Dr Mandy Goldstein
We are excited to have another guest blog post today. Dr Mandy Goldstein is a clinical psychologist with 10 years’ experience in the treatment of eating disorders and trauma, across inpatient and outpatient settings. She is the Principal Clinical Psychologist at Mandy Goldstein Psychology, and works as an Associate at The Redleaf Practice. Mandy completed her Doctorate in Clinical Psychology at Macquarie University, where her research was focused on enhancing the treatment of eating disorders. She has a particular interest in both the use of evidence based treatment, and its dissemination beyond research environments, making effective treatment more accessible to clinicians and patients alike.

Is weight recovery enough?
​​​A recent article in the Journal of Eating Disorders by Murray, Loeb and Le Grange (2018) has made a call to change the way we investigate or report on change following treatment for anorexia nervosa (AN). The article, titled 'Treatment outcome reporting in anorexia nervosa: time for a paradigm shift?' and found here, raises the debate about whether weight restoration alone is enough to draw the conclusion someone with an eating disorder (ED) has recovered. 

Patients with AN typically restrict weight, and experience various symptoms associated with, or exacerbated by, what we now know to be part of a syndrome of starvation. These can include an increasingly obsessive focus on food to the exclusion of other aspects of life, rigidness in thinking, and difficulty seeing the big picture or having the flexibility to behave differently when the situation calls for it. Patients can experience increased irritability, even leading to significant mood difficulties, such as depression or anxiety, which might not have been there before becoming underweight. Starvation and underweight can also put sufferers at risk of increased psychological and serious medical difficulties. It’s no surprise then, that most clinicians working with people with AN agree, that reversing starvation must be the first aim of treatment. But is that enough to consider a patient recovered? The article suggests, no. As the authors point out, if we consider weight restoration alone as an outcome, we stand to neglect core cognitive and body image related aspects of the illness, and if we are not focusing on these as measures of good treatment outcome, we stand to miss treating these parts of the illness. The numbers don’t stack up either. An apparent “good outcome” of around 60% of patients being considered “recovered” based on weight restoration alone, falls quickly to a much lower percentage (40%), when a broader definition of recovery, including reduced disordered thoughts and feelings related to the ED, is used. This fits with our clinical experience in that, while not true for every case, it is not uncommon for weight restoration to mark the very beginning, rather than the end, of a treatment journey. It makes good sense that once out of starvation, patients are able to think more flexibly and clearly, as well as having more access to their feelings. It is often only once weight is restored, that sufferers are more ready, and have the tools available, to embark on the journey of addressing their thoughts, feelings and body image concerns stemming from the ED and often responsible for keeping it going.  

So if weight as an outcome from treatment is not enough, what might be? Some have bundled descriptions of weight and cognitive recovery into a united category, describing whether the patient has made a good, intermediary or poor outcome. But again, as the authors point out, this kind of reporting means we lose focus on the specific contribution that each patient’s weight and cognitive difficulties might make to their ED and makes it tough to provide more targeted treatments to each individual. Not surprisingly, another issue that springs from the confusion about how we report outcomes for EDs, is that there has not been a lot of agreement about this in the research field, leading to difficulties comparing different pieces of research to understand how effective treatments really are. The paper therefore calls for weight restoration and cognitive markers of recovery to be considered distinct entities, measured separately, and reported as independent indices, each contributing to a mark of recovery. That way, clinicians may have the opportunity to focus on specific targets of treatment for each of their clients; and researchers might be better able to compare the results of treatments they are investigating. Interestingly, say the authors, making this shift in how we report on treatment outcome, stands to impact how we use research to influence the development of new, more targetted treatments for AN, the importance of which is likely a whole other blog topic.

We’d love to get your thoughts. Please comment below. 

Today The Redleaf Practice welcomes a guest blogger, Belinda Caldwell, who is a carer consultant and project manager with the Victorian Centre for Excellence in Eating Disorders.  Belinda is the mother of a daughter who developed anorexia nervosa in 2011 at the age of 16 and participated in treatment at the Royal Children’s Hospital in Melbourne with FBT. She previously worked as CEO of APNA, the peak professional organisation for nurses in primary health care and has worked in a variety of primary health care organisations over the last 20 years, managing a range of health improvement programs and projects. She is on the board of Families Empowering and Supporting the Treatment of Eating Disorders (FEAST) and is a carer representative on a number of state/national committees. Belinda is passionate about the role of families in early intervention, effective treatment and sustaining recovery. 

