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Predictors and moderators of response to enhanced cognitive behaviour therapy and interpersonal psychotherapy for the treatment of eating disorders.
Consistent predictors, and more especially moderators, of response to psychological treatments for eating disorders have not been identified. The present exploratory study examined predictors and moderators of outcome in adult patients who took part in a randomised clinical trial comparing two leading treatments for these disorders, enhanced cognitive behavioural therapy (CBT-E) and interpersonal psychotherapy (IPT). Four potentially important findings emerged. Firstly, patients with a longer duration of disorder were less likely to benefit from either treatment. Second, across the two treatments the presence, at baseline, of higher levels of over-evaluation of the importance of shape predicted a less good treatment outcome. Third DSM-IV diagnosis did not predict treatment outcome. Fourth, with the exception of patients with baseline low self-esteem who achieved a better outcome with CBT-E, it was generally not possible to identify a subgroup of patients who would differentially benefit from one or other treatment.
Treating eating disorders using the internet.
PURPOSE OF REVIEW: This article evaluates the empirical standing of online treatment (eTherapy) for people with an established eating disorder. RECENT FINDINGS: There have been four randomized controlled trials of eTherapy for people with an eating disorder. All four focused on eating disorders characterized by binge eating and recruited adult participants direct from the community. The interventions were cognitive behavioural in nature, lasted between 3 and 7 months, and were accompanied by external support. In common with eTherapy for other mental health problems, there were problems engaging and retaining the users, and maximizing their implementation of the intervention. A minority (10-37%, intent-to-treat figures) improved substantially. SUMMARY: This is a new field. The findings of the four randomized controlled trials are consistent with the earlier reports indicating that guided eTherapy interventions of a cognitive behavioural nature are acceptable to (female) adults with a binge eating problem and that a subgroup improves substantially. More effective interventions are required and their use in different healthcare settings needs to be investigated. Direct-to-sufferer eTherapy interventions have the potential to increase access to effective forms of treatment and, in younger cases, they might serve as a form of secondary prevention.
Breaking the cycle: a pilot study on autonomous Digital CBTe for recurrent binge eating.
BACKGROUND: Only a minority of people with eating disorders receive evidence-based psychological treatment. This is especially true for those with recurrent binge eating because the shame that accompanies binge eating affects help seeking and there is a shortage of therapists to provide psychological treatments. Digital programme-led interventions have the potential to overcome both barriers. OBJECTIVE: This study examined the acceptability and effectiveness of a new digital programme-led intervention directly based on enhanced cognitive behaviour therapy (CBT-E), which is an empirically supported psychological treatment for eating disorders. METHODS: One hundred and ten adults with recurrent binge eating (self-reporting characteristics consistent with binge eating disorder, bulimia nervosa, and similar conditions) were recruited through an advertisement on the website of the UK's national eating disorder charity, Beat. The intervention, called Digital CBTe, comprised 12 sessions over 8-12 weeks delivered autonomously (i.e., without external support). Participants completed self-report outcome measures of eating disorder features and secondary impairment at baseline, post-intervention, and 6-month follow-up. RESULTS: Most participants identified as female, White, and were living in the United Kingdom. Most participants (85%) self-reported features that resembled binge eating disorder, and the rest self-reported features that resembled bulimia nervosa (8%) and atypical bulimia nervosa (7%). On average, participants reported that the onset of their eating disorder was more than twenty years ago. Sixty-three percent of the participants completed Digital CBTe (i.e., completed active treatment sessions). Those who completed all sessions and the post-intervention assessment (n = 55, 50%) reported significant decreases in binge eating, eating disorder psychopathology, and secondary impairment at post-intervention. These improvements were maintained at follow-up. Large effect sizes were observed for all these outcomes using a completer analysis and post-intervention data (d = 0.91-1.43). Significant improvements were also observed for all outcomes at post-intervention in the intent-to-treat analysis, with medium-to-large effect sizes. DISCUSSION: A substantial proportion of those who completed Digital CBTe and the post-intervention assessment experienced marked improvements. This provides promising data to support the conduct of a fully powered trial to test the clinical and cost-effectiveness of autonomous Digital CBTe.
