Predictors of Mental Health Outcomes in a Multidisciplinary Weight Management Program for Class 3 Obesity.

This study aimed to examine the potential predictors of improvement in mental health outcomes following participation in an intensive non-surgical outpatient weight management program (WMP) in an Australian public hospital. This was a retrospective cohort study of all adults with Class 3 obesity (BMI ≥ 40 kg/m2) who enrolled in the WMP from March 2018 to June 2021. The participants completed the Eating Disorder Examination Questionnaire Short Version (EDE-QS), Kessler-10 Psychological Distress Scale, and 36-Item Short-Form Survey (SF-36) at baseline and 12-month follow-up. A total of 115 patients completed 12 months in the WMP and were included in the study, with 76.5% being female, a mean ± SD age at baseline of 51.3 ± 13.8 years, a weight of 146 ± 26 kg, and a BMI of 51.1 ± 8.6 kg/m2. The participants lost an average of 8.6 ± 0.2 kg over 12 months, and greater weight loss at follow-up was significantly associated with improved global EDE-QS scores, psychological distress, and improved mental health quality of life. However, improvements in most mental health outcomes were not predicted by weight loss alone. Notably, a lower eating disorder risk at baseline was associated with less psychological distress at follow-up and greater weight loss at follow-up. Our results also found an association between reduced psychological distress and reduced binge eating frequency. These findings support the inclusion components of obesity interventions that target the psychological correlates of obesity to support improved outcomes in people with Class 3 obesity. Future studies should aim to identify which aspects of the WMP helped improve people's psychological outcomes.

A community-embedded approach to increasing the health literacy of Aboriginal children in a regional area: processes of co-design and local implementation.

Purpose: This research explores the implementation of a child-centred, co-designed, community-embedded program called 'Young Doctors for Life' (YDFL). YDFL is designed to improve health and wellbeing outcomes for Aboriginal children in the middle childhood years. Focus is given in this paper to the processes of program adaptation of the YDFL to ensure local cultural relevance, drawing on the experiences and perspectives of children, parents, schoolteachers, and the implementation team. Method: Two focus groups with program stakeholders were convened. The first group consisted of three members from the local Aboriginal implementation team, and the second group comprised two members of the program design team. Children (n = 22) and schoolteachers (n = 2) participated in semi-structured interviews. Parent survey data (n = 16) were also collected and included. The data was analysed, guided by the five elements of implementation as outlined in the Hexagon Implementation framework (Capacity; Fit; Need; Usability; Support; and Evidence), which served as a priori themes. Results: YDFL provides a promising example of how programs can be adapted with and for Aboriginal communities to support child health. Successful adaptation and implementation of this program required a co-design approach engaging program designers and the local implementation team. Community collaboration was also essential to identifying and addressing local community goals and aligning new programs with local service and cultural contexts. Conclusion: Health programs to support positive child outcomes are more likely to be successful when they share their focus between the risks and challenges within a community, and the positive, protective factors that can be leveraged to support children to flourish. Stakeholder engagement and community leadership are necessary to achieve meaningful program adaptation and implementation in Aboriginal communities.

Outcomes and associated clinical features of people with eating disorders participating in residential treatment facilities: a scoping review.

Residential treatment programs for eating disorders (EDs) have gained popularity in recent years, expanding beyond the United States to countries such as Canada, Italy, and the United Kingdom. These programs offer a "home-like" environment where individuals reside for several weeks or months, emphasising both physical restoration and psychological recovery. This scoping review aimed to provide an update since the most recent reviews on the literature regarding outcomes of residential treatment programs for EDs and to explore clinical features that were associated with these outcomes. Methods used followed the Joanna Briggs Institute guidelines for scoping reviews. A systematic search of electronic databases was conducted, and 12 studies met the inclusion criteria. All studies reported improvements in various outcomes from admission to discharge, including changes in eating psychopathology, weight restoration, depression, anxiety, and quality of life. Additionally, three studies reported positive outcomes at intervals after discharge and three predictive factors (self-compassion, personality organisation, and resistance to emotional vulnerability) were reported in a small number of studies. While residential treatment facilities consistently showed positive outcomes, the review highlights the need for randomised controlled studies to establish the efficacy of these programs for EDs. Future research should include controlled studies comparing residential facilities to other treatment settings and incorporate long-term follow-up outcomes and further studies of emergent predictive factors identified in this review.

Key-in-session identity negotiations in a first line treatment for adult anorexia nervosa.

