Assessing clinician competence in the delivery of cognitive-behavioural therapy for eating disorders: development of the Cognitive-Behavioural Therapy Scale for Eating Disorders (CBTS-ED).

Evidence-based cognitive-behaviour therapy for eating disorders (CBT-ED) differs from other forms of CBT for psychological disorders, making existing generic CBT measures of therapist competence inadequate for evaluating CBT-ED. This study developed and piloted the reliability of a novel measure of therapist competence in this domain-the Cognitive Behaviour Therapy Scale for Eating Disorders (CBTS-ED). Initially, a team of CBT-ED experts developed a 26-item measure, with general (i.e. present in every session) and specific (context- or case-dependent) items. To determine statistical properties of the measure, nine CBT-ED experts and eight non-experts independently observed six role-played mock CBT-ED therapy sessions, rating the therapists' performance using the CBTS-ED. The inter-item consistency (Cronbach's alpha and McDonald's omega) and inter-rater reliability (ICC) were assessed, as appropriate to the clustering of the items. The CBTS-ED demonstrated good internal consistency and moderate/good inter-rater reliability for the general items, at least comparable to existing generic CBT scales in other domains. An updated version is proposed, where five of the 16 "specific" items are reallocated to the general group. These preliminary results suggest that the CBTS-ED can be used effectively across both expert and non-expert raters, though less experienced raters might benefit from additional training in its use.

A framework for conceptualising early intervention for eating disorders.

OBJECTIVE: This paper outlines the evidence base for early intervention for eating disorders; provides a global overview of how early intervention for eating disorders is provided in different regions and settings; and proposes policy, service, clinician and research recommendations to progress early intervention for eating disorders. METHOD AND RESULTS: Currently, access to eating disorder treatment often takes many years or does not occur at all. This is despite neurobiological, clinical and socioeconomic evidence showing that early intervention may improve outcomes and facilitate full sustained recovery from an eating disorder. There is also considerable variation worldwide in how eating disorder care is provided, with marked inequalities in treatment provision. Despite these barriers, there are existing evidence-based approaches to early intervention for eating disorders and progress is being made in scaling these. CONCLUSIONS: We propose action steps for the field that will transform eating disorder service provision and facilitate early detection, treatment and recovery for everyone affected by eating disorders, regardless of age, socioeconomic status and personal characteristics.

Implementing evidence-based individual psychotherapies for adults with eating disorders in a real world clinical setting.

OBJECTIVE: This study aimed to evaluate the effectiveness of evidenced-based psychological treatments (specifically, Cognitive-Behaviour Therapy for Eating Disorders [CBT-ED] and Maudsley Anorexia Nervosa Treatment for Adults [MANTRA]) for a transdiagnostic eating disorder population in a routine clinical setting. In particular, it aimed to determine the extent to which treatment was provided in line with current clinical guidelines (NICE, 2017) and how effective treatment was in improving eating disorder and general psychopathology. METHOD: Three hundred and seventy-nine participants meeting criteria for DSM-5 anorexia nervosa, bulimia nervosa, binge-eating disorder or other specified feeding or eating disorder completed pre- and posttreatment measures of eating disorder pathology and general distress. Clinicians recorded weight and episodes of bingeing and purging. RESULTS: Ninety seven percent of participants received treatment in line with evidence-based psychotherapies. Treatment was completed by 59.9% of the whole sample. Using stringent criteria and ITT analysis 21.4% met criteria for remission at end of treatment. In the underweight sample, there was a significant increase in BMI, averaging 1.38 kg/m2 over treatment, with similar outcomes for MANTRA and CBT-ED. DISCUSSION: These findings, in a large transdiagnostic population, add to emerging literature on the translation of evidence-based psychotherapies to real-world clinical settings. Our results converge well with prior similar studies. Findings highlight the need for routine data collection in services and for the ongoing improvement of treatments for the eating disorders.

Assessing the impact of First Episode Rapid Early Intervention for Eating Disorders on duration of untreated eating disorder: A multi-centre quasi-experimental study.