I know Belinda would like to stimulate some discussion around the ideas in her blog post below. Comments can be left below or on our Facebook Page

Beyond the search for the perfect ‘model’ - Family Led Refeeding and Recovery 

​Treatments for eating disorders in adolescents and children, in particular Anorexia Nervosa or AN-like eating disorders, have been transformed in the last decade or so with the introduction of family inclusive treatment. We are now able to achieve relatively quick positive outcomes for a significant number of young people through early aggressive focus on refeeding and weight restoration with families driving the process. Family based approaches were initially developed by Russell and associates and were then refined and manualised by Lock and Le Grange. From these beginnings we are now seeing a range of models and adaptations. In many ways we discovered a magic pill in family based approaches to AN. But it is a pill with many ingredients, and we are not especially clear on which ingredients make more or less of a difference.

We are in a situation where research is telling us that there are no models that are providing much better than about 50% success in full reduction of eating disorder symptomology. What concerns me is a focus on finding the ‘new’ model, when I hypothesise that the relatively similar outcomes between all the family involved models (FBT, APT and MFT-AN) derive from two key shared components – family led refeeding, and focus on weight restoration - and that some of their differences may contribute small equal amounts. We do not have any evidence on which modular components within treatment models are more impactful than others e.g. family meal (FBT), phases (FBT), dietician or not (APT), additional psychological interventions (APT), family therapy activities (MFT-AN) etc.

The high rates of relapse and failure to remit we still experience in managing this illness in young people, behove us as a community to urgently work out what these essential ingredients are and build on them, as well as work out missing ingredients not yet fully explored to research and add into the overall recipe. I will use my personal experience as a carer, carer consultant, member of an eating disorders clinical team and informed parent advocate, to posit my own theory of what the essential ingredients are and the missing elements worthy of further exploration and research.

Attending the recent ANZAED 2017 conference, I participated in a workshop on Adolescent Parent Therapy (APT) based on Adolescent Focussed Therapy (AFT). It is a model of treatment which uses individual therapy by a therapist with the adolescent, alongside parent led refeeding with the assistance of a dietician. AFT theory originates from a self-psychological model and views anorexia as a maladaptive coping tool used by the adolescent to manage the complex demands and transitions associated with adolescence. AFT consists of three phases of treatment spread across approximately one year. Although AFT is an individual approach it makes liberal use of separate sessions with parents with the aim of engaging and educating them about anorexia.

In our family we undertook Family Based Treatment (FBT) as part of a research trial at the Royal Children’s Hospital in Melbourne. FBT tasks families with refeeding the young person with AN in weekly sessions with FBT therapist, family and young person; has three phases over 6-12 months; and does not involve individual therapy for the young person. It is agnostic as to cause, focusses on symptoms in a pragmatic way and the therapeutic alliance is primarily between the parents and the therapist. The trial we were involved in also had an arm where the parents and the therapist met without the young person in the room (Parent Focussed Treatment PFT) and the results for this group were mostly better than our arm.

In my work as a Carer Consultant at the Victorian Centre of Excellence in Eating Disorders (CEED), I have had the privilege in being involved tangentially in the roll out of Multifamily therapy for AN (MFT-AN) in CAMHS services. MFT-AN is an intensive group program run by the Maudsley Hospital UK since 2000 for families with a young person experiencing AN. The program we run involves 5-7 families in an intensive 4 day workshop, complemented by more standard FBT in a CAMHS setting. MFT-AN draws on the principles of FBT  and consists of structured and guided activities, including active support at meals, group therapy, family therapy and psychoeducation, along with creative and reflective activities. MFT-AN promotes a return to physical wellbeing through weight gain and normal eating, as well as encouraging appropriate adolescent development and strengthening family relationships. MFT-AN provides an intense, collaborative environment for families to share experiences and practice new ways of doing things.

At CEED, I have also been involved tangentially in a project training facilitators to deliver Collaborative Carer Skills Workshops (CCSW) across Victoria. CCSW is an evidence-based carer intervention that has been shown to reduce psychological distress, burden, expressed emotion and emotional over-involvement in carers of people experiencing an eating disorder. It involves 6 weeks of weekly workshops for carers.

The other treatment option often offered is CBT-E for Adolescents which is based on the CBT-E model for adults. It is a behaviourally oriented individual therapy model involving engagement & motivation, formulation and understanding, changing eating behaviour, addressing over-evaluation of weight and shape, problem solving and maintaining change. The same treatment approach is used with adolescents with the only significant difference being the routine involvement of the patient's parents, although what this looks like is not clearly articulated.

