'The Relentless Nature of Whiteness': Black Psychologists' Experiences of Racial Microaggressions in Cross-Cultural Supervision.

OBJECTIVES: Research suggests that cross-cultural supervision can be prone to microaggressions with deleterious effects for ethno-racial minorities. There are currently no known studies examining the impact of racial microaggressions in supervision on qualified psychologists. This study aimed to explore Black psychologists' experiences of microaggressions in supervision with a White supervisor and their impact. METHODS: Semi-structured interviews were conducted with 10 individuals who had completed clinical or counselling psychology doctoral training. Interviews were transcribed and analysed using interpretative phenomenological analysis. RESULTS: Three superordinate themes and 12 subthemes were derived from the analysis. The superordinate themes were: 'It's the subtle things', 'It's an ordeal' and 'Surviving Whiteness in psychology'. The findings illustrate the complex nature of racial microaggressions and their profound and lasting impact on individuals. The cumulative impact of these experiences resulted in significant negative psychological outcomes. CONCLUSIONS: The results suggest that there are common microaggressions that recur in supervision. Encountering microaggressions impeded the supervisory relationship, supervision and professional development. Clinical implications include recommendations for including multicultural competency in psychology trainings and ongoing professional development plans.

Acceptability of Specialist Psychotherapy with Emotion for Anorexia in Kent and Sussex (SPEAKS): A novel intervention for anorexia nervosa.

OBJECTIVE: Investigate the acceptability of Specialist Psychotherapy with Emotion for Anorexia in Kent and Sussex (SPEAKS), a novel intervention for anorexia nervosa (AN), conducted as a feasibility trial to provide an initial test of the intervention. METHODS: SPEAKS therapy lasting 9-12 months was provided to 34 people with AN or atypical AN by eight specialist eating disorder therapists trained in the model across two NHS Trusts in the UK (Kent and Sussex) during a feasibility trial. All participants were offered a post-therapy interview; sixteen patients and six therapists agreed. All patient participants were adult females. Interviews were semi-structured and asked questions around individuals' experience of SPEAKS, the acceptability of the intervention and of the research methods. Interviews were analyzed using thematic analysis. RESULTS: Key areas explored in line with research questions led to 5 overarching themes and 14 subthemes: (1) shift in treatment focus and experience, (2) balancing resources and treatment outcomes, (3) navigating the online treatment environment, (4) therapist adaptation and professional development, and (5) research processes. DISCUSSION: SPEAKS was found to be an acceptable intervention for treating AN from the perspective of patients and therapists. The findings provide strong support for delivery of a larger scale randomized control trial. Recommendations for future improvements, particularly pertaining to therapist understanding of the treatment model are detailed, alongside broader clinical implications. PUBLIC SIGNIFICANCE: We aimed to evaluate the acceptability of a new anorexia nervosa treatment called SPEAKS. Interviews were conducted with patients and therapists involved in the pilot study and responses were analyzed. Results showed that both patients and therapists found SPEAKS to be an acceptable treatment for anorexia nervosa. The study suggests that SPEAKS meets the criteria for moving forward with a larger trial to assess its effectiveness.

Specialist psychotherapy with emotion for anorexia in Kent and Sussex: An intervention development and non-randomised single arm feasibility trial.

OBJECTIVE: Anorexia nervosa (AN) is a serious eating disorder treated using psychological interventions, yet outcomes remain limited. Emotional difficulties are recognised as a treatment target. This research programme developed and evaluated feasibility of an emotion-focused therapy for adults with AN. METHODS: Phase One intervention development utilised 'intervention mapping'. Qualitative research drew on lived experience highlighting objectives for change. Empirical evidence was synthesised into hypotheses of core emotional difficulties and an associated model of change. Relevant psychotherapeutic theory-based change methods were integrated to form the Specialist Psychotherapy with Emotion for Anorexia in Kent and Sussex (SPEAKS) intervention, guidebook and clinician training package. Phase Two tested SPEAKS in a single-arm, multisite feasibility trial across two specialist services, utilising prespecified progression criteria, and embedded process evaluation. RESULTS: SPEAKS was 9-12 months (40 sessions) of weekly individual psychotherapy, drawing on a range of psychotherapeutic modalities, predominantly Emotion Focused Therapy and Schema Therapy. Forty-six participants consented to feasibility trial participation; 42 entered the trial and 34 completed. Thirteen of 16 feasibility criteria were met at green level and three at amber, highlighting areas for improving model adherence. CONCLUSIONS: A randomised controlled trial is indicated. Therapist training and guidebook adjustments to improve model adherence are suggested.