BACKGROUND: Duration of untreated eating disorder (DUED), that is, the time between illness onset and start of first evidence-based treatment, is a key outcome for early intervention. Internationally, reported DUED ranges from 2.5 to 6 years for different eating disorders (EDs). To shorten DUED, we developed FREED (First Episode Rapid Early Intervention for EDs), a service model and care pathway for emerging adults with EDs. Here, we assess the impact of FREED on DUED in a multi-centre study using a quasi-experimental design. METHODS: Two hundred and seventy-eight patients aged 16-25, with first episode illness of less than 3 years duration, were recruited from specialist ED services and offered treatment via FREED. These were compared to 224 patients, of similar age and illness duration, seen previously in participating services (treatment as usual [TAU]) on DUED, waiting times and treatment uptake. RESULTS: FREED patients had significantly shorter DUED and waiting times than TAU patients. On average, DUED was reduced by ∼4 months when systemic delays were minimal. Furthermore, 97.8% of FREED patients took up treatment, versus 75.4% of TAU. DISCUSSION: Findings indicate that FREED significantly improves access to treatment for emerging adults with first episode ED. FREED may reduce distress, prevent deterioration and facilitate recovery.

Exploring the use of individualised patient-reported outcome measures in eating disorders: Validation of the Psychological Outcome Profiles.

RATIONALE: Psychotherapies for eating disorders (EDs) are routinely assessed using standardised patient-reported outcome measures (PROMs). PROMs have been criticised for their lack of patient centeredness and clinical utility. The Psychological Outcome Profiles (PSYCHLOPS) is an individualised PROM that allows patients to specify their own outcomes. AIMS: (1) To validate the use of the PSYCHLOPS in ED treatment, and (2) to identify patient concerns beyond those measured by common ED PROMs. METHODS: Two hundred and seventy-eight emerging adult patients, presenting with a first-episode ED (aged 16-25, illness duration <3 years) completed the PSYCHLOPS and two standardised ED PROMs (the EatingDisorder Examination Questionnaire [EDE-Q] and the Clinical Impairment Assessment Questionnaire [CIA]) at four time points across 12 months. Psychometrics of the PSYCHLOPS were assessed quantitatively against the EDE-Q and CIA. Content analysis assessed unique patient concerns identified by PSYCHLOPS. RESULTS: The PSYCHLOPS had adequate to good psychometric properties. A total of 53.3% of participants reported a concern not addressed by the EDE-Q or the CIA, the most common being depression/anxiety, academic problems, treatment concerns and disturbed sleep. DISCUSSION: PROMs can be complemented by the PSYCHLOPS to identify problems specific to an individual's context. As ED patients are typically ambivalent about change, understanding their concerns is vital in building motivation for change.

Cognitive-behavioral therapy in the time of coronavirus: Clinician tips for working with eating disorders via telehealth when face-to-face meetings are not possible.

OBJECTIVE: The coronavirus pandemic has led to a dramatically different way of working for many therapists working with eating disorders, where telehealth has suddenly become the norm. However, many clinicians feel ill equipped to deliver therapy via telehealth, while adhering to evidence-based interventions. This article draws together clinician experiences of the issues that should be attended to, and how to address them within a telehealth framework. METHOD: Seventy clinical colleagues of the authors were emailed and invited to share their concerns online about how to deliver cognitive-behavioral therapy for eating disorders (CBT-ED) via telehealth, and how to adapt clinical practice to deal with the problems that they and others had encountered. After 96 hr, all the suggestions that had been shared by 22 clinicians were collated to provide timely advice for other clinicians. RESULTS: A range of themes emerged from the online discussion. A large proportion were general clinical and practical domains (patient and therapist concerns about telehealth; technical issues in implementing telehealth; changes in the environment), but there were also specific considerations and clinical recommendations about the delivery of CBT-ED methods. DISCUSSION: Through interaction and sharing of ideas, clinicians across the world produced a substantial number of recommendations about how to use telehealth to work with people with eating disorders while remaining on track with evidence-based practice. These are shared to assist clinicians over the period of changed practice.

Evaluation of Teen BodyWise: A pilot study of a body image group adapted for adolescent inpatients with anorexia nervosa.

PURPOSE: Body image disturbance is a key characteristic of anorexia nervosa (AN); however, research into these difficulties among adolescents with AN is limited and is yet to assess the best treatments for this population. METHODS: Fifty-two adolescents receiving inpatient treatment for AN attended Teen BodyWise, an eight-session body image group adapted for adolescents. Measures assessing shape and weight concerns, ability to discuss body image, sociocultural attitudes, body avoidance, body checking, and motivation were given before and after the group, and participant feedback was elicited. RESULTS: Significant improvements were found for shape and weight concerns, ability to discuss body image, body checking and sociocultural attitudes. Participants were generally satisfied with the group and found it helpful, yet some aspects were experienced as challenging. CONCLUSIONS: Teen BodyWise has potential benefits for adolescents with AN. Controlled research is needed to determine the effectiveness of Teen BodyWise. LEVEL OF EVIDENCE: Evidence obtained from multiple time series with or without the intervention, such as case studies, Level IV.

