An interesting article was published recently by Josie Geller and Suja Srikameswaran (Advances in Eating Disorders: Theory, Research & Practice, 3(2) 191-197. In these days of packaged, manualised and promoted evidence based therapies, they ask the question “What effective therapies have in common?” A good question indeed. I do note that the article gives us a list of “effective therapies”, which seems to go beyond the data somewhat and includes therapies with varying degrees of evidence. They are however a list of common therapies used in the treatment of eating disorders. (Although we also know that what people say they do and what they actually do may be somewhat different things – but I digress).
The therapies listed as effective are Cognitive Behavioural Therapy – Enhanced (CBTE), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), Specialist Supportive Clinical Management (SSCM), Integrative Cognitive Affective Therapy (ICAT), Dialectical Behavior Therapy (DBT) and Family Based Therapy (FBT).
The article looks at three questions related to engagement and motivation, skill acquisition and boundaries and expectations in therapy.
Engagement and Motivation
Common to each therapy was a description of a collaborative stance to treatment. This shouldn’t be too surprising. However, within this general category there are nuanced differences. Geller and Srikameswaran describe this as a difference between therapies that are more firm (CBT-E; FBT; DBT) in pushing for behaviour change moving to therapies that are more flexible (MANTRA, SSCM) within a collaborative stance. In my experience of CBT-E, FBT and DBT, there is also significant differences in the “how” of collaboration. For example, FBT is clearly more collaborative with parents than patients, whose motivation is assumed to be precontemplative of change. DBT requires a commitment to change before engagement in the “treatment” phase (although in practice these lines are a bit more blurred). As outlined in the CBT-E manual - engagement and motivation is approached in a somewhat technique driven way – use of a decision balance sheets and an encouragement to “take the plunge” into behavior change. A problem with manual treatments is that the how to engage is reduced to techniques rather than the fluid process it is in the clinic room.
I was really glad to see that the question of early behaviour change is touched on. This seems at the heart of the somewhat theoretical “debate” between Josie Geller and Professor Glenn (does motivation matter) Waller. Waller’s thesis, at least partly, is focused on the idea that early behaviour change leads to later behaviour change (and presumably motivation to continue with more behaviour change), such that pushing hard for early behaviour change is considered more important than focusing on motivation. I would agree with both Geller and Waller. When you can achieve behaviour change you don’t need to focus on motivation and to do so may get in the way of behaviour change. When you don’t see early behavioural change you need to step back and understand why and then work on increasing motivation. In this article Geller and Srikameswaran raise the point that patients who can achieve early behaviour change may be a different population from those that can not. A proportion of patients will turn up to session one having made the decision to change.
A frustration with this discussion was that once again motivation is reflected as a binary and permanent construct, which once turned on remains on forever. Any one who has tried to change anything will know that this is not how motivation works. It is fluid and changing and the level of motivation to make the changes required in therapy needs to be a constant focus of treatment. I also have a slight issue with the notion that when you change your behavior this increases motivation to change because change makes you feel better and want to change more. This is especially not the case in weight regain in anorexia nervosa. The behavioural change required leads to an increase in anxiety levels that low weight has been masking. This often leads to feeling worse until weight has been regained and held for some time.
Do not get me wrong – I’m big on behaviour change – it is just harder than it is made out to be.
What Skills do you need to teach in therapy?
Geller and Srikameswaran note there are more similarities than differences between therapies when considering content. The four areas that emerged were psychoeducation around the development and maintenance of the eating problem (all therapies), emotional regulation (not SSCM or FBT), focus on relationships (all therapies) and using higher values/helping patients see the bigger picture (MANTRA {core focus}; I-CAT, DBT).
Interesting is that helping patients with the eating disordered thinking (remember the C in CBT) seems to have gone out of fashion. I would argue that CBT-E (by looking at defusing from the Eating Disorder Mindset) and DBT (through the use of mindfulness) do have a set of skills for helping the patient with the eating disordered thoughts.
The Non-Negotiables of Treatments
Non- negotiable parts of treatment have always been a strong part of Josie Geller’s stance in therapy. I may have mentioned them once or twice as well (see Freeman, Thornton & Geller 2014 for example). Non negotiables are seen as being crucial in setting the boundaries around therapy.
The main common non-negotiable is the prescription of a regular pattern of eating. This shouldn’t surprise anyone. Again, the issue of firm vs. flexible is important. In some therapies regular eating is held firmly. FBT is the clearest example where eating is prescribed by parents and is the central focus of the therapy sessions. Similarly in CBT-E, regular eating is central and food monitoring and reviewing food logs is central to the therapy. In SSCM, regular eating is prescribed and encouraged, but may not be the central element of treatment sessions.
