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.

Outcomes of brief and enhanced cognitive-behavioural therapy for adults with non-underweight eating disorders: A non-randomized comparison.

OBJECTIVE: Cognitive-behavioural therapy (CBT) is an efficacious and effective treatment for eating disorders, and is particularly valuable in the treatment of non-underweight cases (e.g., bulimia nervosa; binge eating-disorders). However, its recommended length for such cases (up to 20 sessions) makes it a relatively costly therapy. It has been suggested that a 10-session version (CBT-T) can also be effective, but there has been no direct comparison between the two forms (10 vs. 20 sessions). METHOD: This study reports the outcomes of brief and standard-length CBT for non-underweight eating disorders, comparing two cohorts of patients from the same clinic (N = 55 and 138, respectively). RESULTS: The two therapies had very similar results in terms of eating pathology, remission rate, and improved quality of life. Each showed substantial change by the mid-point of therapy and up to 6-month follow-up. CONCLUSION: It appears that brief CBT (CBT-T) is as effective as existing 20-session CBT, and is less demanding of time and resource. The findings need to be replicated in a randomized control trial before this conclusion can be made definitive.

Patients' experiences of brief cognitive behavioral therapy for eating disorders: A qualitative investigation.

OBJECTIVE: Although it is important to analyze the effectiveness of new therapies, it is also necessary to consider how patients experience them. This is particularly important if we are to maximize treatment acceptability and reduce attrition. This study examined patient experiences of a new 10-session cognitive-behavioral therapy (CBT-T), using a qualitative approach. METHOD: The sample was 17 patients with a diagnosis of bulimia nervosa who had received CBT-T (including treatment completers and non-completers) within the previous 2 years. Sample size was determined by saturation of the emergent themes. Responses were analyzed using a six-step thematic analysis process. RESULTS: Rated acceptability and effectiveness of CBT-T were high. Five themes emerged, with subthemes. The key elements of patient experience of the therapy were: the therapeutic relationship; the nature of the therapy; its challenging but beneficial aspects; ending therapy; and the overall experience of CBT-T (including comparison with other therapies). DISCUSSION: The findings build on the effectiveness research for CBT-T, suggesting that it is an acceptable therapy that addresses many of the same themes that matter to patients as other therapies. The findings show that patients were positive about CBT-T relative to other therapies, and offer suggestions as to how CBT-T might be delivered to emphasize the importance of the time-limited nature of the therapy.

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.

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.

Clinicians' concerns about delivering cognitive-behavioural therapy for eating disorders.

Despite research supporting the effectiveness of evidence-based interventions in the treatment of eating disorders, those interventions are under-utilised in routine clinical practice, possibly due to clinicians' concerns about delivering the relevant techniques. This study examined what elements of therapy clinicians worry about when delivering cognitive-behavioural therapy (CBT) for the eating disorders, and what clinician variables are associated with such concerns. The participants were 113 clinicians who used individual CBT with eating disorder patients. They completed a novel measure of concerns about delivering elements of CBT, as well as demographic characteristics and a standardised measure of intolerance of uncertainty. Clinicians worried most about body image work and ending treatment, but least about delivering psychoeducation. Their concerns fell into four distinct factors. Older, more experienced clinicians worried less about delivering the CBT techniques, but those with greater levels of prospective and inhibitory anxiety worried more about specific factors in the CBT techniques. Clinicians' capacity to tolerate uncertainty might impair their delivery of evidence-based CBT, and merits consideration as a target in training and supervision of CBT clinicians.

Attitudes towards psychotherapy manuals among clinicians treating eating disorders.

Clinicians have relatively low uptake and implementation of evidence-based psychotherapies for the eating disorders, and this problem appears to be associated with low use of manualized approaches. This study examines clinicians' positive and negative attitudes to manuals, and possible beliefs and emotional factors that might drive those attitudes. The participants were 125 psychological therapists working with eating-disordered patients. Each completed standardised measures of attitudes to manuals and emotional states. A number of beliefs about the content of manuals were associated with both positive attitudes to the outcome of treatment and negative attitudes to their impact on the treatment process. In addition, a more positive mood was associated with more positive attitudes. Suggestions are made regarding how attitudes might be made more positive, in order to facilitate the use of evidence-based therapies for eating disorders.

"Do you still want to be seen?": the pros and cons of active waiting list management.

OBJECTIVE: This study examined the impact on a clinic waiting list of introducing an "opt-in" system for patients awaiting individual outpatient cognitive behavioral therapy. The proportion of patients opting in was identified, along with demographic, eating, and psychopathological factors that might make some more likely to opt out. METHOD: The sample consisted of 116 patients with eating disorder. Each completed measures of eating and axis 1 and 2 characteristics at assessment. They received one opt-in letter and a reminder. Those who opted in immediately or after a reminder were compared with those who did not. RESULTS: Just over two-thirds of the patients opted to remain on the waiting list. No demographic or eating characteristics differentiated those individuals. Those who did not opt in immediately had higher levels of depression, psychoticism, and borderline personality disorder cognitions. However, that difference disappeared when the reminder letter was sent. DISCUSSION: Waiting list reductions can be achieved through an active "opt-in" mechanism, and this approach does not disadvantage specific individuals but speeds access to treatment for the majority of patients. However, further research is needed to track pathways of care to determine whether such initiatives have longer term positive or negative impacts.

The role of imagery-based techniques in cognitive-behavioural therapy for adults with eating disorders.

Disorder-specific and transdiagnostic cognitive-behavioural models and treatments primarily target surface-level maintaining factors in order to effect symptom change. Despite this approach resulting in the most effective evidence-based approach for most eating disordered patients, a significant proportion of sufferers fail to benefit from such treatments. This conclusion suggests that deeper-level causal factors might also need to be addressed in some cases. Theoretical and empirical findings are considered in terms of the clinical applicability of imagery-based techniques and their ability to enhance cognitive-behavioural treatment of the eating disorders. Imagery techniques (particularly, but not only, imagery rescripting) are proposed as a means to enhance current treatments and improve existing outcomes. Potential treatment targets include core beliefs, emotional regulation difficulties and body image disturbance. The existing literature is limited but early indications suggest that imagery rescripting is effective in modifying core beliefs in this population, and that other imagery-based methods are potentially beneficial. Areas for further clinical application and investigation are identified.