A 10-session cognitive-behavioral therapy (CBT-T) for eating disorders: Outcomes from a case series of nonunderweight adult patients.

OBJECTIVE: Existing forms of evidence-based cognitive behavior therapy for eating disorders (CBT-ED) are relatively effective for nonunderweight cases. However, they are also expensive compared to CBT for other disorders. This study reports the first outcomes for a shorter, 10-session form of CBT-ED (CBT-T) for such cases, designed to be less demanding of resources. METHOD: A case series of 106 nonunderweight eating disordered cases were considered for this effectiveness study. A protocolized 10-session version of CBT-ED was delivered by clinical assistants, under supervision. Measures assessed eating attitudes and behaviors, anxiety, depression, personality pathology, and the working alliance. Intention-to-treat analyses were used. RESULTS: Suitability, acceptability, working alliance ratings, and retention were all positive. Outcomes by the end of therapy and at three-month follow-up were positive for all symptoms, with levels of change, abstinence and remission that were comparable to those from effectiveness studies of longer forms of CBT. Higher levels of pretreatment anxiety predicted retention in treatment, but no factors predicted poorer response. Early change in eating attitudes and the working alliance were the strongest predictors of a positive response. DISCUSSION: This 10-session form of CBT-ED for nonunderweight eating disorders performed at a level that is comparable to versions of CBT-ED that are twice as long, despite being delivered by nonspecialist therapists. Replication and longer-term follow-ups are needed to ensure retained effects. However, CBT-T has promise as a therapy for use in a range of healthcare settings, to enhance access to treatment for such eating disorders.

A pilot evaluation of a novel First Episode and Rapid Early Intervention service for Eating Disorders (FREED).

This pilot study assesses the impact of FREED (First Episode Rapid Early Intervention for Eating Disorders [ED]), a novel transdiagnostic service for emerging adults with recent ED onset, on clinical outcomes. Data were collected from 56 patients and 19 carers for 12 months following enrolment. FREED patients showed significant improvements in ED and other symptoms across time. Carers also showed psychological improvements. For FREED anorexia nervosa (AN) patients, body mass index (BMI) at initial clinical assessment was similar to that of comparable patients (audit cohort) seen in our service before (16.4 vs 16.1 kg/m2 ). By start of treatment, because of their shorter wait, FREED-AN had gained weight whereas audit patients had lost (16.7 vs 15.8 kg/m2 ). This difference continued throughout treatment, and at 12 months, nearly 60% FREED-AN patients returned to a BMI of 18.5 or greater. FREED shows promise as a service model for emerging adults with EDs.

Development, psychometric properties and preliminary clinical validation of a brief, session-by-session measure of eating disorder cognitions and behaviors: The ED-15.

OBJECTIVE: In the treatment research literature on other psychological disorders, there is a move towards session-by-session symptom measurement. The necessary measures need to be brief, focused on core features since the last session, and readily available to clinicians. There is no measure in the eating disorders that meets those criteria. This research reports the development and validation of such a self-report questionnaire. METHOD: The authors generated and refined a brief set of attitudinal and behavioral items. The resulting questionnaire (the ED-15) and an existing measure (Eating Disorders Examination-Questionnaire; EDE-Q) were completed by a large nonclinical adult sample (N = 531), a group of self-reported eating disorder sufferers (N = 63), and a group of women (N = 33) diagnosed with bulimia nervosa or atypical bulimia nervosa and undertaking cognitive-behavioral therapy. RESULTS: Factor analysis identified two scales (Weight and Shape Concerns; Eating Concerns), with strong internal consistency and test-retest reliability. Correlations with the EDE-Q (r = 0.889) indicates that the ED-15 and EDE-Q measure near-identical constructs. The ED-15 differentiated self-reported eating-disordered and nonclinical groups to the same degree as the longer EDE-Q. Session-by-session analysis of the CBT treatment group demonstrated that the different ED-15 scales changed in different patterns across therapy. DISCUSSION: The ED-15 is not proposed as an alternative to existing measures, but as a complementary tool, used to measure session-by-session change for clinical and research purposes. Future research will track changes in ED-15 scores across therapy, to determine the importance of very early response to therapy and sudden changes.

BodyWise: evaluating a pilot body image group for patients with anorexia nervosa.

