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

I have stolen this (stolen, not adapted, just plain stolen) from wonderful ACT therapist Russ Harris.
It is a really nice way of incorporating mindfulness into daily life. 
The Mindful STOP 
We all know that mindfulness is ‘good for us’, just as we all know that exercise is ‘good for us’. However that doesn’t mean we need to do intensive mindfulness meditation for 40 minutes every day! In my workshops for coaches and therapists, I like to say, ‘If we want to motivate people to exercise more, we wouldn’t tell them, “You have to go to the gym for 40 minutes a day!” Rather, we’d say, “Every tiny little bit of exercise makes a difference. If you walk for five minutes at lunchtime, that’s better than not walking at all. If you walk up one flight of stairs instead of taking the lift, that’s better than not walking up any stairs. If you park your car in the parking space that’s furthest away from the supermarket, that’s better than parking in the closest one; even walking those few extra metres across the parking lot will make a difference.” ’

Sure, if you do exercise for 40 minutes a day, you’ll be healthier than if you do it for only 10 minutes a day – but even 5 minutes a day is a whole lot better than none at all! And so it is with mindfulness skills. Just like any skill we learn, the more we practice mindfulness, the better we get. So if you’re willing and able to do 30 or 40 minutes of daily mindfulness meditation (or similar formal mindfulness practices like yoga, or Tai Chi), that’s fantastic! Those are truly excellent practices for effectively developing your mindfulness skills. However, let’s be realistic here; many of us are unable or unwilling to make the time for this type of formal mindfulness practice on a daily basis. That’s just life!

However, that doesn’t mean we need to give up on the idea of regular mindfulness practice. It just means we need to find alternative ways of practicing our mindfulness skills throughout the day. That’s why in all my books you’ll find plenty of suggestions for quick, simple, easy ways to do this – e.g. having a mindful shower, mindfully brushing your teeth, mindfully patting the dog, mindfully hugging your loved ones, mindfully drinking your tea or coffee, mindfully ironing your shirts, mindfully tying your shoe laces, taking ten slow mindful breaths, etc. After all, one of the beautiful things about mindfulness is you can practice it anytime, anywhere, any activity. (To download a one-page handout/worksheet/tip-sheet on informal mindfulness practice, click here.)

Now here’s one especially useful, ultra-brief, and very simple mindfulness practice, that you can easily incorporate into your busy daily routine, no matter how pressed for time you are. I call it the mindful S.T.O.P. Here’s how it goes:

S – Slow down (slow down your breathing; or slowly press your feet into the floor; or slowly stretch your arms; or slowly press your fingertips together) 
T - Take note (with a sense of curiosity, notice your thoughts & feelings; notice what you can see and hear and touch and taste and smell; notice where you are and what you are doing) 
O - Open up (open up and make room for your thoughts & feelings, and allow them to freely flow through you; use any defusion or expansion skill you like) 
P - Pursue values (reconnect with your values, and let them guide whatever you do next)

The lovely thing about a mindful STOP is you can make it as short or as long as you like. You can zip through this in under thirty seconds – e.g. while you’re waiting at a red traffic light, or stuck in a supermarket queue, or waiting for your kids to come sit at to the dinner table – or you can stretch it out into a thirty minute formal meditation practice. I encourage you to try it out for yourself – not just once, but over and over and over again:Slow down; Take note; Open up; and Pursue your values. A regular mindful STOP works wonders.