BACKGROUND: Exploration of client identity negotiations during treatment for Anorexia Nervosa (AN) is a relatively new area of research. Research suggests that difficulties with identity negotiations may present as a barrier to treatment. This study sought to explore individuals' identity negotiations during therapy sessions using Compulsive Exercise Activity Therapy (LEAP) combined with Cognitive Behaviour Therapy for Anorexia Nervosa (CBT-AN). Analysis focused on moments in therapy where individuals' identities were dominated or defined by AN and where alternative identities could be generated. METHOD: 40 in-session transcripts from sessions at early, mid and end points of the CBT-AN (with LEAP) treatment were qualitatively analysed for nine of the 78 participants in the original randomised control trial. Through a constructivist framework, thematic analysis was used to identify surface and latent meanings and discursive material participants used to negotiate their identities in the context of therapy sessions. RESULTS: Analysis of in-therapy transcripts generated two themes pertaining to identity negotiations: (1) troubled identities and (2) rebuilding identities and lives outside of AN. Early therapy sessions explored fragmented and AN dominated identities, including how AN was troubling to participants' sense of self, contributed to conflicted identities, positioned them outside of normality, and was associated with isolated and othering identities. Within therapy sessions, participants engaged in a recursive process of shifting relationships with AN and themselves and building identities and lives outside of the AN identity. This included generating hopes for recovery and the future more frequently in mid- to late- therapy sessions. CONCLUSION: Identity negotiations evident in the therapeutic conversations aligned with the key components of the CBT-AN intervention, including addressing (1) the characterisation of oneself as 'an anorexic' and (2) the diversification of roles and activities to broaden and enhance self-concepts. Future developments of therapeutic interventions for AN would benefit from greater consideration of ways to assist individuals to more comprehensively address problematic identities, including uncovering identities hidden by the AN identity and generating preferred identities. TRIAL REGISTRATION: Ethics approval was obtained at the time of the initial study and for this embedded research by the HREC at the Western Sydney University (HR777332).

Current psychological therapies for Anorexia Nervosa (AN) have recently identified that the sense of AN as part of a person's identity, or who they understand themselves to be, may pose barriers for treatment. In this study, therapy session transcripts from previous research using Compulsive Exercise Activity Therapy (LEAP) combined with Cognitive Behaviour Therapy for AN (CBT-AN) were thematically analysed to explore participants' experiences of identity shifts in-session. Particular attention was paid to moments in therapy where individuals' identities were heavily influenced by AN and moments where alternative and preferred identities were generated. Outcomes from this study suggested that the process of participants negotiating their identities outside of AN was a gradual and repeated one throughout treatment, which involved building hopes for recovery and a future less dominated by AN. Findings from this research support the need for future treatments to broaden their scope to more comprehensively explore changes in identity during intervention, particularly in building new identities outside of the AN identity.

Anorexia nervosa through the lens of a severe and enduring experience: 'lost in a big world'.

BACKGROUND: Severe and enduring anorexia nervosa (SE-AN), is a serious and persistent illness, despite 'state of the art' treatment. Criteria have been theoretically proposed, but not tested, and may not adequately capture illness complexity, which potentially inhibits treatment refinements. The clinical reality of death as an outcome for some people who experience SE-AN (1 in 20) and broadening access to voluntary assisted dying, further complicates the field, which is undeveloped regarding more fundamental concepts such as nosology, treatment, recovery definitions and alternative conceptualisations of SE-AN. The present paper is in response to this and aims to build upon qualitative literature to enhance phenomenological understandings of fatal SE-AN. METHOD: A published book, being the legacy of a 32-year-old professional artist offers a rich account of a life lived with AN, for 18 years with continuous treatment. A polysemous narrative via the interrelationship between the languages of the artist's words and visual art is translated via interpretative phenomenological analysis (IPA), offering rich insight into the SE-AN experience. FINDINGS: The process of analysis induced three superordinate themes (1) Disappearing Self (2) Dialectical Dilemma (3) Death and Dying: Finding Meaning. Two cross cutting themes traversed these themes: (a) Colour and (b) Shifting Hope, where the former produced a visual representation via the 'SE-AN Kaleidoscope'. Collectively the themes produce a concept of SE-AN, grounded in the data and depicted visually through the artist's paintings. CONCLUSIONS: The picture of SE-AN revealed in the analysis extends upon conceptualisations of SE-AN, highlighting key processes which are thus far under explored. These factors are implicated in illness persistence eliciting opportunities for further research testing including diagnostic considerations and treatment directions. In SE-AN, distorted body image extends to a global distortion in the perception of self. Additional criteria for the severe and enduring stages of illness related to (1) self and identity processes (2) measures of 'global impoverishment' across life domains are proposed for consideration in the future testing of putative defining features of SE-AN.

