline parents, rather, it positions them as the primary agents of change in eating-disorder treatment. While additional interventions may be integrated as needed, our approach keeps parents at the center of the process, providing the structure, authority, and day-to-day support that research consistently shows is essential for adolescent recovery.

Adults

For adults with anorexia and bulimia nervosa, treatment begins with a thorough assessment and a shared case formulation that identifies what is maintaining the eating disorder and what treatment(s) are most likely to create meaningful change.

CBT-E typically serves as the foundation of adult eating-disorder treatment. This structured, evidence-based approach addresses the thoughts, eating patterns, and avoidance behaviors that maintain the eating disorder over time.

ERP is integrated whenever fear, avoidance, or OCD symptoms are driving restriction, rituals, checking, or compensatory behaviors. Exposure-based work can be woven into ongoing treatment, but in many cases fear and anxiety needs to be targeted directly and deliberately to create meaningful change.

MED-DBT or RO-DBT is incorporated when temperament-based patterns interfere with nutritional rehabilitation or the ability to engage fully in CBT-E:

• Emotional Undercontrol (rapid, intense emotions; impulsivity; difficulty tolerating distress)
  Some individuals begin treatment in Multi-Diagnostic Eating Disorder DBT (MED-DBT) to build stability and improve emotion regulation. Others may receive targeted DBT skills alongside CBT-E to support behavioral follow-through.
• Emotional Overcontrol (excessive self-control; inhibited emotional expression; perfectionism; social withdrawal)
  Individuals who fall more overcontrolled often benefit from RO DBT, either as a primary treatment or as a flexible addition to CBT-E, to increase openness, flexibility, and emotional expression.

Our team is able to adjust treatment intensity up or down as needed, ensuring momentum and continuity of care. We all coordinate closely with medical and nutrition providers to assure that all of our patients are medically stable, safe, and receiving the best, comprehensive, wraparound support possible.

Family-Based Treatment (FBT) is the most effective, research-supported treatment for adolescents with anorexia nervosa and bulimia nervosa. At CBTTexas™, we take a structured, compassionate, and laser-focused approach to FBT. Our goal is to empower parents to take the lead in their child’s recovery, while providing expert, hands-on guidance every step of the way. Families often tell us that this model finally “makes sense” of what they’ve been living with and gives them a clear path forward.

FBT is not traditional “talk therapy.” Instead, it is a highly practical, action-oriented model that recognizes that adolescents with eating disorders are often unable to make healthy decisions around food and weight due to the powerful neurobiological impact of starvation and malnutrition. Because of this, parents temporarily take over the tasks that the eating disorder has hijacked, with the support and coaching of an expert clinician. FBT happens in three structured phases:

Phase 1: Restoring Health and Taking Back Control from the Eating Disorder

This is the most intensive phase. The primary goals are medical and nutritional stabilization and full interruption of eating-disorder behaviors.

Parents are guided to:

• Take full responsibility for meals, snacks, and all nourishment decisions
• Interrupt compensatory behaviors, such as purging, excessive exercise, or restriction
• Maintain calm, confident authority even when the eating disorder pushes back
• Learn how to distinguish their child from the illness, reducing guilt, blame, and conflict
• Stay out of negotiations with the ED, which only reinforce the illness

Your clinician is highly active during this phase, providing coaching, troubleshooting mealtime challenges, guiding limit-setting, monitoring weight and progress, and helping parents problem-solve as needed. This phase continues until the adolescent is medically safe, gaining weight at an appropriate rate (if indicated), and showing improved eating patterns and behavioral control.

Phase 2: Returning Responsibility to the Adolescent, Deliberately and Gradually

Once eating is more stable and the adolescent is no longer acutely medically or behaviorally compromised, the family begins the gradual transfer of eating-related responsibility back to the teen.

Together, we carefully assess:

• Readiness for autonomy
• Ability to recognize and interrupt ED thoughts
• Consistency of eating patterns
• Emotional and behavioral stability

Families practice slowly loosening supervision while the teen practices increasingly independent choices. The pace is individualized and based on progress, not on age or perceived maturity. Parents remain involved, but less intensely, so the adolescent proves that they can make recovery-aligned decisions. It is not uncommon for families to ebb and flow between Phase 2 and 1 as they continue to work towards successful recovery.

Phase 3: Supporting Normal Adolescent Development & Preventing Relapse

As the eating disorder recedes, therapy shifts toward:

• Rebuilding age-appropriate independence
• Supporting friendships, academics, hobbies, and identity development
• Strengthening family communication and problem-solving
• Identifying early warning signs and building a relapse-prevention plan

This phase helps the teen transition back to typical life without the eating disorder continuing to shape their decisions or identity.

CBT-E is a transdiagnostic, evidence-based treatment for adults with anorexia nervosa, bulimia nervosa, and binge eating disorder.

In CBT-E, the "over-evaluation of body shape and weight" is essential to understanding patients with eating disorders. This preoccupation, and reliance on body shape and weight as a primary source of a person's sense of self-worth, value, and self-esteem forms the core pathology of these conditions.