Seeing Through the Façade of Anorexia: A Grounded Theory of Emotional Change Processes Associated With Recovery From Anorexia Nervosa.

Objectives: Difficulties in managing emotions have been implicated in the development and maintenance of anorexia nervosa (AN), and psychological treatment models seek to address this in putative targets of change. Yet the field of psychotherapy remains unclear and insufficiently evidenced about the process of change and how this is actually achieved, including in what steps and in what order within clinical treatment. This qualitative study sought to develop theory about the process of emotional change during recovery from anorexia. Methods: Semi-structured interviews were carried out with nine women currently engaged in psychological treatment for anorexia. Interviews included questions pertaining to participants' experience of anorexia, emotions, and emotion management. A constructivist version of grounded theory was employed. Results: The analysis produced 10 major categories, comprising over 60 focused codes. Categories were clustered together into three super categories, reflecting 3 distinct but interrelated phases of participants' journeys toward recovery. The phases were: (1) Coping in a world of uncertainty, (2) Seeing through the façade of anorexia, and (3) Recovery and growth. Whilst movement toward later positions often appeared to be contingent on earlier ones, the analysis suggests that this was not an entirely linear process and that participants moved between positions as they grappled with the process of change. Participants came to view behaviors associated with anorexia as emotion-management strategies that were not working and as a façade. As they moved toward recovery and growth, they became less confined by their need for safety, and to see emotions as meaningful and valuable. Becoming more connected to emotional experience and expression, coincided with positive shifts in their intra and interpersonal relationships. Conclusion: These findings support the recent shift toward emotion-focused models of anorexia. They also highlight an important focus in supporting individuals with AN to connect with, and be guided by, emotional experiences in their relationships with themselves and the world around them. This new grounded theory offers a putative process of change that could be utilized to guide intervention development.

SPEAKS study: study protocol of a multisite feasibility trial of the Specialist Psychotherapy with Emotion for Anorexia in Kent and Sussex (SPEAKS) intervention for outpatients with anorexia nervosa or otherwise specified feeding and eating disorders, anorexia nervosa type.

INTRODUCTION: Anorexia nervosa (AN) is a severe mental health condition associated with high mortality rates and significantly impaired quality of life. National guidelines outline psychotherapeutic interventions as treatments of choice for adults with AN, but outcomes are limited and therapy drop-out high, resulting in calls for new innovative treatments. The Specialist Psychotherapy with Emotion for Anorexia in Kent and Sussex (SPEAKS) research programme sought to develop the SPEAKS intervention avoiding some difficulties inherent in development of earlier interventions, such unclear hypotheses about change processes. SPEAKS focuses on a core hypothesised maintaining factor (emotional experience) with clear proposed model of change. The current feasibility trial aims to provide an initial test of SPEAKS and inform design of a full randomised controlled trial protocol. METHODS AND ANALYSIS: This study employs a multisite, single-arm, within-group, mixed-methods design. Up to 60 participants (36 therapy completers) meeting inclusion criteria will be offered the SPEAKS intervention instead of treatment-as-usual (TAU). SPEAKS is a weekly psychotherapy lasting nine to 12 months, provided by trained and experienced eating disorders therapists. All other clinical input remains inline with TAU. Acceptability will be assessed using VAS scales and end of therapy interview. Reach and recruitment, such as recruitment yield, will be monitored. To support sample size estimation and economic estimation, data pertaining to eating disorder-related symptoms will be recorded every 3 months, alongside service usage and intervention-specific measures. Videoed therapy sessions will inform model adherence. Additional analyses coding videoed therapy will test SPEAKS change process hypotheses. ETHICS AND DISSEMINATION: Ethical approval has been granted by London-Bromley Research Ethics Committee (NHS Rec Reference: 19/LO/1530). Data will be disseminated via high-impact, peer-reviewed journals (Open Access preferred), conferences, service user and charity networks (eg, UK charity BEAT) and through a free open conference hosted by National Health Service Trusts and Higher Education Institutions. TRIAL REGISTRATION NUMBER: ISRCTN11778891. TRIAL STATUS: Recruitment began on 12 December 2019 and ends on 28 February 2021. All data will be collected and the trial ended by 28 February 2022. PROTOCOL VERSION: SPEAKS protocol V.3.0 (30 August 2020). Changes were made to the original protocol due to the COVID-19 pandemic. A further set of changes were made to incorporate the measures of change processes, resulting in this being the third version of the protocol.