When I reflect on my family’s journey, and the journeys of the many families I have come into contact with since, in my role as Carer Consultant at CEED and as a Board Director/Executive Director of F.E.A.S.T, I see some core components for success no matter the treatment model.

For our family, being integrally involved as a family in the leadership of our daughter’s recovery was both instrumental to both her return to good health, and our families sense of agency in what is frequently a  paralysing illness. Being empowered to make the decisions of what to feed and when, how much exercise to allow, strategies for symptom alleviation, was both scary and confidence building. And as families we are required to provide assistance well beyond when most people leave formalised treatment, so our feeling confident and enabled to provide this support is critical to continue the work needed and prevent relapses. When hearing the presentation on Adolescent Focussed/Parent Therapy, my gut response to some of the presentation was strong ambivalence at the sense of the family being somewhat sidelined in terms of leadership, with the stronger therapeutic relationship/alliance being between the therapist and the young person. While I recognise that it is not possible in all family situations for the treatment to be led by the parents, it seems to me this should at least be the first option offered, with the key therapeutic alliance between the therapist and the family.

However, just letting families lead the way is not sufficient. Some families are better resourced internally, professionally and environmentally to be able to embrace this role. Additional skills and knowledge are frequently needed to complement existing strengths. We certainly found we were very reliant on online information sources and informal peer support in the absence of this support in our experience of treatment. In the research trial using manualised FBT, we were more or less told “you know how to feed your child”. We did not know how to feed a malnourished child with an intense phobia of eating. We credit much of our success to our access to online information and peer support. It would seem to me the desirable elements for good treatment could include the additional support provided to families in AFT both in terms of family education and access to a dietician, and the very hands on team support with skill building e.g. meals and peer support provided in MFT.

All of these models, with the possible exception of CBT-E (role of family poorly explained), have families take the lead on refeeding the young person. The focus on family led refeeding is in response to the compromised ability of the young person to understand they are ill or the need for weight gain and the intense fear they experience on eating. This change of focus in treatment over the last 10-20 years to move away from requiring young people to be ‘ready’ for change to tasking families with refeeding has changed the landscape of eating disorder treatment to a more optimistic recovery focussed one.

A challenge I found when listening to the AFT/APT presentation was the theory of causation which is that AN develops as a maladaptive response to the challenges of adolescence. For us, our daughter had always been extremely anxious since a baby but adolescence seemed to pose no particular additional problems. Her rapid plunge into severe AN occurred after a trip to Nepal where she lost a lot of weight in a short period of time, experienced several episodes of hunger whilst trekking which made her feel calm and yet, even beyond that, the behaviours and rapid descent into AN hell was beyond any simple explanation for both her or us – it was a compulsion that took on a life of its own. For me, the neurobiological explanations of AN offer the best framework for explaining this loss of the child I knew and explosion of inexplicable bizarre behaviours. Families wherever I go have completely and utterly different stories of the journey into AN and some can fit theories of bullying, trauma, maladaptive responses to adolescent challenges and others are more like ours, a bolt out of the blue, weight loss for some reasons, either dieting or unintentional. Yet others experience the onset of illness as an extension of OCD or ASD traits. Whenever I hear theories of causation, I get concerned because it is likely to feed into treatment approaches which may or may not fit the individual circumstances. We do not currently have any evidence for what causes AN. Saying things cause AN or AN is a response to x, even with the best of intentions, can lead to families blaming themselves which is a key contributor to families feeling disempowered.

One of the difficulties we experienced in manualised FBT was a lack of attention on our daughter’s pre-existing comorbidities during FBT. We never made it to Phase 3 of FBT, where some of this discussion occurs, due to the timelines of the research trial. Even those who do get to the end of treatment, often experience a lack of priority on the often extensive work that may need to be done individually with our young people after weight restoration and cessation of ED symptoms. The actual journey of having an eating disorder seems to exacerbate pre-existing anxiety, depression, and body image concerns or lead to their development when they may not have existed before onset. Whether they predated the illness or arose out of the illness, not addressing comorbidities and giving our young people the skills to manage them, can leave them vulnerable to relapses because they have now learnt that restriction, exercise or purging are soothing. CBT (along with Acceptance Commitment Therapy, Dialectical Behavioural Treatment and more) provide very useful strategies for our young people to adopt.