Treatment begins with drawing out a personalized case formulation, a collaborative process that helps patients, often for the first time, understand why they have not been able to simply “will themselves” out of their eating disorder. By mapping out the maintaining mechanisms that keep their eating disorder going, patients and families can see how the disorder persists and why it can feel as though the eating disorder often seems to be "running on autopilot".

These comprehensive and personalized roadmaps allow us to provide highly tailored interventions to help patients dismantle their specific eating disorder. Patients are supported in reducing the behaviors, and inaccurate assumptions that maintain their "over-evaluation of body shape and weight" while actively helping them to build a broader and more balanced sense of self, one that reflects their values, relationships, achievements, and identity beyond appearance. In doing so, CBT-E helps people begin to see themselves more as the rest of the world tends to see them: defined not by their shape or weight, but by their full worth as a person.

Treatment typically begins with twice-weekly sessions, tapering in frequency as progress is made. Together, we work collaboratively with patients to set goals, track progress, and practice skills between sessions.

CBT-E is particularly well-suited for those who are ready to take an active role in recovery and who are seeking a focused, skills-based pathway to lasting change.

ERP is the most effective and well-researched treatment for conditions that involve fear and avoidance, and it plays a fundamental role in recovery from eating disorders. At its core, ERP helps patients approach stimuli that provoke anxiety, while preventing the rituals or avoidance strategies that people use to temporarily relieve their distress. At CBTTexas™, ERP is integrated into our evidence-based treatments, including CBT-E, FBT, and CBT-AR. When ERP is implemented effectively, it can strengthen a patient’s ability not only to eat but to do so with greater tolerance of the anxiety that often accompanies nourishment and weight restoration. ERP further helps patients challenge and disconfirm maladaptive beliefs, particularly the tendency to overestimate both the probability (how likely a feared outcome is to occur) and the cost (how intolerable or catastrophic that outcome would be) of increasing food intake and the body changes that may follow.

In many ways, our team views eating disorders as anxiety disorders. While eating disorders start for any number of reasons, typically what maintains them is significant anxiety and avoidance of feared outcomes (fear of certain foods, fear of weight and body changes, fear of losing control, and ultimately, fear of what might happen if they were to allow themselves to normalize their eating). These fears drive people to engage in all kinds of avoidance behaviors: restrictive eating, compulsive exercise, purging, constant body/weight checking or body/weight avoidance. These behaviors all contribute to patients becoming entirely preoccupied with food, their body, and their weight. While these behaviors may reduce distress in the moment, it strengthens the patient's eating disorder in the long run. ERP interrupts this cycle by creating opportunities for patients to confront their fears directly, while refraining from the safety behaviors that keep anxiety, and therefore, their eating disorder, alive. Over time, this repeated practice teaches the brain that feared situations are tolerable, that anxiety naturally subsides, and that catastrophic predictions rarely come true, allowing our patients to face their fears to find freedom from their eating disorders.

Some people simply have too much of a good thing. Not all emotional suffering comes from a lack of self-control. For many individuals, especially those with restrictive eating disorders, distress stems from excessive self-control: perfectionism, emotional inhibition, rigid routines, and a tendency to keep feelings tightly contained. Over time, these patterns can narrow a person’s world and lead to profound emotional loneliness.

RO DBT is an evidence-based treatment designed specifically for individuals who struggle with overcontrol. It is particularly helpful for people experiencing restrictive anorexia nervosa, chronic or treatment-resistant depression, obsessive-compulsive personality disorder (OCPD), autism spectrum disorder, social anxiety, treatment resistant anxiety, or long-standing patterns of perfectionism and emotional restraint.

RO DBT is grounded in the understanding that while self-control is often valued, too much of it can interfere with flexibility, emotional openness, and the ability to form close, supportive relationships. Many individuals who benefit from RO DBT describe themselves as responsible, composed, or high achieving on the outside, yet disconnected, unseen, or misunderstood on the inside.

In treatment, clients learn to:

• Express emotions more openly and authentically
• Increase psychological flexibility and comfort with uncertainty
• Strengthen social connection and healthy communication
• Loosen rigid, rule-governed behavior
• Move toward a life guided by values instead of perfectionism or fear

RO DBT focuses on openness, social signaling, and the capacity to connect with others. This approach is particularly effective for people who appear calm and capable externally but struggle internally with emotional shutdown or chronic isolation.

Our RO DBT program includes:

• Individual RO DBT Therapy
• RO DBT Skills Training Class
• Therapist Consultation Team
• Between-Session Skills Coaching

If you are highly self-disciplined yet still suffering, or if your eating disorder is intertwined with perfectionism, rigidity, and emotional overcontrol, RO DBT may provide a new way forward, helping you build a life marked by connection, authenticity, and ease.

Multidiagnostic Eating Disorder–Dialectical Behavior Therapy (MED-DBT) is a specialized adaptation of standard Dialectical Behavior Therapy to treat individuals with eating disorders who present with significant emotional, behavioral, and psychiatric complexity. This approach was designed for clients whose eating disorder exists alongside chronic emotion dysregulation, impulsivity, self-harm, suicidality, trauma histories, or multiple co-occurring diagnoses.