Anorexia Nervosa and a Lost Emotional Self: A Psychological Formulation of the Development, Maintenance, and Treatment of Anorexia Nervosa.

In this paper, we argue that Anorexia Nervosa (AN) can be explained as arising from a 'lost sense of emotional self.' We begin by briefly reviewing evidence accumulated to date supporting the consensus that a complex range of genetic, biological, psychological, and socio-environmental risk and maintenance factors contribute to the development and maintenance of AN. We consider how current interventions seek to tackle these factors in psychotherapy and potential limitations. We then propose our theory that many risk and maintenance factors may be unified by an underpinning explanation of emotional processing difficulties leading to a lost sense of 'emotional self.' Further, we discuss how, once established, AN becomes 'self-perpetuating' and the 'lost sense of emotional self' relentlessly deepens. We outline these arguments in detail, drawing on empirical and neuroscientific data, before discussing the implications of this model for understanding AN and informing clinical intervention. We argue that experiential models of therapy (e.g., emotion-focused therapy; schema therapy) be employed to achieve emergence and integration of an 'emotional self' which can be flexibly and adaptively used to direct an individual's needs and relationships. Furthermore, we assert that this should be a primary goal of therapy for adults with established AN.

Are socio-emotional and neurocognitive functioning predictors of therapeutic outcomes for adults with anorexia nervosa?

BACKGROUND: Emotional, social, and neurocognitive factors are theorised to maintain anorexia nervosa (AN). Yet whether they predict outcomes or relate to clinical change remains unclear. METHODS: Seventy-one consecutive adult outpatient eating disorder service referrals presenting with AN, who participated in a randomised controlled trial comparing 2 psychotherapies, were assessed for emotional processing, social cognition, and neurocognition pretherapy and posttherapy. Intention-to-treat analysis employed maximum-likelihood methods to model missing data. Baseline self-reported emotional processing, social cognitive, or neurocognitive task performance was entered into forward stepwise regression models with posttreatment clinical outcomes (weight, eating disorder psychopathology, psychosocial functioning) as dependent variables. Correlation analyses examined relationships between clinical and self-report/task score change. RESULTS: Self-reported emotional avoidance (behavioural/cognitive avoidance, low acceptance) and submissive behaviour predicted clinical outcomes. Social cognitive (emotion recognition, emotional theory of mind) and neurocognitive performance (set-shifting, detail focus) had limited predictive ability. CONCLUSIONS: Emotional avoidance and submissiveness may represent maintenance factors for AN.

Social attribution in anorexia nervosa.

People with anorexia nervosa (AN) report socioemotional difficulties; however, measurement has been criticised for lacking ecological validity and the state or trait nature of difficulties remains unclear. Participants (n = 122) were recruited across 3 groups: people who are currently ill with AN (n = 40); people who recovered (RecAN, n = 18); healthy-control participants (n = 64). Participants completed clinical questionnaires and the Social Attribution Task. The Social Attribution Task involves describing an animation of moving shapes, scored for number of propositions offered, accuracy, and social relevance. Groups were compared cross-sectionally. Those with current AN were assessed prepsychological and postpsychological treatments. People with AN provided fewer propositions than other groups and fewer salient social attributions than healthy-control participants. Those who recovered scored intermediately and not significantly different from either group. Following treatment, people with AN demonstrated (nonsignificant) improvements, and no significance between group differences were observed. Findings suggest difficulties for people with AN in providing spontaneous social narrative and in identifying social salience.