The problem is we don’t know what is more effective. Should I be firm or flexible? Or more realistically, in what combination should I use these ingredients and with which patients? If my patient is not making behaviour change should I become firmer or more flexible?
So many questions to think about?
The therapies listed as effective are Cognitive Behavioural Therapy – Enhanced (CBTE), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), Specialist Supportive Clinical Management (SSCM), Integrative Cognitive Affective Therapy (ICAT), Dialectical Behavior Therapy (DBT) and Family Based Therapy (FBT).
The article looks at three questions related to engagement and motivation, skill acquisition and boundaries and expectations in therapy.
Engagement and Motivation
Common to each therapy was a description of a collaborative stance to treatment. This shouldn’t be too surprising. However, within this general category there are nuanced differences. Geller and Srikameswaran describe this as a difference between therapies that are more firm (CBT-E; FBT; DBT) in pushing for behaviour change moving to therapies that are more flexible (MANTRA, SSCM) within a collaborative stance. In my experience of CBT-E, FBT and DBT, there is also significant differences in the “how” of collaboration. For example, FBT is clearly more collaborative with parents than patients, whose motivation is assumed to be precontemplative of change. DBT requires a commitment to change before engagement in the “treatment” phase (although in practice these lines are a bit more blurred). As outlined in the CBT-E manual - engagement and motivation is approached in a somewhat technique driven way – use of a decision balance sheets and an encouragement to “take the plunge” into behavior change. A problem with manual treatments is that the how to engage is reduced to techniques rather than the fluid process it is in the clinic room.
I was really glad to see that the question of early behaviour change is touched on. This seems at the heart of the somewhat theoretical “debate” between Josie Geller and Professor Glenn (does motivation matter) Waller. Waller’s thesis, at least partly, is focused on the idea that early behaviour change leads to later behaviour change (and presumably motivation to continue with more behaviour change), such that pushing hard for early behaviour change is considered more important than focusing on motivation. I would agree with both Geller and Waller. When you can achieve behaviour change you don’t need to focus on motivation and to do so may get in the way of behaviour change. When you don’t see early behavioural change you need to step back and understand why and then work on increasing motivation. In this article Geller and Srikameswaran raise the point that patients who can achieve early behaviour change may be a different population from those that can not. A proportion of patients will turn up to session one having made the decision to change.
A frustration with this discussion was that once again motivation is reflected as a binary and permanent construct, which once turned on remains on forever. Any one who has tried to change anything will know that this is not how motivation works. It is fluid and changing and the level of motivation to make the changes required in therapy needs to be a constant focus of treatment. I also have a slight issue with the notion that when you change your behavior this increases motivation to change because change makes you feel better and want to change more. This is especially not the case in weight regain in anorexia nervosa. The behavioural change required leads to an increase in anxiety levels that low weight has been masking. This often leads to feeling worse until weight has been regained and held for some time.
Do not get me wrong – I’m big on behaviour change – it is just harder than it is made out to be.
What Skills do you need to teach in therapy?
Geller and Srikameswaran note there are more similarities than differences between therapies when considering content. The four areas that emerged were psychoeducation around the development and maintenance of the eating problem (all therapies), emotional regulation (not SSCM or FBT), focus on relationships (all therapies) and using higher values/helping patients see the bigger picture (MANTRA {core focus}; I-CAT, DBT).
Interesting is that helping patients with the eating disordered thinking (remember the C in CBT) seems to have gone out of fashion. I would argue that CBT-E (by looking at defusing from the Eating Disorder Mindset) and DBT (through the use of mindfulness) do have a set of skills for helping the patient with the eating disordered thoughts.
The Non-Negotiables of Treatments
Non- negotiable parts of treatment have always been a strong part of Josie Geller’s stance in therapy. I may have mentioned them once or twice as well (see Freeman, Thornton & Geller 2014 for example). Non negotiables are seen as being crucial in setting the boundaries around therapy.
The main common non-negotiable is the prescription of a regular pattern of eating. This shouldn’t surprise anyone. Again, the issue of firm vs. flexible is important. In some therapies regular eating is held firmly. FBT is the clearest example where eating is prescribed by parents and is the central focus of the therapy sessions. Similarly in CBT-E, regular eating is central and food monitoring and reviewing food logs is central to the therapy. In SSCM, regular eating is prescribed and encouraged, but may not be the central element of treatment sessions.
The problem is we don’t know what is more effective. Should I be firm or flexible? Or more realistically, in what combination should I use these ingredients and with which patients? If my patient is not making behaviour change should I become firmer or more flexible?
So many questions to think about?
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