Anorexia Nervosa (AN) is a serious and life-threatening illness. There is a need to understand more about why AN persists in becoming severe and enduring (SE-AN) for some people. One such way to build understanding of a condition is via the stories of those who experience it. This study utilizes a person's unique artistic language to do so. This has the potential to generate new ideas about a condition, especially those that may be beyond words for some people and therefore progress classifications for SE-AN for research and treatment purposes. The artist in this study contributes a unique perspective offering new areas for potential research such as understudied complex psychological processes for example shame, dissociation, 'self', emotional literacy, and anorexia as an identity. Additionally, other factors to be considered in the assessment and classifications of long-term cases of AN as well as an alternative understanding of AN persistence is proposed, beyond the concept of 'body image disturbance'. Alternative treatment approaches such as art therapy are indicated.

"I Need Someone to Help Me Build Up My Strength": A Meta-Synthesis of Lived Experience Perspectives on the Role and Value of a Dietitian in Eating Disorder Treatment.

Dietitians are included in eating disorder (ED) treatment teams for their expertise in nutrition. However, little is known about an individual's experience of dietetic intervention as part of their ED treatment and what they value as part of dietetic care. Therefore, the aim of this review was to synthesise the available qualitative literature to understand the role and value of a dietitian in ED treatment from the perspective of individuals with lived experience. Six databases and Google Scholar were searched and a thematic synthesis and meta-synthesis of fifteen studies were conducted. Four themes were constructed from the data: (1) "guidance and structure"-Provision of nutrition knowledge and skills; (2) "having all my bases covered"-Dietitians as part of a multidisciplinary team; (3) Challenges in nutritional treatment; and (4) "it was my treatment and my recovery"-Person-centred dietetic treatment. Across all identified themes was the cross-cutting theme of a shared treatment journey between the dietitian and the individual receiving treatment. These findings support dietitians having a role that is not limited only to the provision of nutrition treatment in ED care and illustrates the importance of dietitians engaging with clients by centring on the individual's needs and preferences. Further understanding helpful dietetic treatment components and identifying gaps in training is needed to develop these broader roles for dietetic care.

Conceptualisation of severe and enduring anorexia nervosa: a qualitative meta-synthesis.

BACKGROUND: Severe and enduring anorexia nervosa (SE-AN) is amongst the most impairing of all mental illnesses. Collective uncertainties about SE-AN nosology impacts treatment refinement. Qualitative research, particularly lived experience literature, can contribute to a process of revision and enrichment of understanding the SE-AN experience and further develop treatment interventions. Poor outcomes to date, as evidenced in clinical trials and mortality for people with SE-AN (1 in 20) demonstrate the need for research that informs conceptualisations and novel treatment directions. This interpretative, meta-ethnographic meta-synthesis aimed to bridge this gap. METHODS: A systematic search for qualitative studies that explored the AN experiences of people with a duration of greater than 3 years was undertaken. These studies included those that encompassed phenomenology, treatment experiences and recovery. RESULTS: 36 papers, comprising 382 voices of SE-AN experiences informed the meta-ethnographic findings. Four higher order constructs were generated through a synthesis of themes and participant extracts cited in the extracted papers: (1) Vulnerable sense of self (2) Intra-psychic processes (3) Global impoverishment (4) Inter-psychic temporal processes. Running across these meta-themes were three cross cutting themes (i) Treatment: help versus harm, (ii) Shifts in control (iii) Hope versus hopelessness. These meta-themes were integrated into conceptualisations of SE-AN that was experienced as a recursive process of existential self-in-relation to other and the anorexia nervosa trap. CONCLUSIONS: The alternative conceptualisation of SE-AN proposed in this paper poses a challenge to current conceptualisations of AN and calls for treatments to engage with the complex intra and inter-psychic processes of the SE-AN, more fully. In doing so, clinicians and researchers are asked to continue to be bold in testing novel ideas that may challenge our own rigidity and attachment to dominant paradigms to best serve the individual person with SE-AN. The 'global impoverishment of self', found in this synthesis of AN experiences, should inform proposed diagnostic criteria for SE-AN.

Impact of LEAP and CBT-AN Therapy on Improving Outcomes in Women with Anorexia Nervosa.