Emotion generation and regulation in anorexia nervosa: a systematic review and meta-analysis of self-report data.

This systematic review sought to examine the generation and regulation of emotion in people with Anorexia Nervosa (AN). Key databases (Medline, Embase, PsychINFO and Web of Science) were searched for peer-reviewed articles published by March 2015 yielding 131 studies relevant to emotion generation and emotion regulation (ER) processes as defined by Gross (1998). Meta-analyses determined pooled group differences between AN and healthy control (HC) groups. More maladaptive schemata were reported by people with AN than HCs, with largest pooled effects for defectiveness/shame (d=2.81), subjugation (d=1.59) and social isolation (d=1.66). Poorer awareness of and clarity over emotion generated and some elevated emotionality (disgust and shame) were reported. A greater use of 'maladaptive' ER strategies was reported by people with AN than HCs, alongside less use of 'adaptive' strategies. Pooled differences of particularly large effect were observed for: experiential avoidance (d=1.00), negative problem-solving style (d=1.06), external/social comparison (d=1.25), submissiveness (d=1.16), attention concentration (worry/rumination; d=1.44) and emotion suppression (d=1.15), particularly to avoid conflict (d=1.54). These data support the notion that emotion regulation difficulties are a factor in AN and support use of associated cognitive-affective models. The implications of these findings for further understanding AN, and developing models and related psychological interventions are discussed.

Quality of life in anorexia nervosa, bulimia nervosa and eating disorder not-otherwise-specified.

BACKGROUND: This study aimed to assess differences in Quality of Life (QoL) across eating disorder (ED) diagnoses, and to examine the relationship of QoL to specific clinical features. RESULTS: 199 patients with a diagnosed ED completed the Clinical Impairment Assessment (CIA) [Cognitive Behavior Therapy and Eating Disorders, 315-318, 2008] and the Eating Disorders Examination (EDE) [Int J Eat Disord 6:1-8]. Differences between diagnostic groups were examined, as were differences between restrictive and binge-purge subtypes. CIA scores and EDE scores were positively correlated and higher in groups with binge-purge behaviours. CIA scores were not correlated with BMI, illness duration or frequency of bingeing/purging behaviours, except in the binge-purge AN group, where CIA scores negatively correlated with BMI. CONCLUSIONS: Patients with EDs have poor QoL and impairment increases with illness severity. Patients with binge/purge diagnoses are particularly impaired. It remains unclear which clinical features best predict the degree of impairment experienced by patients with EDs.

Worry and rumination in anorexia nervosa.

BACKGROUND: Difficulties with comprehending and managing emotions are core features of the pathology of anorexia nervosa (AN). Advancements in understanding aetiology and treatment have been made within other clinical domains by targeting worry and rumination. However, worry and rumination have been given minimal consideration in AN. AIMS: This study is the largest to date of worry and rumination in AN. METHOD: Sixty-two outpatients with a diagnosis of AN took part. Measures of worry, rumination, core AN pathology and neuropsychological correlates were administered. RESULTS: Findings suggest that worry and rumination are elevated in AN patients compared with both healthy controls and anxiety disorder comparison groups. Regression analyses indicated that worry and rumination were significant predictors of eating disorder symptomatology, over and above the effects of anxiety and depression. Worry and rumination were not associated with neuropsychological measures of set-shifting and focus on detail. CONCLUSIONS: The data suggest that worry and rumination are major concerns for this group and warrant further study.

Out-patient psychological therapies for adults with anorexia nervosa: randomised controlled trial.