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.
Cognitive behavioral therapy for eating disorders.
Cognitive behavioral therapy (CBT) is the leading evidence-based treatment for bulimia nervosa. A new "enhanced" version of the treatment appears to be more potent and has the added advantage of being suitable for all eating disorders, including anorexia nervosa and eating disorder not otherwise specified. This article reviews the evidence supporting CBT in the treatment of eating disorders and provides an account of the "transdiagnostic" theory that underpins the enhanced form of the treatment. It ends with an outline of the treatment's main strategies and procedures.
Interpersonal psychotherapy for eating disorders.
Interpersonal psychotherapy (IPT) is a leading evidence-based treatment for those eating disorders in which binge eating is a feature. This article begins with a consideration of the rationale for using IPT to treat patients with eating disorders. This is followed by a review of the evidence supporting its use and a brief description of treatment including an illustrative clinical case vignette. The article closes with a discussion of possible future directions for research on IPT for eating disorders.
How do psychological treatments work? Investigating mediators of change.
Little is known about how psychological treatments work. Research on treatment-induced mediators of change may be of help in identifying potential causal mechanisms through which they operate. Outcome-focused randomised controlled trials provide an excellent opportunity for such work. However, certain conceptual and practical difficulties arise when studying psychological treatments, most especially deciding how best to conceptualise the treatment concerned and how to accommodate the fact that most psychological treatments are implemented flexibly. In this paper, these difficulties are discussed, and strategies and procedures for overcoming them are described.
Bridging the gap: a mixed-methods real-world pilot of a digital intervention for adults with binge eating.
BACKGROUND: Many individuals who experience binge eating face significant challenges in accessing timely and adequate treatment, often due to limited healthcare resources. To address this, the digital, programme-led (self-help) version of Enhanced Cognitive Behaviour Therapy (CBT-E) has been developed. This service improvement project piloted the digital programme with adults on a specialist eating disorder service waiting list in the UK's National Health Service (NHS). Its aim was to assess the feasibility, acceptability, and preliminary clinical effects of a digital programme for adults on a waiting list for an eating disorder characterised by binge eating. METHODS: The digital programme was offered to patients with eating problems characterised by binge eating (binge eating disorder or bulimia nervosa or atypical or subclinical threshold cases), for whom a programme-led treatment was appropriate and who were on a waiting list for a specialist outpatient service. Patients used the programme independently, without any additional support. They completed self-report measures assessing eating disorder features, secondary impairment, and features of depression before and after the programme. Patients provided feedback through semi-structured interviews, and staff completed a survey. RESULTS: Fifty patients started the programme, and 19 completed all active programme sessions. Those who completed the full programme and the post-programme assessments (n = 14) reported significant reductions in binge eating frequency, eating disorder psychopathology, secondary impairment, and features of depression. Qualitative feedback from patients and staff highlighted the programme's value as a waiting list offer and its role in supporting patients' progress towards recovery. Some patients expressed a desire for human interaction to help them better engage with the programme. CONCLUSIONS: These findings suggest that the digital, programme-led version of CBT-E is feasible, acceptable, and shows promise in reducing binge eating and related impairments in adults on a waiting list for a specialist outpatient eating disorder services. Offering this evidence-informed programme could help address the challenge of long delays in accessing care. Future research should focus on strategies to enhance patient engagement and adherence, improve human interaction within the programme, and explore ways to scale the intervention to benefit broader populations, including its use as an early intervention.