Anorexia nervosa (AN) is a mental health disorder that has serious physical, emotional and social consequences. Whilst cognitive behavioural therapy for AN (CBT-AN) has demonstrated efficacy, there remains a global need to improve AN treatment. Compulsive exercise activity therapy (LEAP) is an active therapy consisting of the addition to CBT-AN of eight specific sessions that focus on exercise and motivation for behavioural change. This paper presents a secondary analysis of 74 female participants in a randomised control trial of LEAP plus CBT-AN versus CBT-AN alone. The main aim of this study was to explore putative predictors and to estimate the magnitude of changes due to LEAP for specific outcome measures. Participants (LEAP: n = 36; CBT-AN: n = 38) were assessed at three successive surveys: baseline, end of therapy, and 6 months post-therapy. The overall effect sizes for changes between baseline to end of therapy and baseline to 6-month follow-up assessment showed large effect sizes (Cohen's d > = 0.80) for mental-health-related quality of life (MHRQoL), weight concern, dietary restraint, eating concern, AN stage change, and psychological distress (all p < 0.05). The results also indicated that several pre-treatment characteristics, including body mass index (BMI), level of eating disorder (ED) symptoms, and MHRQoL are important for identifying whether a treatment is likely to be effective. Future treatment programs should aim to optimise early improvements in BMI, ED symptoms, and MHRQoL.

A systematic review of people's lived experiences of inpatient treatment for anorexia nervosa: living in a "bubble".

BACKGROUND: Treatment for anorexia nervosa (AN) is typically delivered on a continuum of care, starting with outpatient treatment, and moving onto intensive outpatient, day or residential treatment and/or inpatient hospitalisation. However, minimal attention has been afforded to the lived experiences of persons undergoing inpatient treatment for AN. In particular, qualitative literature pertaining to the lived experiences of specialist inpatient or residential treatment of AN remains fragmented and incomplete. The aim of this review was to synthesise current literature exploring patients' lived experiences of residential and inpatient treatment for AN within eating disorder-specific treatment services. METHODS: Five databases were searched and a qualitative thematic systematic review and meta-synthesis of 11 studies were conducted. RESULTS: Eleven studies of 159 participants were included. Four meta-themes were constructed from the data: (1) a medical discourse-"I don't think it's individualised here"; (2) restrictive practice-living in a "bubble"; (3) myself, others and "a similar demon"; and (4) I am "not just another anorexic". The data also revealed two cross-cutting themes: (1) more than a single experience; and (2) meaning making and identity. CONCLUSIONS: These findings highlight the complex and multifaceted nature of the inpatient treatment experience as well as the inherent conflicts in balancing the necessity of medical and psychological intervention with person-centred treatment approaches in the treatment of AN.

Treatment for anorexia nervosa (AN) is typically delivered on a continuum of care, starting with outpatient treatment, and moving onto intensive outpatient, day or residential treatment and/or inpatient hospitalisation. However, not much is known about the lived experiences of people going through inpatient treatment for AN. An improved understanding of individuals' treatment experiences is essential in informing the development of new models of care with the potential to improve outcomes. In this systematic review, we examined the lived experiences of individuals going through inpatient treatment for AN available in the current literature. Searching in scientific databases resulted in 10,666 articles, 11 of which met the rigorous inclusion criteria. Four meta-themes and two cross-cutting themes were observed in patient experiences across the studies reviewed. These themes provide insight into the complex and multifaceted nature of the inpatient treatment experience as well as the inherent conflicts in balancing the necessity of medical and psychological intervention with person-centred treatment approaches in the treatment of AN.

Current approaches in the recognition and management of eating disorders.

Eating disorders are now well acknowledged mental health problems that are common and present in people from diverse sociodemographic backgrounds. The past decade has seen a rapid expansion in research into eating disorder interventions. In response to the increasing burden of eating disorders, the Australian Government Department of Health and Aged Care has implemented significant policy changes to improve patient access to Medicare and inpatient treatment facilities. There are several international clinical practice guidelines and a robust evidence base particularly for first line care with specific psychological therapies, including guidelines for the management of eating disorders in individuals with a high weight. Medications play an important adjunct role in care, and novel neuromodulating treatments, such as psychostimulants, are under study. There is emerging evidence for increased person-centred care, with more choice in the form of alternatives to hospital inpatient programs and more respectful consideration of care for all who experience an eating disorder, including people with high weight.

Effects of maternal depression on maternal responsiveness and infants' expressive language abilities.