BACKGROUND: Very limited evidence is available on how to treat adults with anorexia nervosa and treatment outcomes are poor. Novel treatment approaches are urgently needed. AIMS: To evaluate the efficacy and acceptability of a novel psychological therapy for anorexia nervosa (Maudsley Model of Anorexia Nervosa Treatment for Adults, MANTRA) compared with specialist supportive clinical management (SSCM) in a randomised controlled trial. METHOD: Seventy-two adult out-patients with anorexia nervosa or eating disorder not otherwise specified were recruited from a specialist eating disorder service in the UK. Participants were randomly allocated to 20 once weekly sessions of MANTRA or SSCM and optional additional sessions depending on severity and clinical need (trial registration: ISRCTN62920529). The primary outcomes were body mass index, weight and global score on the Eating Disorders Examination at end of treatment (6 months) and follow-up (12 months). Secondary outcomes included: depression, anxiety and clinical impairment; neuropsychological outcomes; recovery rates; and additional service utilisation. RESULTS: At baseline, patients randomised to MANTRA were significantly less likely to be in a partner relationship than those receiving SSCM (3/34 v. 10/36; P<0.05). Patients in both treatments improved significantly in terms of eating disorder and other outcomes, with no differences between groups. Strictly defined recovery rates were low. However, MANTRA patients were significantly more likely to require additional in-patient or day-care treatment than those receiving SSCM (7/34 v. 0/37; P = 0.004). CONCLUSIONS: Adults with anorexia nervosa are a difficult to treat group. The imbalance between groups in partner relationships may explain differences in service utilisation favouring SSCM. This study confirms SSCM as a useful treatment for out-patients with anorexia nervosa. The novel treatment, MANTRA, designed for this patient group may need adaptations to fully exploit its potential.

The effect of cognitive behavior therapy on decision making in adolescents who self-harm: a pilot study.

Research shows poor decision making in adolescents who self-harm and a positive correlation between decision-making abilities and duration since last self-harm episode. This exploratory study investigated whether decision making in self-harming adolescents could be improved through treatment with a novel cognitive behavior therapy (CBT). It also investigated whether improvement in decision making following treatment was linked to self-harm cessation. Adolescent self-harmers receiving CBT (n = 24) or no treatment (n = 9) and healthy controls (n = 22) were longitudinally compared on the Iowa gambling task (IGT). Significant IGT improvements were only observed for adolescents who self-harm following CBT. CBT may benefit adolescent self-harmers and generate decision-making improvements.

Emotional processing following recovery from anorexia nervosa.

OBJECTIVE: Evidence suggests that poor emotional processing perpetuates anorexia nervosa (AN); however, emotional processing following recovery and interactions between aspects of processing remain unknown. This study examined beliefs about emotions, emotional tolerance and avoidance and emotion suppression to preserve relationships in recovered AN patients. It also explored whether beliefs about emotion are related to emotional avoidance. DESIGN: A cross-sectional between-groups design was employed. METHOD: Currently ill (n = 40), recovered AN patients (n = 24) and a sample of healthy controls (n = 48) completed measures of clinical and demographic background in addition to the Beliefs About Emotions, Distress Tolerance and Silencing the Self emotional processing questionnaires. RESULTS: Recovered and healthy control groups were comparable (except for higher externalised self-perception in recovered participants) and both had better emotional processing than current AN patients. Beliefs about emotions correlated with level of emotional avoidance. CONCLUSIONS: This study demonstrates functional levels of emotional processing following recovery from AN. It substantiates models proposing that maladaptive beliefs about emotions link to emotional avoidance and supports inclusion of these factors as treatment foci.

Emotional expression, self-silencing, and distress tolerance in anorexia nervosa and chronic fatigue syndrome.

OBJECTIVES. Difficulties in processing emotional states are implicated in the aetiology and maintenance of diverse health conditions, including anorexia nervosa (AN) and chronic fatigue syndrome (CFS). This study sought to explore distress tolerance, self-silencing, and beliefs regarding the experience and expression of emotions in individuals diagnosed with AN and CFS. These conditions were chosen for this study because their clinical presentation is characterized by physical symptoms, yet cognitive behavioural models suggest that emotional processing difficulties contribute to the aetiology and maintenance of both. DESIGN. A between-subjects cross-sectional design was employed. METHODS. Forty people with AN, 45 with CFS, and 48 healthy controls (HCs) completed the Distress Tolerance Scale (DTS), Silencing the Self Scale (STSS), Beliefs about Emotions Scale (BES), and measures of clinical symptomatology. RESULTS. Initial group comparisons found that both AN and CFS participants scored higher than HCs on a subscale measuring difficulties in distress tolerance. AN and CFS participants were also more likely to judge themselves by external standards, endorse statements reflecting a tendency to put the needs of others before themselves, and present an outwardly socially compliant image of themselves whilst feeling hostile within. Relative to HCs, AN participants reported more maladaptive beliefs regarding the experience of having negative thoughts and feelings and revealing these emotions to others, with CFS participants showing a non-significant trend in the same direction. After controlling for differences in age, anxiety, and depression the only significant difference to remain was that observed for the STSS care as self-sacrifice subscale. More maladaptive beliefs about the experience and expression of emotions were associated with greater degree of eating disorder symptomatology in the AN group. CONCLUSIONS. Differences in emotional processing are present in AN and CFS compared to HCs, with some disorder-specific variation, and may be associated with greater clinical symptomatology. These findings support current explanatory models of both AN and CFS, and suggest that emotional processing should be addressed in the assessment and treatment of individuals with these illnesses.