Evolving perspectives on CBT-E for eating disorders: Clarifying ten key points - Misconceptions and communication gaps explored
Drawing on extensive experience in training and supervising clinicians in enhanced cognitive behaviour therapy (CBT-E), we have identified ten prevalent misconceptions and communication gaps. These misunderstandings can impact the implementation of CBT-E and may potentially reduce its effectiveness. They include misconceptions regarding CBT-E's flexibility, suitability for certain patient groups, real-world applicability, and alignment with anti-weight stigma principles. Such misunderstandings may make clinicians hesitant to recommend or deliver CBT-E appropriately. In the present paper, we address these misconceptions and gaps in communication and provide evidence-based guidance on CBT-E practice. We aim to enhance clinicians' confidence in using CBT-E flexibly and appropriately, with the hope that this will improve its effectiveness. Key learning aims (1) Recognise common misconceptions and communication gaps about enhanced cognitive behaviour therapy (CBT-E) for eating disorders. (2) Develop an understanding of how CBT-E can be implemented across diverse clinical settings and patient populations. (3) Strengthen therapists' confidence in delivering CBT-E flexibly while maintaining fidelity to its evidence-based framework.
Treatment Targets and Strategies for Eating Disorders Recovery: A Delphi Consensus With Lived Experience, Carers, Researchers, and Clinicians.
OBJECTIVE: Long-term recovery rates following eating disorders (EDs) treatment remain low. This might be partly due to a lack of agreement between key stakeholder groups, including people with lived experience, carers, clinicians, and researchers, regarding optimal therapeutic targets and strategies. We aimed to reach a consensus across these diverse groups on the most valued treatment targets and strategies for fostering ED recovery. METHOD: We used the Delphi method with two phases: (i) Survey development and (ii) Expert rating. The survey development phase included the design of an initial set of items through scoping review and feedback from a committee of 14 experts. During the survey rating, we engaged a larger panel of 185 experts who comprised the stakeholder groups: Individuals with lived ED experience (n = 49), carers (n = 44), researchers (n = 46), and clinicians (n = 46). RESULTS: Thirty-one targets and 29 strategies reached consensus (> 70% agreement over three rounds). Psychological-emotional-social targets including quality of life, sense of purpose, and emotion regulation, along with ED behaviors, reached the highest agreement (> 90%). Strategies reflecting an individualized approach to treatment (i.e., considering diversity, assessing comorbidities, and enhancing rapport) achieved the highest agreement (> 90%). Responses across groups were similar, except researchers leaning more towards consideration of weight- and eating-related targets. DISCUSSION: Holistic targets and individualized therapeutic strategies have consistent support from the different stakeholder groups involved in ED treatment. The agreed set of targets/strategies may be used, in triangulation with other sources of evidence, to design and evaluate coproduced and personalized interventions.
"In Their Own Words": A Qualitative Exploration of Lived Experience and Healthcare Professional Perspectives on Evaluating a Digital Intervention for Binge Eating.
OBJECTIVE: Eating disorders characterized by binge eating are prevalent yet under-recognized, limiting access to effective care. The digital, programme-led (self-help) version of Enhanced Cognitive Behavior Therapy (CBT-E) offers a potentially scalable treatment. This study gathered insights from individuals with lived experience of binge eating (LE) and healthcare professionals (HCPs) to inform the design of a randomized controlled trial evaluating the intervention's effectiveness and to support early-stage implementation planning. METHOD: Four focus groups were conducted with 20 participants (8 with LE, 12 HCPs). Discussions explored recruitment strategies, participant engagement, meaningful outcome measures, and barriers to implementation. Data were analyzed using thematic analysis. RESULTS: Two overarching themes were identified: (1) Reach People in Accessible and Supportive Ways, and (2) Be Open to Different Experiences of Progress. Participants emphasized inclusive recruitment and compassionate, hopeful messaging. Stigma and limited recognition of binge eating were cited as recruitment barriers in healthcare settings. Both groups recommended community and online platforms to enhance reach. Participants stressed the importance of outcomes beyond symptom reduction (e.g., emotional well-being) and qualitative methods to capture recovery narratives. Findings also highlighted implementation-relevant factors, including how interventions are framed and delivered, and how engagement can be optimized. DISCUSSION: Perspectives from individuals with LE and HCPs support a person-centred trial aligned with the needs of those experiencing binge eating and those providing care, while considering both evaluative and implementation priorities. Findings inform strategies to enhance reach and understanding of digital intervention outcomes, contributing to trial designs that are consistent with real-world care and meaningful to participants.
