Brief Cognitive Behavioural Therapy for Non-Underweight Patients

CBT-T for Eating Disorders

Glenn Waller, Hannah Turner, Madeleine Tatham, Victoria Mountford, Tracey Wade

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429576676
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Most people with eating disorders struggle to find an effective therapy that they can access quickly. Brief Cognitive Behavioural Therapy for Non-Underweight Patients: CBT-T for Eating Disorders presents a new form of cognitive behavioural therapy (CBT) that is brief and effective, allowing more patients to get the help that they need.

CBT is a strongly supported therapy for all adults and many adolescents with eating disorders. This 10-session approach to CBT (CBT-T) is suitable for all eating disorder patients who are not severely underweight, helping adults and young adults to overcome their eating disorder. Using CBT-T with patients will allow clinicians to treat people in less time, shorten waiting lists, and see patients more quickly when they need help. It is a flexible protocol, which fits to the patient rather than making the patient fit to the therapy.

Brief Cognitive Behavioural Therapy for Non-Underweight Patients provides an evidence-based protocol that can be delivered by junior or senior clinicians, helping patients to recover and go on to live a healthy life. This book will appeal to clinical psychologists, psychiatrists, psychotherapists, dietitians, nurses, and other professionals working with eating disorders.

Chapter 1

The background to CBT-T and its evidence base

Eating disorders carry substantial costs for the individual, their family and friends, and society more broadly. Those costs include the emotional, practical, developmental, and financial (e.g. Beat, 2015). Therefore, clinicians need to use treatments that are as effective as possible and ensure that those with eating disorders know there are such options.

Cognitive behaviour therapy (CBT) is a key tool in the armoury of psychological clinicians working with eating disorders. However, existing forms of effective CBT for eating disorders (CBT-ED) are relatively long and expensive compared to the treatment of other psychological disorders. For example, while CBT-ED is commonly 20–40 sessions long, 8–10 sessions of therapy is a more common duration for effective treatment of other disorders, such as anxiety and depression (e.g. Clark et al., 2018). Obviously, if this number of sessions is necessary to treat eating disorders, then that is what should be done. But what if we could get good outcomes with briefer treatment for a substantial group of such patients?

We developed CBT-T with just that question in mind. As clinicians, we know that it matters if we fail to treat patients efficiently – the lack of recovery for the individual, the ongoing emotional, practical, and financial costs of their eating disorder for them, the impact on their family and friends, the other patients waiting to get into treatment, and so on. Undertaking therapy is a substantial commitment for many, who may need to arrange time off work or childcare, and who, in some cases, travel considerable distances to the clinic. The cost to the patient of treatment is substantial in some settings (e.g. where the only option is private healthcare, or where there is little availability of publicly funded treatment for non-underweight patients). Therefore, it is reasonable to conclude that patients might also prefer a treatment that takes half the time, and where non-expert clinicians could deliver it (rather than having no access due to a lack of trained experts). So, we raised the question: what if we could reduce 20 sessions to 10? We would have the capacity to treat twice as many patients. But would there be a reduction in effectiveness that made that reduction unacceptable? This chapter answers that question.

This manual outlines the protocol for delivering CBT-T (the T stands for 10). The principles and processes of treatment begin in the next chapter. However, before describing the therapy, it is important to detail the context and the evidence for CBT-T. Therefore, this chapter will address:

• The context of CBT for eating disorders (CBT-ED).
• The evidence that existing forms of CBT-ED are effective.
• The problems of CBT-ED.
• The development of a ten-session form of CBT-ED – known as CBT-T.
• The evidence for CBT-T.
• What is needed to do CBT-T.

1.1 The context of CBT for eating disorders (CBT-ED)

Cognitive behaviour therapy (CBT) is a family of treatments that focus on the interaction of behaviours, beliefs, emotions, and physiology, all in the context of the social environment. These therapies have their origins in behavioural therapies, and some of the most effective elements of CBT are the behavioural interventions that preceded the development of cognitive approaches. The cognitive behaviour therapies have added processes such as cognitive restructuring, which aim to test the validity of unhelpful/dysfunctional beliefs (cognitive content). This development includes more explicitly using behaviour change to weaken unhelpful cognitions and to strengthen alternative and helpful cognitions (behavioural experiments).

More recently, a so-called ‘third wave’ of CBT approaches has been developed. While these are less cohesive than the behavioural (first wave) or cognitive-behavioural (second wave) therapies, their focus tends to be more on developing more adaptive cognitive processes. At present, the strongest evidence sits with the behavioural and cognitive-behavioural treatments, across most psychological disorders. That is also true of the evidence regarding eating disorders, where the evidence base is strongest for ‘second-wave’ CBT, where both behavioural and cognitive approaches are used. With the possible exception of dialectical behaviour therapy for binge-eating disorder, the ‘third-wave’ therapies remain in need of strong evidence before they can be recommended for eating disorders. At present, CBT has the strongest evidence base for a range of disorders (Roth & Fonagy, 2005), including anxiety and depression (both of which are most responsive to the behavioural elements, such as exposure and behavioural activation). As a result, the UK IAPT initiative uses CBT as its core therapeutic approach, offered to a very large number of patients who otherwise would have been unlikely to receive an effective therapy for their substantial problems.

