​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.

All comments welcome here or on the Facebook link.

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?

 

 

 

An article coauthored by the influential Christopher Fairburn  has stated that there is little evidence that etherapy is helpful in the treatment of eating disorders. Etherapy was defined as online self help programs with either little or no clinician intervention or app based interventions.  Interestingly there was no data on app-based interventions.  Etherapy, as reviewed in this study, did not include therapy sessions delivered by video conferencing (such as Skype) or guided self-help interventions where there is an active clinician component.

 

The results of the Loucas study found only 20 studies that met strict inclusion criteria, which was based on criteria used in medical research.  The use of inclusion criteria is important as it reduces the impact of results of weaker studies. 

 

Only six of the studies involved therapy treatments and one relapse prevention study (etherapy post hospital).  These studies were primarily based around a CBT intervention.  When compared to a waitlist control group etherapy did show some modest benefit in binge eating (especially in Binge Eating Disorder) and  purging behaviour.  However confidence in the effect size was low. 

 

This study has different results from two other previous reviews which were more positive regarding the role of etherapy.  This is largely due to the stricter inclusion criteria applied in the Loucas study. 

 

It is also a different results to other disorders, where internet delivered therapies appears to be more helpful.

 

Investigation of the efficacy of etherapy is important.  One of the dilemmas facing the field of eating disorders is the difficulty of people to access evidence based treatments.  The Internet is one way of addressing this.  Otherwise we have fairly good treatments available only to those that can attend face-to-face therapy during office hours.  The cost of treatment is also an impediment that etherapy will address.  Taking an evidence-based approach to etherapy is also important as some websites will claim that etherapy (ie the package that they provide) is an effective treatment.  This is a claim that needs to be proven to protect those suffering from an eating disorder.  If the etherapy provided is not as helpful as face-to-face therapy, engaging in etherapy may be stopping engagement in a more helpful treatment modality.

 

One of the problems with the way current etherapy is delivered is that it is in a self help format.  There seems to be little difference between the content of self help books and most etherapy programs apart from the mode of delivery.  Evidence based therapies are often accused (usually by people who don’t practice them) as mechanistic and minimizing the role of the clinician.  I don’t think that this is the case when they are delivered well.  Indeed, therapist should be trained to use the manuals in a flexible way focusing on the individual needs of the patient.  Etherapy needs to involve to become more interactive and delivered in a flexible manner with the specific needs of the patient in mind.

 

Of course, as a living and breathing therapist I am glad there is still a role for the therapist and a therapeutic relationship, which is a nice way of saying I am biased here. I have found that a way to disseminate evidence-based therapy to regional areas is via Skype video. One study (Mitchell et al 2008) compared face-to-face therapy with Skype delivered therapy and there was no significant difference in outcome or drop out rate.  Given the difficulties in disseminating therapist training, Skype (or similar solutions) is a possible solution to disseminating evidence-based treatments.

 

As always, comments or questions are welcome.

 

 

 

Hot off the press is an excellent review article by The Redleaf Practice Director of Family Therapy (currently a Post Doctoral Fellow at University of California San Diego) and our own Research Fellow, Scott Griffiths and Daniel le Grange.
You can read it below or as a link here