High levels of maternal responsiveness are associated with healthy cognitive and emotional development in infants. However, depression and anxiety can negatively impact individual mothers' responsiveness levels and infants' expressive language abilities. Australian mother-infant dyads (N = 48) participated in a longitudinal study examining the effect of maternal responsiveness (when infants were 9- and 12-months), and maternal depression and anxiety symptoms on infant vocabulary size at 18-months. Global maternal responsiveness ratings were stronger predictors of infants' vocabulary size than levels of depression and anxiety symptoms. However, depression levels moderated the effect of maternal responsiveness on vocabulary size. These results highlight the importance of screening for maternal responsiveness-in addition to depression-to identify infants who may be at developmental risk. Also, mothers with elevated depression need support to first reduce their symptoms so that improvements in their responsiveness have the potential to be protective for their infant's language acquisition.

Psychosocial interprofessional perinatal education: Design and evaluation of an interprofessional learning experience to improve students' collaboration skills in perinatal mental health.

BACKGROUND: Perinatal mental health disorders are one of the leading causes of maternal illness and suffering and care and services need to be well coordinated by an interprofessional team who are skilled in working collaboratively. AIM: The aim of this paper is to describe the design and evaluation of an innovative interprofessional education initiative to increase midwives and other health professional students' knowledge and skills in caring collaboratively for women with psychosocial issues in the perinatal period, including women experiencing domestic and family violence. METHODS: The Psychosocial Interprofessional Perinatal Education workshop was designed for midwifery, psychology, social work and medical students. It provided a simulated learning experience with case studies based on real life situations. Students undertook pre and post surveys to measure changes in students' perceptions of interprofessional collaboration and their experiences of participating in the interprofessional simulation-based learning activity. Quantitative survey data were analysed using paired t-tests and a qualitative content analysis was undertaken on the open-ended questions in the survey. FINDINGS: Comparison of pre and post surveys found students from all disciplines reported feeling more confident working interprofessionally following the workshop. The following categories were generated from analysis of the open ended survey data: Greater understanding of each others' roles; Recognising benefits of interprofessional collaboration; Building on sense of professional identity; Respecting each other and creating a level playing field; and Filling a pedagogical gap. CONCLUSION: Through this innovative, simulated interprofessional education workshop students developed skills essential for future collaborative practice to support women and families experiencing psychosocial distress.

Paper 1: a systematic synthesis of narrative therapy treatment components for the treatment of eating disorders.

BACKGROUND: There are presently a number of eating disorder treatment interventions that have a research-evidence base to support their effectiveness. However, rates of attrition and treatment outcomes demonstrate that there is no one-size fits all for the treatment of eating disorders. Narrative therapy is a promising, but under-researched, intervention for the treatment of eating disorders (EDs). The aim of this study was to conduct a narrative synthesis of the literature to explore the content and use of narrative therapy in the treatment of EDs. METHOD: Data were extracted from 33 eligible included studies following systematic search of five data bases. Data included aims and objectives, sample characteristics, treatment details and components of narrative therapy, which informed the narrative synthesis. The study is reported according to the Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Narrative therapy interventions for EDs consisted of several components including the narrative worldview; unpacking the problem story; finding, thickening the meaning and performance of stories hidden by the problem story; and safety considerations. A notable proportion of the extracted articles discussed components of unpacking problem stories, and finding and re-authoring openings (or unique outcomes) that were hidden by problematic stories. Relatively fewer papers discussed the processes by identity shifts were performed or lived out, including in the eating practices of those with a lived ED experience. Furthermore, few papers addressed how therapists established client safety within the narrative framework when working with EDs. CONCLUSION: This narrative synthesis found that narrative practitioners utilise a variety of narrative therapy techniques in working with individuals with a lived ED experience. The current literature has emphasis on specific narrative therapy techniques used in ED treatments, with some aspects of the narrative worldview and safety considerations left undiscussed. Additional research is needed to explore how identity shifts in narrative therapy are performed and lead to measurable behavioural changes, and to consider how safety considerations can be established within the narrative worldview. There are a number of psychological therapies for eating disorders that have research evidence-base. These treatments, however, do not work for everyone as indicated by drop-out rates and eating disorders running a severe and enduring course for some people. Narrative therapy is a therapeutic intervention that has been reported as a promising intervention for people with an eating disorder. The focus of narrative therapy is to engage the person in finding identities hidden by problem-saturated identities and in the performance of these hidden identities. In this review, we have explored the use of narrative therapy for eating disorders to identify what aspects of this therapy are currently being used and which components are less referenced in the literature. Findings from this study support the need for further research into narrative therapy components in the treatment of eating disorders, particularly how hidden identities are performed and safety considerations are integrated into this therapeutic intervention.