Interpersonal Psychotherapy (IPT) for Eating Disorders
As the scientific literature accumulates a body of information regarding these clinical problems, this book serves as an invaluable reference providing a summary of the current evidence in the literature.
Improving programme-led and focused interventions for eating disorders: An experts' consensus statement-A UK perspective.
OBJECTIVE: Eating disorders are associated with significant illness burden and costs, yet access to evidence-based care is limited. Greater use of programme-led and focused interventions that are less resource-intensive might be part of the solution to this demand-capacity mismatch. METHOD: In October 2022, a group of predominantly UK-based clinical and academic researchers, charity representatives and people with lived experience convened to consider ways to improve access to, and efficacy of, programme-led and focused interventions for eating disorders in an attempt to bridge the demand-capacity gap. RESULTS: Several key recommendations were made across areas of research, policy, and practice. Of particular importance is the view that programme-led and focused interventions are suitable for a range of different eating disorder presentations across all ages, providing medical and psychiatric risk are closely monitored. The terminology used for these interventions should be carefully considered, so as not to imply that the treatment is suboptimal. CONCLUSIONS: Programme-led and focused interventions are a viable option to close the demand-capacity gap for eating disorder treatment and are particularly needed for children and young people. Work is urgently needed across sectors to evaluate and implement such interventions as a clinical and research priority.
Challenges and opportunities for enhanced cognitive behaviour therapy (CBT-E) in light of COVID-19.
UNLABELLED: In the past few weeks, coronavirus disease 2019 (COVID-19) has dramatically expanded across the world. To limit the spread of COVID-19 and its negative consequences, many countries have applied strict social distancing rules. In this dramatic situation, people with eating disorders are at risk of their disorder becoming more severe or relapsing. The risk comes from multiple sources including fears of infection and the effects of social isolation, as well as the limited availability of adequate psychological and psychiatric treatments. A potential practical solution to address some of these problems is to deliver enhanced cognitive behaviour therapy (CBT-E), an evidence-based treatment for all eating disorders, remotely. In this guidance we address three main topics. First, we suggest that CBT-E is suitable for remote delivery and we consider the challenges and advantages of delivering it in this way. Second, we discuss new problems that patients with eating disorders may face in this period. We also highlight potential opportunities for adapting some aspects of CBT-E to address them. Finally, we provide guidelines about how to adapt the various stages, strategies and procedures of CBT-E for teletherapy use in the particular circumstances of COVID-19. KEY LEARNING AIMS: (1)To appreciate that CBT-E is suitable for remote delivery, and to consider the main challenges and potential advantages of this way of working.(2)To identify and discuss the additional eating disorder-related problems that may arise as a result of COVID-19, as well as potential opportunities for adapting some aspects of CBT-E to address them.(3)To learn how to adapt CBT-E for remote delivery to address the consequences of COVID-19. Specifically, to consider adaptations to the assessment and preparation phase, the four stages of treatment and its use with underweight patients and adolescents.
The development of an online measure of therapist competence.
The topic of therapist training has been relatively neglected in the research literature. Similarly, the related issue of the measurement of the outcome of training, especially therapist competence, has been largely overlooked. Data supporting the effectiveness of various methods of clinician training and those providing estimates of the level of competence achieved by clinicians are scarce. Validated scalable methods for the measurement of clinician outcomes such as competence are required to evaluate both existing and new methods of training. This study focuses on the development and testing of an online measure (eMeasure) to assess therapists' applied knowledge of Enhanced Cognitive Behaviour Therapy (CBT-E), a transdiagnostic evidence-supported treatment for the full range of eating disorders. The eMeasure meets the stringent requirements of the Rasch model and has three equivalent versions making it suitable for repeat testing of trainees in outcome studies. Preliminary best cut points to distinguish between those who are competent and those who are not are identified. While the present work focused on CBT-E, the method described may be used to develop and test other measures relating to therapist competence.