Finally, the journey for families is long and traumatic. Much of it occurs outside of formalised treatment settings. Phase 2 in FBT for many families, including ours, is a long dance of allowing the child some independence in eating and taking back food decisions when they struggle. Family dynamics change and orient around the child with the illness. Siblings get sidelined. The number of therapist sessions at the end of treatment are frequently insufficient to return the adolescent to his/her normal trajectory and the family back to a normal functioning family. This can have ramifications for years with families overreacting to wobbles in our young people or not reacting fast enough, siblings disengaging from the family or having their own mental health struggles. And families who are compromised as a result of the first episode of AN, really struggle to provide the care needed in subsequent relapses should they occur. To improve outcomes in adults with AN, we need strong, supportive and empowered families not shattered ones.  

What has been key to my own family’s journey has been access to a wide range of peer support. I sought out online peer support in the form of the Around the Dinner Table online forum, and through that developed friendships with some key families in my home town. These connections gave me hope that recovery is possible, ideas for strategies, confidence when I was feeling defeated, and general support from people who ‘got it’. It normalised our experiences and made us feel more able to see a way out. In an illness which deeply challenges one’s own resilience, can be pretty traumatic and tends to isolate families within in their own communities, peer support is critical. I now provide carer consultations to families undertaking treatment (FBT) in our CAMHS services and we frequently see startling shifts in family approaches and successful refeeding when having access to a fellow ‘expert’ parent, even if for just one visit.

If I had to design my ideal mix of ingredients, it would have elements of all the models discussed above plus a few more. It would include:

• Support of family leadership in the treatment team
• Key therapeutic alliance for refeeding  and recovery is between the therapist and the family, unless contraindicated
• Provision of significant knowledge and skill building programs for families
• Provision of peer support from time of diagnosis, preferably formalised
• Care to take place as close to home as possible to enable continued community support for families and engagement of young person in normal daily life as soon as able to.
• Refeeding to a healthy weight as a critical non-negotiable element of treatment
• Avoidance of causation based theories until we have any strong evidence to  support them
• Focus on treatment of comorbidities as part of treatment
• Stronger support for families in the recovery phase to return to normal functioning with regular ongoing checking in

I would call this set of principles “Family Led Refeeding and Recovery” to reflect both the refeeding/weight restoration ingredients but also include all the other ingredients needed for full recovery of both the young person and the family. 
 
Bibliography 

1. Russell GFM, Szmukler GI, Dare C et al. An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Arch Gen Psychiatry 1987;44: 1047-56
2. LE GRANGE D. The Maudsley family-based treatment for adolescent anorexia nervosa. World Psychiatry. 2005;4(3):142-146
3. Eisler I, Simic M, Hodsoll J, et al. A pragmatic randomised multi-centre trial of multifamily and single family therapy for adolescent anorexia nervosa. BMC Psychiatry. 2016;16:422. doi:10.1186/s12888-016-1129-6.
4. Lock J, Le Grange D, Agras WS, Moye A, Bryson SW, Jo B. Randomized Clinical Trial Comparing Family-Based Treatment With Adolescent-Focused Individual Therapy for Adolescents With Anorexia Nervosa. Arch Gen Psychiatry. 2010;67(10):1025–1032. doi:10.1001/archgenpsychiatry.2010.128
5. Dalle Grave R, Calugi S, Doll HA, Fairburn CG. Enhanced cognitive behaviour therapy for adolescents with anorexia nervosa: An alternative to family therapy? Behaviour Research and Therapy. 2013;51(1):R9-R12. doi:10.1016/j.brat.2012.09.008.

Treatment manuals tell clinicians what to do in therapy. They outline the things that we think to be useful in helping someone suffering from an eating disorder. What is underemphasised in those manuals is the stance of the therapist that may be most helpful in making the most of the treatment manual.
 
Collaboration or Direction?

A ‘collaborative stance’ is central to most therapies.  Josie Geller from Canada is one of the worlds leading investigators of stance in eating disorder treatment.  Geller defines a collaborative stance as one that is supporting or encouraging change, whilst also supporting the individuals and showing concern and caring that is not contingent upon the individual’s behaviour.  You are working collaboratively toward goals that are agreed upon by the clinician and the individual. An example of a collaborative stance may be “What do you think got in the way of completing that challenge? You mentioned last week you really wanted to face that fear. How can I help you with this?” This is an invitation to understand a barrier to change together. It shows an understanding that change is hard.
 