Paper 2: a systematic review of narrative therapy treatment outcomes for eating disorders-bridging the divide between practice-based evidence and evidence-based practice.

BACKGROUND: Narrative therapy has been proposed to have practice-based evidence however little is known about its research evidence-base in the treatment of eating disorders. The aim of this study was to conduct a systematic review of the outcome literature of narrative therapy for eating disorders. METHOD: Treatment outcome data were extracted from 33 eligible included studies following systematic search of five data bases. The study is reported according to Preferred Reporting items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Of the identified 33 studies, 3 reported positive outcomes using psychometric instruments, albeit some were outdated. Otherwise, reported outcomes were based on therapy transcript material and therapist reports. The most commonly reported treatment outcome was in relation to shifts in identity narratives and improved personal agency with a trend towards under-reporting shifts in ED symptoms. Some improvements were reported in interpersonal and occupational engagement, reduced ED symptoms, and improved quality of life, however, there was an absence of standardized measures to support these reports. CONCLUSIONS: This systematic review found limited support for narrative therapy in the treatment of eating disorders through practice-based evidence in clinician reports and transcripts of therapy sessions. Less is known about systematic treatment outcomes of narrative therapy. There is a need to fill this gap to understand the effectiveness of narrative therapy in the treatment of EDs through systematic (1) Deliveries of this intervention; and (2) Reporting of outcomes. In doing so, the research arm of narrative therapy evidence base will become more comprehensively known.

Narrative therapy has been proposed as a promising intervention for the treatment of eating disorders. However, the treatment outcomes of narrative therapy for eating disorders are under-researched. This systematic review of the literature has demonstrated limited support for narrative therapy through practice-based evidence in clinician reports and transcripts of therapy sessions. These reports demonstrated how narrative therapy was associated with identity shifts, some symptom reduction, reduced hospitalisations, improved agency over the problem and improvements in quality of life. There is a need for future research to systematically report treatment outcomes. This will fill a gap in research evidence-base for narrative therapy in the treatment of eating disorders.

Associations between therapy experiences and perceived helpfulness of treatment for people with eating disorders.

BACKGROUND: Although eating disorders cause significant impairment to an individual's function, many people disengage from treatment. There is a paucity of literature that focuses on both positive and negative aspects of eating disorder treatment experiences as perceived by the experiencing person. This study aimed to identify the associations between features of therapy with perceived treatment helpfulness across individuals' most and least helpful treatment experiences. METHODS: An online cross-sectional survey was developed and disseminated, with the data of participants (n = 235) being utilised for statistical analyses, including multiple linear regressions. RESULTS: As predicted, factors in the therapeutic relationship such as the therapist's ability to instil a sense of hope, provide freedom of choice, understand the person, and address participant concerns had significant explanatory value in perceived treatment helpfulness. Contrary to our hypothesis, change being retrospectively identified as important or possible by the participant did not have a high degree of relation. These outcomes highlighted the significance of the therapeutic relationship in governing positive treatment experiences and responses. The results also suggested motivation to change when commencing treatment may not be strongly related to perceived treatment helpfulness and support further exploration.

Eating disorders can cause a large impact to the lives of those living with them and their loved ones. There is a need for research from the perspective of the individual with lived eating disorder experience to shape treatment for these conditions. This study aimed to address this need by investigating features of therapy and how they impacted the overall perception of treatment helpfulness. It was found that therapist related factors, such as providing freedom of choice around change and instilling hope, accounted for a large contribution to helpfulness. It was also found that motivation may not necessarily have to be high when commencing treatment to result in better ratings of treatment helpfulness.

Perspectives on barriers to treatment engagement of people with eating disorder symptoms who have not undergone treatment: a qualitative study.