Many individuals with severe or longstanding eating disorders experience intense emotions, difficulty regulating distress, and patterns of behavior that interfere with treatment. MED-DBT directly targets these challenges. It maintains the core DBT structure while integrating eating disorder–specific strategies focused on nutritional rehabilitation, eating patterns, body-image distress, and medical safety.

MED-DBT is particularly helpful for individuals who have:

• Binge eating, purging, or other impulsive eating-disorder behaviors
• Frequent treatment-interfering behaviors or prior unsuccessful ED treatments
• Co-occurring conditions such as depression, anxiety, PTSD, or personality pathology
• Histories of self-harm or suicidal behavior
• Difficulty using traditional coping skills during high emotional arousal
• Complex trauma or chronic difficulties with emotion regulation

Grounded in DBT’s biosocial theory, MED-DBT recognizes that biological vulnerability and heightened emotional sensitivity can make it difficult for individuals to effectively regulate feelings, tolerate distress, and remain engaged in nutrition and behavioral recovery tasks. Treatment helps clients understand the relationship between emotions, urges, and eating-disorder behaviors, while strengthening the skills needed to interrupt impulsive patterns and build lasting stability.

Our MED-DBT program includes:

• Individual DBT Sessions
• DBT Skills Training Group
• DBT Therapist Consultation Team
• Between-Session Phone Coaching

DBT includes four core skills modules taught in a structured Skills Training Group and reinforced in individual therapy. The four skills modules are:

1. Mindfulness
Mindfulness is the foundation of all DBT skills. It teaches individuals to notice thoughts, feelings, and body sensations without judgment, stay present in the moment, and respond intentionally rather than react impulsively. Mindfulness increases awareness, grounding, and emotional clarity.

2. Distress Tolerance
Distress Tolerance skills help individuals cope with intense emotions without making the situation worse. These skills focus on crisis survival strategies, grounding techniques, and healthy ways to navigate emotional pain when it cannot be changed in the moment.

3. Emotion Regulation
Emotion Regulation skills strengthen the ability to understand emotions, reduce emotional vulnerability, and increase resilience. Clients learn strategies to shift emotional states, prevent emotional spirals, and build day-to-day habits that support stability and well-being.

4. Interpersonal Effectiveness
Interpersonal Effectiveness skills help individuals communicate clearly, set boundaries, manage conflict, and build or maintain healthy relationships. These skills support asking for needs, saying no, and navigating interpersonal situations with confidence and respect.

For clients whose eating disorder is intertwined with intense emotions, impulsive behaviors, or chronic psychiatric comorbidity, MED-DBT provides a comprehensive, evidence-informed pathway toward stabilization, safety, and meaningful long-term recovery.

CBT-AR is a structured, time-limited, and exposure-based treatment specifically developed for avoidant/restrictive food intake disorder (ARFID). ARFID is a condition characterized by significant food restriction driven by one or more maintaining mechanisms: sensory sensitivity to taste, texture, smell, or appearance; low appetite or limited interest in eating; and/or fear of aversive consequences such as choking, vomiting, or abdominal pain. Although individuals with ARFID may not express concerns about weight or shape, the disorder can lead to nutritional deficiencies, impaired growth, dependence on supplements, and marked interference with daily functioning. CBT-AR is appropriate for children, adolescents, and adults.

CBT-AR proceeds through a clearly defined sequence of stages. Early sessions focus on psychoeducation, motivation building, and establishing a consistent pattern of eating. Treatment then moves toward identifying the individual’s maintaining mechanisms, increasing nutritional adequacy, and expanding food volume and variety through systematic and graded exposure. Exposures are conducted both in session and between sessions to help clients reduce avoidance and build confidence. To support behavioral change, CBT-AR also entails brief, targeted cognitive strategies such as updating predictions after exposures and addressing rigid or fear-based expectations about food or eating sensations. When indicated, treatment also includes structured weight-gain support to restore healthy growth and nutritional status.

Family-Based CBT-AR: Parents or caregivers take an active, central role in helping their child meet nutritional needs, try new foods, complete exposures, and reduce avoidance behaviors at home. Caregivers are coached to provide consistent structure, support, and reinforcement, positioning them as essential parts of their child's progress.

Individual CBT-AR: This format is best suited for clients who are medically stable, not underweight, and sufficiently motivated to lead their own exposure work. Treatment focuses on increasing flexibility with food, addressing sensory or fear-based drivers of restriction, and restoring a more complete and sustainable pattern of eating.

Although research on CBT-AR is still developing, early clinical trials and real-world data consistently show improvements in nutritional adequacy, food variety, weight restoration (when needed), and overall functioning. In our program, clients often experience meaningful, measurable gains as they expand their diets, reduce anxiety related to food, and re-engage more fully in daily life. CBT-AR offers a compassionate, practical roadmap for individuals and families seeking evidence-based help for ARFID.