This is contrasted to a ‘directive stance’, which is thought about as offering intrusive facilitation or contingent praise in order to get the patient to eat more, exercise less or agree to something.  Examples of a therapist being directive would be “You just need to stick to the meal plan” or “You are not motivated enough to change.”
 
Both patients and clinicians rate a collaborative stance as more helpful in the treatment of eating disorders.  Collaboration is seen as more acceptable and likely to lead to treatment retention and adherence.  So it is a no brainer – we should all be using a collaborative stance. I would imagine that most therapists would tell you that they indeed do use a collaborative stance. However, Zatisoff et al. (2015) found that collaborative and directive approaches were equally likely to occur in clinical practice.
 
As clinicians we are not as collaborative as we think we are.  What about carers?
 
Geller et al. (2016) ask the same question about carers. Are carers as collaborative as they think they are? This is important as a collaborative carer style has been associated with higher motivation for change (van der Kaap-Deeder et al., 2014).
 
The carers recruited by Geller were the family and friends of patients with a mean age of 29 years and an average duration of illness of 12 years.  Importantly, these were adult patients. The stance for carers for adolescents may need to be different.
 
Predictably, carers felt that a collaborative stance was more helpful than a directive stance, but when faced with a series of clinical vignettes the majority (60%) of responses were coded as directive. Like clinicians, carers are less collaborative than they think.
 
Carers who believed that taking a directive stance was more helpful would, understandably, use a more directive approach to caring. It may be that teaching carers about the disadvantages of a directive stance and the benefits of a collaborative stance may be beneficial.  Geller et al (2016) tentatively concluded that their sample who had attended some sessions about the potential drawbacks of a directive approach and who were introduced to the concepts of stages of change were more likely to endorse a collaborative stance.  Psychoeducation to carers may be vital in enhancing change.
 
Collaboration was also positively associated with a warmer and more understanding interpersonal style and the use of a combination of concern and encouraging stance.  Helping carers manage their own distress would again seem important in facilitating a more helpful collaborative stance. 
 
Sydney Workshop
 
One of Josie Geller’s current interests is looking at how to help carers by educating about the process of change and also looking at training carers to use self compassion to manage their own distress.
 
I am looking forward to Geller’s return to Australia in 2017. Josie will be holding a workshop for carers (and those working with carers) at the 2017 Australia and New Zealand Academy of Eating Disorders Conference to be held in Sydney on September 1-2.  For clinicians and carers who would be interested in attending this workshop, or for more information about the conference, contact Jeremy Freeman at jeremy.freeman@anzaed.org.au or visit the ANZAED website.




Van der Kaap-Deeder J, Vansteenkiste M, Soenens B, Verstuyf J, Boone L, Smets J. Fostering self-endorsed motivation to change in patients with an eating disorder: The role of perceived autonomy support and psychological need satisfaction. Int J Eat Disord 2014; 47:585–600. 

Zaitsoff S, Yiu A, Pullmer R, Geller J, Menna R. Therapeutic engagement: Perspectives from adolescents with eating disorders. Psychiatry Res 2015; 230: 597–603.


 

Self compassion is one of the pretty trendy topics in eating disorders.  It is becoming part of many therapist treatment packages despite it not being in any of the evidenced based treatment programs.  In fact,  strident evidence based practitioners, such as Glenn Waller warn against the incorporation of self compassion as an indication of therapist drift.  It is seen as somewhat the realm of fluffy bunnies rather than having a scientific base. I wonder if that is fair.
 
Self-compassion is a multi-dimensional construct based on the recognition that suffering, failure, and inadequacy are part of the human condition, and that all people—oneself included—are worthy of compassion. It is most eloquently written about by Kristen Neff who I often post about on the Redleaf Facebook page.
 
To move away from fluffy bunny idea (fans of Buffy the Vampire Slayer may recognise the image) we need to look at the science behind self compassion in the treatment of eating disorders?  Bruan et al (2016) provide an overall review of the link between self compassion, eating disorder symptoms and body image.  Of most interest to me were the studies on clinical samples, rather than on people who do not have eating disorders (although that is important for prevention).  There are a number of studies looking at self compassion is patients with eating disorders.  Overall the studies do indicate a correlation between self compassion and eating disorder symptoms. There is evidence that patients with eating disorders have less self compassion and a greater fear of self compassion than university students without eating symptoms. Ferreira, Matos, Duarte, & Pinto-Gouveia, (2014) found that self kindness explained 38% of the variance of symptoms. Kelly, Vimalakanthan, & Carter (2014) found that fear of self compassion predicted disordered eating more powerfully than BMI, self esteem or, a bit weirdly, self compassion.
 