BACKGROUND: Many people with an eating disorder (ED) never engage with an evidence-based ED treatment. Of the few studies that have qualitatively explored barriers to receiving treatment, some do so in relation to mental health conditions in general, and others focus on participants who have already undergone treatment. This study aims to address this gap in the literature by exploring the barriers to ED treatment engagement from the perspectives of individuals in the community with an ED (either self-identified or professionally diagnosed) and had not received ED treatment/s. METHOD: Fifty-six of 772 participants in an online Eating Disorders Treatment Experience survey had self-identified as having symptoms consistent with an ED, or had received a diagnosis of an ED and indicated that they had never undergone treatment for an ED. They were asked to share the reasons for which they did not receive treatment with an open-ended question. Qualitative analysis of survey responses was completed using the Framework Method to generate overarching themes that encapsulated the diverse participant accounts. RESULTS: The thematic analysis generated two main themes, each with two subthemes. The first theme was the negotiation of the need for treatment within oneself (intrapersonal factors; theme 1). The second theme explored interpersonal contexts that shaped the participant's decision not to seek treatment (interpersonal/external factors; theme 2). Two cross-cutting subthemes of fear and health literacy were also generated that demonstrated a high degree of overlap with the aforementioned main themes. CONCLUSIONS: The process by which individuals decide whether or not to engage with ED treatment services is complex and involves intra- and interpersonal negotiations intertwined with health literacy and fear. A factor not prominent in previous research was negative self-perceptions and the belief of being undeserving of treatment. These factors have implications for ongoing community and clinical interventions to further address barriers to ED treatment engagement.

Conceptualising specialist supportive clinical management (SSCM): current evidence and future directions.

BACKGROUND: Current evidence-based treatments for adult anorexia nervosa (AN) have limitations, with high attrition, very poor outcomes for 20% of people, and no clearly superior manualised therapy for adults with AN. Specialist Supportive Clinical Management (SSCM) was designed as a control treatment but has evolved as a valid first line treatment. The present paper aims to provide an overview of the evidence base for SSCM and a pedagogical reconceptualization with expansion by theoretical integration (TI). BODY: A secondary meta-analysis endorses SSCM as a promising treatment. This paper positions SSCM as a manualised therapy for adult AN with six unique features, namely (1) a philosophy which is person-centred, non-prescriptive, and informed by the person's strengths and values, (2) a focus on the person through inclusion of supportive psychotherapy and problem (clinical management), within target symptoms as defined in relation to AN, (3) a flexible and responsive therapy that could be delivered by a variety of clinicians with experience treating AN (4) a commitment to reversing starvation though a directional approach and a defined yet flexible stance on dietetic intervention (5) a commitment to the therapeutic relationship within all three phases of treatment, and (6) a therapy 'uncluttered' by specific mandates. In addition, this paper positions SSCM as a treatment that may be strengthened by other modalities and may also be adapted to the treatment of other eating disorders (ED), not just AN. The level of therapist sophistication to deliver upon the supportive psychotherapy component is explored and future directions are offered. CONCLUSION: SSCM is a unique and valid first line treatment for AN and would benefit from further expansion in line with emerging understandings of AN to strengthen it as a treatment. Speculation on aspects of potency would benefit from further testing. The proposed re-conceptualisation of SSCM in the context of its evidence may strengthen it as a treatment overall, position it as adaptable for treatment of other eating disorders and make it more accessible to clinicians.

The few established treatments for anorexia nervosa have limited success rates with high patient dropout. Specialist Supportive Clinical Management (SSCM) is a promising treatment for eating disorders. It would be beneficial to understand SSCM better and how and why it may work, which this paper proposes. SSCM is collaborative and flexible to people's needs, offering them treatment choices and to progress at their own pace. It is less prescriptive than other manualised therapies and therefore could be offered to people more than once, building hopefulness. It requires an experienced psychotherapist to deliver it as SSCM addresses both the symptom of the ED (food and exercise behaviours) as well as life issues causing difficulty to a person (psychotherapy), as presented by the patient. Grounded in a sound scientific basis, SSCM is a promising treatment that would benefit from further development, in line with evolving understandings of AN, and some ideas for this are offered within the paper.

Beyond Refeeding: The Effect of Including a Dietitian in Eating Disorder Treatment. A Systematic Review.