Cognitive flexibility and clinical severity in eating disorders.

OBJECTIVES: The aim of this study was to explore cognitive flexibility in a large dataset of people with Eating Disorders and Healthy Controls (HC) and to see how patient characteristics (body mass index [BMI] and length of illness) are related to this thinking style. METHODS: A dataset was constructed from our previous studies using a conceptual shift test--the Brixton Spatial Anticipation Test. 601 participants were included, 215 patients with Anorexia Nervosa (AN) (96 inpatients; 119 outpatients), 69 patients with Bulimia Nervosa (BN), 29 Eating Disorder Not Otherwise Specified (EDNOS), 72 in long-term recovery from AN (Rec AN) and a comparison group of 216 HC. RESULTS: The AN and EDNOS groups had significantly more errors than the other groups on the Brixton Test. In comparison to the HC group, the effect size decrement was large for AN patients receiving inpatient treatment and moderate for AN outpatients. CONCLUSIONS: These findings confirm that patients with AN have poor cognitive flexibility. Severity of illness measured by length of illness does not fully explain the lack of flexibility and supports the trait nature of inflexibility in people with AN.

Development and pilot evaluation of a manualized cognitive-behavioural treatment package for adolescent self-harm.

BACKGROUND: Manualized cognitive-behavioural therapy (MCBT) approaches to treating adolescent anxiety and depression have been shown to be effective in recent years, as have MCBT for adult self-harm (SH). AIMS: This paper describes the rationale for, development and pilot evaluation of the efficacy of a novel manualized CBT package for adolescent self-harm (SH). It also addresses the acceptability of this treatment package to therapists and patients. METHOD: Twenty-five adolescents (aged 12-18 years) presenting to a Community Child and Adolescent Mental Health Service (CAMHS) in Greater London with SH behaviour began the "Cutting Down" programme and 16 (64%) completed the treatment. Outcomes were assessed at baseline, at the end of treatment and at 3 month follow up. RESULTS: Significant reductions in self-harm behaviour, depression symptoms and trait anxiety were reported. There was no change in state anxiety or in levels of parental expressed emotion as perceived by the adolescent. CONCLUSION: These pilot findings provide preliminary support for the efficacy and acceptability of this time-limited CBT package for adolescents who self-harm.

Is anorexia nervosa a version of autism spectrum disorders?

OBJECTIVES: Similarities have been noted between cognitive profiles of anorexia nervosa (AN) and autism spectrum disorders (ASD). However, there are no direct comparison studies. This study aimed to compare the cognitive profile of AN against published ASD data on tasks measuring empathy, executive function and central coherence. METHODS: Currently ill AN outpatients (n = 40) were statistically compared against published ASD scores on Reading the Mind in the Eyes, Voice and Films tasks (assessing empathy), Wisconsin Card Sorting Task (WCST) (assessing executive function) and Embedded Figures Task (EFT) (assessing detail focus aspect of central coherence). RESULTS: Cognitive profiles of the groups were statistically similar, except for differences in the relative patterns of empathy scores. CONCLUSIONS: The cognitive profile in current AN resembles that of ASD with important clinical implications. Replication studies with planned comparisons, examination of the state-or trait-nature of AN profile and clarification of factors underpinning similarities are required in order to broaden understanding of both disorders.