Body image disturbance can be enduring and distressing to individuals with eating disorders and effective treatments remain limited. This pilot study evaluated a group-based treatment-BodyWise-developed for use in full and partial hospitalization with patients with anorexia nervosa at low weight. A partial crossover waitlist design was used. BodyWise (N = 50) versus treatment as usual (N = 40) were compared on standardized measures of body image disturbance. Results demonstrated significant improvement in the group compared to treatment as usual for the primary outcome measure (Eating Disorder Examination-Questionnaire Shape Concern subscale) and other manifestations of body image disturbance including body checking and body image quality of life. BodyWise appeared acceptable to participants, and was easy to deliver within the pragmatics of a busy eating disorder service. There is potential for its wider dissemination as a precursor to more active body image interventions.

Cognitive-behavioral therapy for bulimia nervosa and atypical bulimic nervosa: effectiveness in clinical settings.

OBJECTIVE: The efficacy of cognitive-behavioral therapy (CBT) for bulimic disorders has been established in research trials. This study examined whether that efficacy can be translated into effectiveness in routine clinical practice. METHOD: Seventy-eight adult women with bulimic disorders (bulimia nervosa and atypical bulimia nervosa) undertook individual CBT, with few exclusion criteria and a treatment protocol based on evidence-based approaches, utilizing individualized formulations. Patients completed measures of eating behaviors, eating attitudes, and depression pre- and post-treatment. Eight patients dropped out. The mean number of sessions attended was 19.2. RESULTS: No pretreatment features predicted drop-out. Treatment outcome was similar whether using treatment completer or intent to treat analyses. Approximately 50% of patients were in remission by the end of treatment. There were significant improvements in mood, eating attitudes, and eating behaviors. Reductions in bingeing and vomiting were comparable to efficacy trials. DISCUSSION: The improvements in this "real-world" trial of CBT for adults with bulimic disorders mirrored those from large, funded research trials, though the conclusions that can be reached are inevitably limited by the nature of the trial (e.g., lack of control group and therapy validation).

Premature termination of treatment for anorexia nervosa: differences between patient-initiated and staff-initiated discharge.

OBJECTIVES: To investigate treatment drop-out by comparing clinical indicators of patients whose discharge was initiated by staff with those who initiated discharge themselves. METHOD: Ninety participants with anorexia completed questionnaires at admission and four weeks into hospitalized treatment. Weight data was collected over this same period. At discharge, participants were categorized into completer (n = 38) or patient-initiated (n = 36) /staff-initiated (n = 16) premature termination groups. RESULTS: Significant differences between staff-initiated and patient-initiated discharge groups were found at admission. Staff initiated groups were on average older (p = .035), and more likely to have had prior compelled treatment (p = .039). At 4 weeks those in the patient-initiated group had put on weight at a faster rate (p = .032) and reported a decrease in alliance (p = .017). At discharge, staff initiated discharge demonstrated greater time in treatment (p = .001), greater weight gain (p = .027), and a higher discharge BMI (p = .013). At discharge, staff-initiated drop-outs had comparable end-of-treatment outcomes to those who completed treatment as planned. DISCUSSION: There are key differences between those who prematurely discharge themselves from treatment, compared to those who are prematurely discharged by clinical staff. Future research into drop-out needs to take into account and recognize these differences.

Rules of engagement: qualitative experiences of therapeutic alliance when receiving in-patient treatment for anorexia nervosa.

Recent research has emphasised the importance of therapeutic alliance to treatment outcomes for anorexia nervosa. This study aimed to examine the experiences of service users in developing therapeutic alliance whilst in treatment for their eating disorders. This qualitative study, using purposive sampling, recruited a sample of service users receiving treatment at a national eating disorders service. In-depth interviews were audiotaped and transcribed, with transcriptions being subject to interpretative phenomenological analysis. Participants were eight adult women receiving tertiary level eating disorder treatment in a specialist setting. The text analysis produced four dominant categories: alliance as a key experience; being active, not passive; taboo talking; and first impressions count. The development of therapeutic alliance is a core component of treatment. This study identifies important areas that contribute to the successful cultivation of positive therapeutic alliance.

Is the therapeutic alliance overvalued in the treatment of eating disorders?

In this article, we make the case for a systematic program of research into the causal relationship between the therapeutic alliance and outcomes of psychological treatments for the eating disorders. To make that case, we need to begin by considering the validity of existing assumptions about that alliance-outcome relationship. We will then suggest what research is needed to allow clinicians to structure their work to best effect (e.g., should therapists focus on establishing a strong alliance even if it means not applying more therapy-specific techniques, or should they stress the application of those techniques even when the working alliance might seem likely to be weakened as a result). Although the authors have a background in cognitive-behavioral therapy (CBT), our aim is to suggest a research base that applies to a variety of psychotherapies, allowing for common or different conclusions about the alliance-outcome relationship, depending on what the proposed research indicates.