Eating disorders are potentially life-threatening mental health disorders that require management by a multidisciplinary team including medical, psychological and dietetic specialties. This review systematically evaluated the available literature to determine the effect of including a dietitian in outpatient eating disorder (ED) treatment, and to contribute to the understanding of a dietitian's role in ED treatment. Six databases and Google Scholar were searched for articles that compared treatment outcomes for individuals receiving specialist dietetic treatment with outcomes for those receiving any comparative treatment. Studies needed to be controlled trials where outcomes were measured by a validated instrument (PROSPERO CRD42021224126). The searches returned 16,327 articles, of which 11 articles reporting on 10 studies were included. Two studies found that dietetic intervention significantly improved ED psychopathology, and three found that it did not. Three studies reported that dietetic input improved other psychopathological markers, and three reported that it did not. One consistent finding was that dietetic input improved body mass index/weight and nutritional intake, although only two and three studies reported on each outcome, respectively. A variety of instruments were used to measure each outcome type, making direct comparisons between studies difficult. Furthermore, there was no consistent definition of the dietetic components included, with many containing psychological components. Most studies included were also published over 20 years ago and are now out of date. Further research is needed to develop consistent dietetic guidelines and outcome measures; this would help to clearly define the role of each member of the multidisciplinary team, and particularly the role of dietitians, in ED treatment.

"I'm still here, but no one hears you": a qualitative study of young women's experiences of persistent distress post family-based treatment for adolescent anorexia nervosa.

BACKGROUND: Family-based treatment (FBT) is the current treatment of choice for adolescent AN based on positive outcomes that include weight restoration in around two-thirds of adolescents. Nevertheless around a quarter drop-out from treatment, particularly in the earlier phases, and a notable proportion of treated adolescents are reported to experience ongoing psychological distress during and post-treatment. This study explores the under-researched experiences of these adolescents. METHOD: Fourteen participants from Australia, New Zealand and the United Kingdom were interviewed about their experiences of FBT. An inductive thematic analysis of interview transcript data generated key themes related to their experiences, identity negotiations and the discursive materials these used to construct these. RESULTS: The participants identified working as a family unit as key to their recovery, highlighting the importance of family therapy interventions for adolescent AN. However, they perceived an almost exclusive focus on weight restoration in the first phase of FBT was associated with experiences that included a relative neglect of their psychological distress and a loss of voice. Key within these experiences were processes whereby the adolescent engaged in identity negotiation and (re)claiming of their voice and implicit in their family standing with them in the treatment was that their life was worth saving. What was noted as most helpful was when therapists advocated and took into consideration their unique needs and preferences and tailored treatment interventions to these. CONCLUSIONS: There is a need to develop and research treatments that address, from the outset of treatment, the adolescents' psychological distress (including as experienced in the context of their weight restoration). This should be with priority accorded to the adolescent's voice and identity negotiations, as they and their families take steps to address the physical crisis of AN and in doing so, support more holistic and durable recovery.

Family-Based Treatment (FBT) is a well-established, intensive approach to the treatment of adolescent anorexia nervosa (AN). The first phase of treatment focuses on eating and weight restoration, where parents are given responsibility for the adolescent's home-based refeeding. This is followed by handing over of this responsibility to the adolescent with the final-phase a focusing on adolescent-specific psychological issues. While the majority of adolescents gain weight with this treatment, a substantive proportion experience ongoing psychological distress and around a quarter of families drop out in the first phase. Little is known about these adolescents' experiences.In this project, we interviewed 14 individuals who, with their family, had either dropped out of FBT and/or experienced ongoing psychological distress post-treatment. The participants noted that their parents' stance in supporting them was life-saving and contributed to a sense that their life was worth saving. However, they also noted a relative absence of focus on their psychological distress, particularly in the early stages of treatment. Most helpful for participants was when therapists took into consideration and tailored treatments to them. Future treatments need to consider ways to support an adolescent's psychological distress more comprehensively, prioritise their voice and support them in finding an identity outside of the AN identity.

Maternal Depression Affects Infants' Lexical Processing Abilities in the Second Year of Life.

Maternal depression and anxiety have been proposed to increase the risk of adverse outcomes of language development in the early years of life. This study investigated the effects of maternal depression and anxiety on language development using two approaches: (i) a categorical approach that compared lexical abilities in two groups of children, a risk group (mothers with clinical-level symptomatology) and a control non-risk group, and (ii) a continuous approach that assessed the relation between individual mothers' clinical and subclinical symptomatology and their infants' lexical abilities. Infants' lexical abilities were assessed at 18 months of age using an objective lexical processing measure and a parental report of expressive vocabulary. Infants in the risk group exhibited lower lexical processing abilities compared to controls, and maternal depression scores were negatively correlated to infants' lexical processing and vocabulary measures. Furthermore, maternal depression (not anxiety) explained the variance in infants' individual lexical processing performance above the variance explained by their individual expressive vocabulary size. These results suggest that significant differences are emerging in 18-month-old infants' lexical processing abilities, and this appears to be related, in part, to their mothers' depression and anxiety symptomatology during the postnatal period.