When bullying focuses on weight, trauma-focused CBT is promising treatment, research reveals

Researchers at Yale School of Medicine (YSM) have tested the first psychotherapeutic treatment of any kind for bullying—specifically weight-related bullying. It is important work, because no evidence-based treatments aimed at youth who experience bullying are currently in use, according to the researchers.

Bullying can lead to a number of harmful results, such as social and academic difficulties, anxiety, depression, self-harm, and suicide. Weight-related bullying, in particular, can be a precursor for eating disorders, weight gain, and obesity. Yet until now, efforts have been directed at reducing bullying rather than treating its victims.

“Most of the research has been about preventing bullying from happening or helping schools to manage the effects of bullying, but nothing really for the individual patient, which is bizarre because we know that bullying has all of these really severe consequences,” says Janet Lydecker, Ph.D., assistant professor of psychiatry at YSM and first author of a study published in the International Journal of Eating Disorders on July 15.

Lydecker and her team adapted a trauma-focused cognitive-behavioral therapy (TF-CBT) combined with CBT for eating disorders to treat youth who experienced weight-related bullying, called “TF-CBT-WB,” (which stands for trauma-focused CBT for weight bullying), and tested its feasibility in 30 adolescents.

The study found that the treatment improved such symptoms as traumatic stress, eating disorder severity, and body image concerns. Lydecker hopes to expand on these promising results in future studies.

A trauma-focused approach

Historically, TF-CBT has been used to treat youth who have had such traumatic experiences as abuse or a near-death incident, but researchers are beginning to expand the definition of what counts as trauma. Bullying, in particular, has been found to cause clinical levels of traumatic stress in children. Because bullying occurs as distinct events, causing children to feel unsafe and leading to distress, it meets the criteria for treatment with TF-CBT.

“People will say [bullying] is a ‘little-T’ trauma, meaning it’s not the official trauma that the DSM [Diagnostic and Statistical Manual of Mental Disorders] may talk about,” says Lydecker. “But it still does function like a trauma, especially among adolescents whose whole world revolves around their peers and their peer relationships.”

Although it has not been tested clinically, a standard CBT approach to treating bullying might frame it as a stressor and help patients to learn coping strategies. By treating bullying as a trauma, Lydecker’s approach requires patients to create a narrative by recounting the bullying experiences, then go back through the narrative and identify distorted thoughts and emotions.

Lydecker says she expected TF-CBT-WB for appearance-related bullying to help prevent later development of eating disorders, rather than treat existing ones. Therefore, she was surprised to find a high initial rate of severe eating disorder psychopathology among the participants.

After three months of weekly treatment sessions, she and her team compared the participants’ eating disorder symptoms before and after TF-CBT-WB treatment and saw clinically significant reductions in eating disorder severity, body image and eating concerns, and binge eating.

Lydecker believes these results demonstrate that TF-CBT-WB may be promising not only for bullying treatment, but for eating disorder treatment, as well.

“In the eating disorder field, we need more treatment,” she says. “This could be a way to treat some of that underlying self-concept and distress that come from these appearance-related bullying experiences. This may be a different option for people with eating disorders, and we really need that flexibility.”

The future of TF-CBT-WB

While the results were promising, additional research will be needed to learn more about the treatment’s efficacy.

For one, it was difficult to comprehensively gauge the success of TF-CBT-WB because no other treatment was studied. For ethical reasons, the study did not have an inactive control group (such as a waitlist), and because no evidence-based treatment for bullying exists, there was no standard of care to use as comparison—something Lydecker hopes that future studies will address.

Lydecker has already begun planning for studies that will have larger cohorts and extended follow-up periods to see how long the effects of the treatment last. She’s also interested in figuring out a way to assess whether a patient would benefit more from TF-CBT or standard CBT.

Additionally, she’d like to determine whether there are any differences in outcomes for youth who are “bully victims,” children who are both bullies and have been bullied. Lydecker hopes that the research will gain interest, both for scientists and patients alike.

“The goal is to get this as quickly as possible to clinicians and patients who need it,” she says.

“If kids have experienced bullying, they don’t have to just work through it on their own. Bullying might be common, but it’s not a normal part of childhood development that can be brushed over. It really does require working with a mental health provider if there’s any sort of distress.”