Prospective studies have indicated that lower self compassion and fear of self compassion are significantly correlated with disordered eating. Those patients that increased self compassion during treatment exhibited the greatest drop in eating disordered scores over 12 weeks of treatment.  Patients with binge eating appeared to benefit more from self compassion interventions than patients with restricting behaviours.
 
A pilot treatment study by (Gale, Gilbert, Read, & Goss, 2014) investigated a 16 week self compassion program in 139 outpatients with Eating Disorders in England. Significant improvements were observed in psychological distress, self-esteem, self-directed hostility, perceived external control; as well as weight and shape concerns, eating restraint, and cognitive and behavioural AN and BN symptoms. With respect to eating behaviours, binge eating and excessive exercise significantly improved, with marginal improvements for vomiting, laxative, and diuretic use. Those with BN and, to a lesser extent, EDNOS, derived substantially greater benefit from the intervention than those with AN.
 
In a study with patients with BED, Kelly & Carter (2014), randomised 41 patients to either a self compassion self help program (Goss 2011), a behavioural program based Cognitive Behavioural Therapy (using Overcoming Binge Eating by Fairburn 1995) or a wait list control.  From the description this CBT was not delivered in an optimal format for this trial. Both intervention groups reduced weekly binge days relative to the control condition.  The self-compassion intervention was most effective in reducing global ED pathology, weight, and eating concerns, and produced greater improvements in self-compassion than CBT or the wait list control group.  Again, patients with a higher fear of self compassion did less well in Compassion Focused Therapy interventions.  Unfortunately both Kelly and Carter (2014) and Gale et al are hidden behind a pay wall, so I couldn’t access the full article.
 
So, there is a small but growing base of evidence that would suggest a role for adding in a compassion focused therapy to the treatment of eating disorders. I am not sure I am ready for it to be a stand alone treatment, but it is certainly a set of skills that may be helpful particularly in BN and BED.
 
As always feedback and comments welcome.
 
 
 
 
 
 
 
 

Almost all my patients talk to me of the “voice” that they hear. The (usually) harsh and critical voice that talk, shouts and cajoles all the time.  Sometimes it is reported as a friend, sometimes more like a dictator. Patients often feel scared and trapped by this voice, compelled to do what it says in an effort to silence it.  Often the voice feels more powerful than the person.
 
 
What is the relationship between the anorexic voice and anorexic symptoms. 

In a paper that I was involved with we (Scott, Haystack & Thornton, 2014) found that the voice played a role as an “abuser” and also an “ascetic voice” – which highlighted a moral attitude to thinness.  We found that the anorexic voice was strongly associated with eating disorder symptoms and severity.
 
What can be done to help with the voice.  At Redleaf we teach patients to understand the voice as part of the eating disordered mindset.  We teach people to take a defused stance from this pattern of thinking in order to have more of a choice between following the voice or not.  We help people learn to reflect whether following that voice moves them in the direction of their values or away from them.  Often what happens is if people act against the voice they learn that what the voice tells them is often not true or not as bad as predicted.  Acting against the thoughts, by doing behavioural experiments, is one of the most effective ways to change the voice.
 
A recent study by Pugh & Waller (2016) also investigated the relationship between the anorexic voice and the symptoms of the eating disorder.  In the most clinically interesting finding is that the anorexic voice was more powerful and more malevolent when weight was low.  What this is likely to mean is that as you normalize your eating the power of the eating disorder voice will decrease. This study doesn’t give information as to how long this takes. Those who have undergone the process of nutritional restoration and weight regain will often report that the voice gets worse as it is challenged by healthy eating behaviour and recovery. However, after a period of weight being stable at a healthy weight and normal eating it has been my experience that the voice diminishes over time.
 
I would love to here the experiences of those that have recovered about how that voice changed during that recovery.  I am curious about what others think are the key factors in this voice becoming less powerful.

What to do when the ‘evidence based treatments’ are not successful?
 
