This programme is a treatment manual for mental health professionals. It assumes clinical training, experience with eating disorders, and a supervision framework. It replaces neither your clinical judgement nor your professional responsibility. The diagnostic criteria here are reworded in our own terms, never reproduced. Two warnings specific to this indication. This manual does not cover anorexia nervosa or presentations with low weight, which call for a different service: section 3. And it deliberately contains no figures for weight, calorie intake or measurements, because those figures turn into targets.
1. The programme at a glance
Indication. Bulimia or binge-eating disorder in an adult, in outpatient care, at a weight that does not require specific physical management, with a medical assessment done.
Reference model. Cognitive behavioural therapy for eating disorders: early restoration of regular eating, withdrawal of compensatory behaviours and dietary rules, then underlying work on the overvaluation of shape and weight in self-esteem.
Format. Twenty sessions over twenty weeks in ordinary practice; this manual describes twelve, tightened up, with the points for extension indicated. Sessions of 50 minutes, weekly and not negotiable at the start: the twice-weekly rhythm of the first weeks is an active ingredient. Three boosters, at one month, three months and six months.
Mechanism targeted. Interrupting the restriction-binge-compensation cycle from the top, that is, through regularity of eating, and not through a strengthening of control. Then withdrawing what maintains the system: the rules, the food avoidances, the body checking, and the outsized place that weight occupies in self-esteem.
| Session |
Subject |
Deliverable of the session |
| 1 |
Assess and engage |
Safety checked, model explained |
| 2 |
The record and the weighing |
Real-time record, weekly weighing installed |
| 3 |
Regular eating |
Three meals, two snacks, times written down |
| 4 |
Replacing the binges |
Two alternative behaviours tried |
| 5 |
Stopping the compensations |
Compensation dropped after a planned meal |
| 6 |
Mid-point review |
Obstacles identified, plan revised |
| 7 |
Dietary rules |
Three rules deliberately broken |
| 8 |
Avoided foods |
Five foods reintroduced |
| 9 |
Body image |
The self-esteem diagram, drawn |
| 10 |
Checking |
Checking behaviours listed, two withdrawn |
| 11 |
Events and emotions |
One written alternative per emotion |
| 12 |
Review, relapse, maintenance |
Written plan, measures repeated |
What the person takes away. Seven printable worksheets, listed in section 39: my record, my times, my rules, my foods, my diagram, the corner for those close, my plan for what comes next.
What sets this programme apart from the other manuals on this site. Three things. An early behavioural intervention that comes before any cognitive work. An explicit refusal of the goal that half the patients come looking for — weight loss. And an underlying target that is not eating behaviour but the place of weight in self-esteem.
2. Before you start
Who this programme is for
This text is for psychologists, psychiatrists, psychotherapists, doctors and dietitians trained in cognitive behavioural therapy, working in liaison with a doctor. It assumes that you can talk about food, vomiting and bodies precisely and without embarrassment, and that you have examined your own relationship to weight: in this indication, an unintended remark is costly.
It is intended neither for patients nor for those close to them.
The four preliminary decisions
Is the weight low, or has the loss been rapid? If so, this manual does not apply: the presentation calls for a specialist service. Section 3.
Is there a physical risk? Frequent vomiting, use of laxatives or diuretics, faints, palpitations, diabetes with manipulation of insulin. Section 10. The medical assessment comes before the programme.
Is there a suicide risk or self-harming behaviour? Frequent in this population, to be asked about explicitly.
And what exactly is it? Bulimia, binge-eating disorder, or another presentation. Section 3.
What this programme does not treat
It does not treat anorexia nervosa or low-weight presentations, which require supervised refeeding and close physical monitoring.
It does not treat physical emergencies. Electrolyte disturbances, faints, chest pain, vomiting blood: these are emergencies.
It does not conduct weight loss. Section 34.
And it does not on its own treat an eating disorder associated with major instability, which requires an integrated service.
What this programme is not
It is not a diet, nor a nutrition education programme. Dietetics has a place in it and it is not the treatment.
It is not a therapy of distant causes. It is often requested, and it does not interrupt the binges.
And it is not work on willpower. Section 4: it is in fact exactly the opposite.
How to use it
Read the whole before the first session, in particular sections 4, 10, 29, 32 and 34: restriction, medical safety, regular eating, body image, and the question of weight.
Each session is described according to the same framework: the aim, the steps, what you say, common errors, and the criterion for moving on.
Three warnings specific to this reason for consulting.
The shame is immense and it organises the secrecy. Many patients have never told anyone what they do in the evening. The first session decides what will be said afterwards.
The patient often comes for the wrong reason. They come to stop putting on weight, or to lose weight. That request is not to be refused: it is to be worked with, and section 34 says how.
And the first weeks are counter-intuitive. You ask someone who is afraid of eating to eat more, and more regularly. Without an explanation, nobody does it.