Facilitating a benign interpretation bias in a high socially anxious population.
Previous research has shown that high socially anxious individuals lack the benign interpretation bias present in people without social anxiety. The tendency of high socially anxious people to generate more negative interpretations may lead to anticipated anxiety about future social situations. If so, developing a more benign interpretation bias could lead to a reduction in this anxiety. The current study showed that a benign interpretation bias could be facilitated (or 'trained') in a high socially anxious population. Participants in the benign training groups had repeated practice in accessing benign (positive or non-negative) interpretations of potentially threatening social scenarios. Participants in the control condition were presented with the same social scenarios but without their outcomes being specified. In a later recognition task, participants who received benign interpretation training generated more benign, and less negative, interpretations of new ambiguous social situations compared to the control group. Participants who received benign training also predicted that they would be significantly less anxious in a future social situation than those in the control group. Possible implications of the findings for therapeutic interventions in social phobia are discussed.
A transdiagnostic comparison of enhanced cognitive behaviour therapy (CBT-E) and interpersonal psychotherapy in the treatment of eating disorders.
UNLABELLED: Eating disorders may be viewed from a transdiagnostic perspective and there is evidence supporting a transdiagnostic form of cognitive behaviour therapy (CBT-E). The aim of the present study was to compare CBT-E with interpersonal psychotherapy (IPT), a leading alternative treatment for adults with an eating disorder. One hundred and thirty patients with any form of eating disorder (body mass index >17.5 to <40.0) were randomized to either CBT-E or IPT. Both treatments involved 20 sessions over 20 weeks followed by a 60-week closed follow-up period. Outcome was measured by independent blinded assessors. Twenty-nine participants (22.3%) did not complete treatment or were withdrawn. At post-treatment 65.5% of the CBT-E participants met criteria for remission compared with 33.3% of the IPT participants (p < 0.001). Over follow-up the proportion of participants meeting criteria for remission increased, particularly in the IPT condition, but the CBT-E remission rate remained higher (CBT-E 69.4%, IPT 49.0%; p = 0.028). The response to CBT-E was very similar to that observed in an earlier study. The findings indicate that CBT-E is potent treatment for the majority of outpatients with an eating disorder. IPT remains an alternative to CBT-E, but the response is less pronounced and slower to be expressed. CURRENT CONTROLLED TRIALS: ISRCTN 15562271.
Mediators of change in cognitive behavior therapy and interpersonal psychotherapy for eating disorders: A secondary analysis of a transdiagnostic randomized controlled trial.
OBJECTIVE: Understanding the mechanisms of action of psychological treatments is a key first step in refining and developing more effective treatments. The present study examined hypothesized mediators of change of enhanced cognitive behavior therapy (CBT-E) and interpersonal psychotherapy for eating disorders (IPT-ED). METHOD: A series of mediation studies were embedded in a randomized controlled trial (RCT) comparing 20 weeks of CBT-E and IPT-ED in a transdiagnostic, non-underweight sample of patients with eating disorders (N = 130) consecutively referred to the service. Three hypothesized mediators of change in CBT-E (regular eating, weighing frequency, and shape checking) and the key hypothesized mediator of IPT-ED (interpersonal problem severity) were studied. RESULTS: The data supported regular eating as being a mediator of the effect of CBT-E on binge-eating frequency. The findings were inconclusive regarding the role of the other putative mediators of the effects of CBT-E; and were similarly inconclusive for interpersonal problem severity as a mediator of the effect of IPT-ED. DISCUSSION: This research highlights the potential benefits of embedding mediation studies within RCTs to better understand how treatments work. The findings supported the role of regular eating in reducing patients' binge-eating frequency. Other key hypothesized mediators of CBT-E and IPT-ED were not supported, although the data were not inconsistent with them. Key methodological issues to address in future work include the need to capture both behavioral and cognitive processes of change in CBT-E, and identifying key time points for change in IPT-ED.