One of the big questions in the field is what should you do if an evidence based treatment is not successful. If we look at binge eating as a behaviour, and thus covering the diagnosis of bulimia nervosa (BN) and binge eating disorder (BED), then the “treatment of choice” would be Cognitive Behavioural Therapy (CBT). Yet we know that not all people recover using CBT and some relapse after treatment ends. It has been suggested that an ‘additive’ design, where other therapy protocols are added onto the treatment of choice, may be useful to examine.
 
McIntosh et al. (2016) from Christchurch have recently published a paper in Psychiatry Research looking at adding two additional treatments to CBT for binge eating. 
 
The first protocol is CBT-Appetite.  This treatment assumes that diminished recognition of hunger and fullness cues are a maintaining factor in binge eating.  The focus is on monitoring appetite rather than food intake as in traditional CBT. Patients are taught to eat in response to moderate hunger and to stop eating when moderately full. Food choices are encouraged around foods with greater volume and lower energy density and greater satiety potential (e.g. including protein throughout the day and choosing lower GI carbohydrates). Patients learn to recognize and not respond to emotional and situational triggers for eating.  The reference given for this treatment is a chapter by McIntosh et al. in Wilson and Latner (2007) ‘Self-Help for Eating and Obesity’.  I haven’t read the chapter (but will) but I am really curious as to whether or not it uses a dietitian in its delivery. Much of what is described in the article are core dietetic interventions for binge eating.
 
The second additional protocol looked at in this study is that of Schema Therapy.  This seems to take a few forms in the eating disorders.  It is based on the idea that early life experiences lead to a series of core beliefs about the self (rather than automatic thoughts) which may in turn maintain eating disorders. There is some evidence for Schema Therapy (using schema modes; Simpson et al. 2010). Therapy aims to increase awareness of early maladaptive schemas and schema modes and the early experience from which they developed and then to modify the schemas in an effort to reduce eating disordered behaviour. Schemas are modified by using imagery and other experiential techniques. A healthier ‘adult self’ is developed in order to bring about a more mature perspective, including more reasoned and rational responses.  This approach looks at these ‘underlying’ cognitions rather than a focus on challenging automatic thoughts and assumptions relating to food, weight and shape. (Although to be fair, the more recent incarnations of CBT, such as CBT-E, do not focus on this level of cognitive content either).  It is assumed that binge eating serves a function of regulating the strong emotion that arises when schemas are activated, rather than thoughts about food, weight and shape.
 
In a way this study is trying to look at what might be a core maintaining factor of binge eating. Is it over-evaluation of weight and shape (CBT), dysregulation of response to appetite (CBT-A) or emotional dysregulation (Schema Therapy)? From a clinical perspective, all three may or may not be involved. It is not as though these things are mutually exclusive.
 
What happened during the study?
 
You can read the details of the study in the attached link, but I will summarise them. In brief, no differences were found in three groups on the outcome measure of binge frequency or other behavioural or psychological aspects of the eating disorders. At the end of treatment and at 12 month follow up there were large changes in binge eating, indicating that in this study all treatments were effective.  That is an example of the Dodo hypothesis where ‘everyone gets a prize’.   This always raises the issue of whether any therapy may be helpful, so therapists can do whatever they want and achieve results. I would warn against this. All these therapies are based on a sound theoretical understanding of binge eating, as I have outlined above.
 
Should we be surprised by a Dodo hypothesis? I am not. In a clinical setting, where I happily work with the patient to develop an individual formulation of what drives their problem, it may be over-evaluation of weight and shape, dysregulation of appetite or emotion regulation.  I would agree with the patient and decide where the best place to focus treatment may be.
 
The study outcomes were in line with previous findings of studies of CBT. Around 50% of the sample was abstinent from binge eating at end of treatment and follow up. That is, half of the sample were not abstinent at the end of treatment, which is of course not to say they were not helped by the treatment.  A study which would be more interesting to me as a clinician would be to take the 50% of patients not abstinent at end of treatment and then deliver either CBT-A or Schema Therapy to see if adding an additional treatment at the end of CBT increases outcome.
 
As always, thoughts and feedback welcome, either in the comments section or on the Facebook link.

Words can be tricky things and need to be used carefully. A brief article by former editors of the International Journal of Eating Disorders (Weissman et al., 2016) look at words we should avoid or reconsider in the field of eating disorders. The article seems largely written for researchers submitting articles to the journal, but has application to clinicians as well. 
 