3. Four presentations not to be confused
1. Bulimia
What you observe. Recurrent binges — a clearly large quantity of food, within a limited time, with a feeling of loss of control — followed by compensatory behaviours: vomiting, laxatives, diuretics, fasting, excessive exercise. And a self-esteem very largely determined by shape and weight.
What that implies. It is the programme described here.
2. Binge-eating disorder
What you observe. The same binges, without regular compensatory behaviours. They go with eating fast, to the point of discomfort, without hunger, alone out of shame, and with a feeling of self-disgust afterwards.
What differs. The weight is more often high, the restriction is less systematic between binges but it almost always exists in the form of repeated diets, and the request for weight loss is almost constant.
What that implies. The same programme, with two differences: sessions 5 and 7 change content, and the question of weight takes up more room. Section 34.
3. Anorexia nervosa
What you observe. A restriction leading to a low weight, an intense fear of putting on weight, and an altered perception of the body. Binges and vomiting may also be present.
What settles it. The weight, and the weight trajectory.
What that implies. A different service: close physical monitoring, supervised refeeding, often a team. This manual does not apply there, and applying it would be dangerous.
4. The other presentations
What you observe. Forms that do not meet all the criteria: less frequent binges, compensations without binges, night-time episodes, restriction with food avoidance without concern about weight.
What that implies. These forms are frequent, they are not milder, and the programme generally applies.
The three other things to have ruled out
A medical cause. A digestive condition, an endocrine disorder, or the effects of a treatment.
Overeating without loss of control. Eating a lot is not a binge; what defines the binge is the feeling of being unable to stop.
And the manipulation of a treatment. In a person with diabetes, deliberately reducing insulin to control weight is a compensation, it is serious, and it is never reported spontaneously.
The three sorting questions
"Do you sometimes eat an amount that others would find abnormal, without being able to stop?" The question that isolates the binge.
"What do you do afterwards?" The question that isolates the compensations, and each one has to be named, because patients spontaneously report only the vomiting.
"Does your weight or your shape decide how you judge yourself?" The question that isolates the underlying mechanism, and that predicts relapse.
4. Restriction: the engine of the cycle
What has to be understood above all
Binges are not a problem of willpower. They are the predictable consequence of an irregular deprivation. An organism that does not receive enough, or not regularly enough, produces a pressure towards food that ends by winning — and that wins all the more violently the stricter the restriction has been.
That is what the work on semi-starvation in volunteers without any disorder has long shown: obsessive preoccupation with food, loss of control over eating, unstable mood, social withdrawal. These features appear in people who had no disorder beforehand, and they disappear with refeeding.
What that changes
You do not strengthen the control. Every attempt to eat less in order to avoid binges produces binges.
You eat more regularly, and often more, from the third session onwards.
And you explain it before asking for it. Without that explanation, the instruction looks absurd and nobody follows it.
The forms of restriction
Skipping a meal. No breakfast, no lunch, and an evening that ends badly.
Delay. Waiting as late as possible before the first meal.
Quantity. Meals too light to last.
Quality. The avoidance of whole categories.
Rules. "Nothing after 8 pm." "No starch in the evening." "Nothing until I have done my workout."
And anticipatory compensation. Eating less because there is an evening out ahead, which guarantees the binge.
The full cycle
Restriction, physiological hunger and growing preoccupation, breakdown, binge, distress and a sense of failure, compensation, a decision to do better tomorrow and therefore a stricter restriction, and the cycle starts again more tightly.
Two further entry points also lead into it: an event or an emotion that directly triggers the binge, and a broken rule that produces the thought "it is ruined, I may as well carry on".
That is the diagram you draw in session 1.
5. The compensatory behaviours
What they are
Everything done to undo what has been eaten, or to control weight in a way that falls outside ordinary eating.
Self-induced vomiting.
Laxatives.
Diuretics.
Fasting and skipping meals after a binge.
Excessive or compulsive physical exercise, often not counted as a compensation by the patient.
The manipulation of a treatment, in particular insulin.
And appetite suppressants or slimming products, including those sold without prescription.
What has to be known, and said
Vomiting does not remove everything that has been eaten, far from it. That piece of information alone brings the frequency down in some patients, because the benefit-cost ratio of vomiting collapses once it is known.
Laxatives do not act on the absorption of calories. They act further down. The weight loss they produce is a loss of water, it is regained immediately, and they maintain a constipation that makes them indispensable.
Diuretics have no effect on fat mass and carry real risks.
And the compensations keep the binges going. Knowing that one will be able to compensate removes the inhibition: that is what allows the binge to happen, and that is why withdrawing them is part of the treatment of the binges and not the other way round.
How they are withdrawn
After regular eating has been installed, never before.
Starting with the compensations that follow a normal meal, not those that follow a binge.
Handling the stopping of laxatives with the doctor, because stopping produces a transient constipation and water retention, which are the leading cause of restarting.
And by announcing the water retention. The weight goes back up for a few days when vomiting or laxatives are stopped. Not announcing it guarantees that the person gives up.