Cognitive-behaviour therapy for eating disorders (CBT-ED) includes a range of CBT protocols that have an evidence base when used with such cases. The term CBT-ED was coined for the NICE (2017) guideline, to describe the collection of different versions of CBT that are supported by evidence and that address a number of key targets using the same therapeutic methods. An umbrella term was used to stress that none of the different versions of evidence-based protocols has a superior outcome (e.g. Linardon et al., 2017).

In CBT-ED, the target characteristics and methods include: collaborative weighing; healthy eating; weight gain where necessary (never intentional weight loss); addressing nutrition; addressing risk; monitoring diet, weight, thoughts, and feelings; cognitive restructuring through the use of behavioural experiments; mood regulation; body image concerns; reducing emphasis on control over weight, shape and eating for defining self-worth; and relapse prevention. The length of treatment and inclusion of any family members are dependent on the history and issues that the person brings to therapy. Consequently, while some forms of CBT can be considered to be CBT-ED (e.g. Fairburn et al., 1993; Fairburn, 2008; Waller et al., 2007), other forms cannot, as they lack key elements and/or an evidence base.

For most cases of eating disorders (i.e. the 80–85% who have non-underweight eating disorders, such as bulimia nervosa, binge-eating disorders, and most atypical cases), the recommended length of CBT-ED is approximately 20 sessions (NICE, 2017). However, there is no evidence to suggest that this is the ‘right’ number of sessions. Furthermore, it is clear that clinicians do not necessarily restrict themselves to this number, with many patients reporting that they are being given far more than 20 sessions (e.g. Cowdrey & Waller, 2015). On the other hand, some patients opt to cease therapy before 20 sessions elapse: are they ‘dropping-out’ before recovery or are they voting with their feet because they have enough tools on board to journey on alone on their recovery pathway?

1.2 The evidence for CBT-ED

Considering the evidence from randomised control trials, NICE (2017) identifies CBT-ED as the most effective approach for non-underweight adults with eating disorders; one of three effective treatments for adults with anorexia nervosa; and a second therapy for adolescents with eating disorders. More importantly, those results translate well to routine clinical settings. There is now substantial evidence that CBT-ED is equally effective in everyday clinical practice (Byrne et al., 2011; Knott et al., 2015; Raykos et al., 2013; Signorini et al., 2018; Turner et al., 2015; Waller et al., 2014), including out-, day- and in-patient settings. It is also effective with the so-called ‘severe and enduring’ eating disorders (e.g. Calugi et al., 2016; Raykos et al., 2018).

It is also important to note that the evidence indicates that therapies need to aim for early change, as their level of impact tails off by the tenth session – a finding that is true for a range of psychological disorders (e.g. depression and anxiety – Delgadillo et al., 2014) and therapies (e.g. Bell et al., 2017). In CBT-ED, therapy has its maximal effect by about the same point (Rose & Waller, 2017). Early therapeutic change (i.e. typically in the first 4–6 weeks or sessions of therapy) is the single best predictor of how well a patient will do in therapy for an eating disorder (Vall & Wade, 2015), and that finding is equally true of CBT-ED (e.g. Raykos et al., 2013; Turner et al., 2015). Lack of early change should be seen as an indicator that the therapy should be adapted, intensified, or discontinued.

Furthermore, CBT-ED has a substantial effect on the very prominent levels of comorbidity in the eating disorders. Despite not addressing these problems directly, CBT-ED reduces anxiety, depression, personality disorder characteristics, and alcohol misuse, while improving self-esteem and quality of life (e.g. Karačić et al., 2011; Linardon & Brennan, 2017; Raykos et al., 2013; Turner et al., 2015). In short, comorbidity is not a good clinical reason not to use CBT-ED in its existing forms. Rather, the rule of thumb should be to treat the eating disorder and re-assess for any residual comorbidity. These findings are summarised in Table 1.1.

Table 1.1 Evidence-based guidance for clinicians (drawn from NICE, 2017)

For most adult cases of eating disorders, CBT-ED is the best therapy to use. CBT-ED works just as well in real-world clinical settings. Do not let comorbid conditions or the duration/severity of the patient’s eating disorder get in the way of the plan to deliver CBT-ED. Press for early change as it predicts a better outcome for the patient; change is far less likely later in therapy.

1.3 The problems of CBT-ED

First, no therapy works for everybody, and CBT-ED is no different. Delivered well, CBT-ED has a better recovery rate than other psychological therapies for non-underweight adults (Linardon et al., 2017), around 50% recovery and another 25% improving substantially without full recovery. Its recovery rate is lower for anorexia nervosa among adults (c. 30%) but equivalent to the other NICE-supported therapies (Maudsley Model of Anorexia Nervosa Treatment for Adults; MANTRA and Specialised Supportive Clinical Management SSCM) for this group (NICE, 2017). It is effective with younger cases too, but Family Based Treatment has somewhat superior outcomes. Whatever the limits of CBT-ED’s outcomes, overall it is the strongest therapy that we can use when treating people with eating disorders.

However, that takes us to the second problem with CBT-ED – clinicians routinely fail to deliver empirically supported treatments (Waller & Turner, 2016). For example, Tobin et al. (2007) have shown that fewer than one clinician in 10 delivers evidence-based therapies for eating disorders. The reasons for this are manifold, but include: clinicians who are untrained or whose training is not up to date (Institute of Medicine, 2001; Royal College of Psychiatrists, 2011; 2013); clinicians who have a preferred way of working; supervision that is not oriented towards patient outcomes (Simpson-Southward et al., 2018); and services that do not support evidence-based practice (e.g. do not train or recruit sufficient staff with the required skill set; ...