Terms that we should no longer use include “anorexic” “bulimic” and “binge eater”. These terms confuse the person with the disorder and refer to them as one and the same thing. We don’t refer to someone with a diagnosis of cancer as “canceric”. There is a clear illness that is effecting the individual. The same needs to be held for people who make criteria for an eating disorder.  Of course, we work really hard to do this in the clinic room by externalizing the eating disorder and separating this from the individual. 
 
The authors suggest using a number of terms to replace “anorexic,” one of which is “patient”. I wonder if patient is a term we should also rethink?  It is suggested that the field reconsiders referring to people with an eating disorder as “sufferers” or as “struggling with an eating disorder”. They question if these terms are pejorative.  I wonder if they are not a pretty accurate description. The article does not mean to imply that people who are “seeking treatment” for an eating disorder (which is a term they suggest) are not suffering with the consequences of a life threatening illness. (I don’t know what it implies for those who don’t seek treatment for an eating disorder – see, words are tricky).
 
Now, I’m pretty sure someone might go through things I have written and find that I have frequently used a term that the article suggests no longer using.  The term is “gold standard”. This is frequently used to suggest that a treatment (such as FBT or CBT) is the best treatment available and should be the treatment you are offered or offering. However, it may imply that the treatment is perfect and has a guaranteed outcome.  The rationale for not using this term is that even well validated treatments are imperfect.  Better terms (but less catchy) are “extensively validated” (although can we define ‘extensively’?) or “demonstrably superior to other treatments”. I can live with that term. Given a plenary I organized at a conference in Boston was titled “Dissemination and Development of Psychological Treatments in Eating Disorders: Evidence-Based or How to Sell Snake Oil?”, removing sales pitch terms when describing treatments is something worth putting into practice – as long as we don’t ignore the data that does suggest some treatments seem superior to others with certain populations.
 
It is also suggested that we reconsider the use of the word “refeeding”.  This is a term I have always been uncomfortable with as it has been described to me by my patients as conjuring up images of battery hens and animals being “fattened up”.  Better terms are “renourishing” or “nutritional rehabilitation”.  The problem is that whatever we call this one, for a person undergoing the process it is so difficult and anxiety provoking that calling it by a different name may not be that important in the whole scheme of things.
 
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​The Redleaf Practice has always been an ardent supporter of evidence based treatment of the eating disorders.  A key feature of all treatments that have some evidence in the eating disorders is that they focus on the symptoms of the eating disorder early in treatment, and they push to achieve change in these symptoms.
 
We have known for a while that early change in eating behaviours is correlated with a better outcome in target behaviours, and that this is common across most disorders.  There are some studies that indicate having a good outcome from CBT is associated with changes in anxiety and depression, impulsive behaviour and harm avoidance.  However, is the impact of early symptom change predictive of a better overall outcome?
 
A recent study by Turner et al. (2016) in Behavior Research and Therapy investigated if mood and personality changes are effected by early symptom changes in an eating disorder outpatient community. A total of 179 outpatients engaged in a CBT program completed measures of anxiety and depression and “Personality Beliefs”, which identifies beliefs associated with personality disorders.   Rapid change was defined as changes in eating psychopathology (as rated by the Eating Disorders Examination (Questionnaire) after six sessions.
 
As was predicted by the authors, early behaviour change in eating psychopathology resulted in positive changes to anxiety/depression scores and personality disorder pathology scores. The most significant result of early symptom change was found on the personality questionnaire. Early reductions in restraint were related to changes in “Cluster B” personality (Histrionic and Borderline) and also in “Cluster C” personality (Avoidant, Obsessive Compulsive and Dependent).  Of interest is that where there was an early change in eating disorder thoughts (such as body image concerns) this was negatively associated with changes in personality pathology. The authors reflect that this may be a disadvantage of therapeutic drift away from a focus on early behaviour change. This finding would need to be replicated to see if that conclusion holds.
 
COMMENT
 
I know I am showing selective bias in summarizing this paper. It adds to a bunch of studies that show that early behaviour change – which is the focus of CBT and FBT – leads to better outcomes.  If therapy does not initially start with a behavioural focus there is a need to question why.  Of course, not all patients will be able to achieve early behavioural change. My inclination is to look at where the patient is on the stages of change and work at increasing readiness to change. I suspect the authors of this study would disagree and suggest that taking a motivational approach reduces the focus on early behaviour change and does a disservice to the patient. The question then is, if you aren’t able to achieve early behaviour change what do you do? This is a question for the whole ED community – therapists, researchers, families and those suffering from the illness.

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