Cognitive behavioural therapy for individuals with longstanding anorexia nervosa: adaptations, clinician survival and system issues.

Despite recent advances in the treatment of anorexia nervosa, some individuals will progress to a severe and enduring illness, with associated physical, psychological and social consequences. Working with these patients, however, may leave clinicians feeling overwhelmed, risking difficulties in the therapeutic relationship including disengagement or despair. Cognitive behaviour therapy has shown some promise in the treatment of eating disorders, yet some features may not be appropriate for this group. In this paper, we outline the ways in which we have adapted cognitive behaviour therapy to best meet the complex and challenging needs of this group. We stress the importance of maintaining a reassuring, accepting and motivational approach in combination with clear goal setting and boundaries.

The First Episode Rapid Early Intervention for Eating Disorders - Upscaled study: Clinical outcomes.

BACKGROUND: First Episode Rapid Early Intervention for Eating Disorders (FREED) is a service model and care pathway for emerging adults aged 16 to 25-years with a recent onset eating disorder (ED) of <3 years. A previous single-site study suggests that FREED significantly improves clinical outcomes compared to treatment-as-usual (TAU). The present study (FREED-Up) assessed the scalability of FREED. A multi-centre quasi-experimental pre-post design was used, comparing patient outcomes before and after implementation of FREED in participating services. METHODS: FREED patients (n = 278) were consecutive, prospectively ascertained referrals to four specialist ED services in England, assessed at four time points over 12 months on ED symptoms, mood, service utilization and cost. FREED patients were compared to a TAU cohort (n = 224) of similar patients, identified retrospectively from electronic patient records in participating services. All were emerging adults aged 16-25 experiencing a first episode ED of <3 years duration. RESULTS: Overall, FREED patients made significant and rapid clinical improvements over time. 53.2% of FREED patients with anorexia nervosa reached a healthy weight at the 12-month timepoint, compared to only 17.9% of TAU patients (X2 [1, N = 107] = 10.46, p < .001). Significantly fewer FREED patients required intensive (i.e., in-patient or day-patient) treatment (6.6%) compared to TAU patients (12.4%) across the follow-up period (X2 [1, N = 40] = 4.36, p = .037). This contributed to a trend in cost savings in FREED compared to TAU (-£4472, p = .06, CI -£9168, £233). DISCUSSION: FREED is robust and scalable and is associated with substantial improvements in clinical outcomes, reduction in inpatient or day-patient admissions, and cost-savings.

Associations between body checking and disordered eating behaviors in nonclinical women.

OBJECTIVE: Recent research suggests that body checking cognitions and behaviors are differentially associated with pathological eating behaviors in clinical women. However, it is unknown whether similar associations exist in nonclinical populations. The aim of this study is to examine whether body checking (cognitions and behaviors) is associated with pathological eating behaviors in a nonclinical sample of women. METHOD: Validated measures of pathological eating behaviors, body checking cognitions, and body checking behaviors were completed by 342 nonclinical university women. RESULTS: Women engaging in binging (objective and subjective), purging, restraint, and excessive exercise reported consistently higher scores across all body checking cognitions and behaviors. All body checking cognitions and behaviors independently contributed to distinguishing those who reported each behavior as opposed to those who did not. The predicted classification was most accurate for the cardinal diagnostic symptoms for bulimia-objective binging and purging. DISCUSSION: Body checking cognitions are implicated in the development of pathological eating behaviors in nonclinical populations, requiring consideration for planning prevention programs.

One size fits all: or horses for courses? Recovery-based care in specialist mental health services.

INTRODUCTION: The 'recovery approach' to the management of severe mental health problems has become a guiding vision of service provision amongst many practitioners, researchers, and policy makers as well as service users. METHOD: This qualitative pilot study explored the meaning of 'recovery' with users of three specialist mental health services (eating disorders, dual diagnosis, and forensic) in 18 semi-structured interviews. RESULTS: The relevance of themes identified in mainstream recovery literature was confirmed; however, the interpretation and relative weight of these themes appeared to be affected by factors that were specific to the diagnosis and treatment context. 'Clinical' recovery themes were also seen as important, as were aspects of care that reflect core human values, such as kindness.