Eating disorders (EDs) are associated with high medical and psychiatric comorbidity, poor quality of life, and high mortality, and mortality from anorexia nervosa (AN) is the highest of all mental disorders. Fortunately, there are a number of evidence-based psychological treatment approaches for EDs.
Eating disorders (EDs) affect individuals from every socioeconomic status, race, ethnicity, and gender, with approximately 10% of the population affected by an ED at some point in their lifetime.1 EDs are associated with high medical and psychiatric comorbidity, poor quality of life, and high mortality, and mortality from anorexia nervosa (AN) is the highest of all mental disorders.2 Fortunately, there are a number of evidence-based psychological treatment approaches for EDs. Three well-established treatments have emerged for patients who are medically and psychiatrically stable enough for outpatient care.3
The basic tenets of family-based treatment-often referred to as the Maudsley method-for adolescents with anorexia nervosa include4:
1) The family is not blamed as the cause of the illness.
2) The adolescent’s acceptance of family and parent involvement in therapy is crucially important; thus, parents are tasked with taking charge of weight gain in their malnourished child.
3) The entire family is an important part of treatment success.
4) Normal adolescent development is seen as having been interrupted by the illness.
The treatment typically consists of 10 to 20 sessions over the course of 6 to 12 months. Full nutrition is viewed as a critical first step toward recovery, and the early part of treatment is focused on the therapist coaching the parents to provide this nutrition by actively feeding their child.
Cognitive behavioral therapy (CBT) is a treatment for bulimia nervosa and binge eating disorder. According to the cognitive-behavioral theory of EDs, the over-evaluation and control of shape and weight is central to ED maintenance, with most of the other clinical features understood as directly resulting from this psychopathology, including extreme weight-control behavior and preoccupation with thoughts about eating, shape, and weight.
The core components of CBT are designed to be delivered in 20 sessions over 5 months. Key strategies include establishing control over eating with behavioral techniques, such as self-monitoring and establishing a regular pattern of eating and addressing maintaining factors (eg, control and over-evaluation of shape and weight, dietary restraint). In the enhanced version of CBT for EDs (CBT-E), modules can be added to address one or more external processes that may be maintaining the ED, including perfectionism, low self-esteem, and interpersonal problems.
Research findings suggest that guided self-help based on CBT can be effective in treating bulimia nervosa and binge eating disorder as well.5 Guided self-help can be defined as a psychological treatment where the patient takes home a standardized treatment, which is often written down in book form or available through some other media, and primarily works through it independently but also has the guidance of a therapist or coach. This guidance is primarily supportive or facilitative in nature and is meant to support the patient in working through the standardized treatment themselves.
The amount of contact in guided self-help is minimized relative to standard treatment approaches. It is acceptable to patients, highly cost-effective, and can be implemented successfully by a wide variety of individuals (eg, nurses, non-specialists with no formal clinical qualifications). For these reasons, as of 2017, the United Kingdom National Institute for Health and Care Excellence (NICE) guidelines for EDs recommend guided self-help CBT as the first-line treatment for adults with bulimia nervosa and binge eating disorder.6
Interpersonal psychotherapy is another treatment for bulimia nervosa and binge eating disorder. It assumes that ED symptoms develop and are maintained in an interpersonal context. Specifically, interpersonal problems may contribute to negative affect and low self-esteem, which can in turn lead to the use of ED behaviors as a coping strategy.7 Engaging in ED behaviors can further intensify social difficulties, perpetuating the cycle. Interpersonal psychotherapy works to break this cycle by helping patients improve relationships and communication and resolve interpersonal issues.
Interpersonal psychotherapy typically includes 15 to 20 sessions over 4 to 5 months. During the early part of treatment, the onset and maintenance of the ED are linked to at least one of four identified problem areas (ie, interpersonal deficits, interpersonal role disputes, role transitions, grief) and interpersonal goals are developed. The focus of treatment then transitions to working towards these goals. During this process, the therapist helps the patient recognize the connections between improvement in ED symptoms and positive changes in interpersonal functioning.
The research-practice gap
Many international, evidence-based clinical treatment guidelines recommend use of these evidence- based psychological treatments for EDs. Despite the recommendations, when individuals with EDs receive care, it is frequently not evidence- based treatment. Referred to as the research-practice gap, this is the discrepancy between what is known about effective treatment and what is actually provided to patients who receive care. Indeed, the number of ED specialist clinicians who report adhering to evidence-based protocols is between 6% and 35%. Far more clinicians report using an eclectic mix of techniques derived from both evidence-based treatments and techniques with no evidence for efficacy.8 Furthermore, even when clinicians say they are using an evidence-based treatment for EDs, key elements may be omitted.9
Disseminating evidence-base treatment
Thomas Insel, MD, the past director of the National Institute of Mental Health has said, “We have powerful, evidence-based psychosocial interventions, but they are not widely available . . . A serious deficit exists in training for evidence-based psychosocial interventions.”10 The following models can be used to increase the dissemination of evidence-based treatments for EDs (Table).
Train-the-trainer. Current approaches to training therapists to conduct new treatments typically consist of a 1- or 2-day workshop delivered by an expert; attendees are provided with a therapy manual. While workshops increase therapists’ knowledge, without further consultation their effect may be short-lived. Alternatively, there is a strong theoretical case for the “train-the-trainer” approach, which centers around an individual (the trainer) from a given setting (eg, community mental health center, college counseling center) who will be trained and will then train his or her colleagues. In addition, the trainer provides consultation as needed to anyone implementing the new treatment. In this way, the trainer becomes an internal coach and champion for the treatment.
This approach has been recommended as the most effective means of changing therapist behavior.11 The train-the-trainer approach also has the benefit of being more sustainable and cost-effective over time, as the trainer can continue to train new cohorts of therapists at relatively low cost. There is preliminary support for the usefulness of this method for guided self-help CBT.12 This approach is currently being tested as a method for training college counselors in interpersonal psychotherapy for EDs and depression.13
Web-centered training. Another method is web-centered training, which is scalable and low cost.
It has several key advantages:
1) Training can be offered to geographically dispersed trainees using minimal person-based resources.
2) The website can be accessed anytime, anywhere to effectively accommodate busy schedules.
3) It enables trainees to repeatedly review material, reinforcing learning.
4) The process can be customized to the trainee with quizzes, feedback, and refresher courses.
5) The website can be updated regularly, facilitating incorporation of new information.
6) Data collection on website usage can provide valuable information on the most accessed program features, informing refinement.
A comprehensive platform for training in CBT for EDs has been developed; findings indicate that the use of the platform may increase competence scores.14,15 Likewise, a comprehensive online training program in interpersonal psychotherapy has also been developed, including telephone-based simulation assessment for measurement of adherence and competence in the treatment, with testing currently underway.16
Best-buy interventions. When selecting an evidence-based treatment to disseminate, selection criteria should be based on best-buy interventions and include: efficacy, cost-effectiveness, clinical range, ease of training and learning, and mode of treatment delivery.17 Transdiagnostic treatments may be considered best buys because they have the advantage of offering greater clinical range and thus more practicality, which may enhance adoption of the method by therapists. In that sense, interpersonal psychotherapy might be considered a best-buy intervention given its ability to not only address EDs but also a variety of other problems, including depression, anxiety, and PTSD.18
Cost-effectiveness is also a key consideration in defining a best buy. Family-based treatment might be considered a best buy given that it is cost effective compared with weight restoration via inpatient hospitalization. Likewise, guided self-help CBT has the advantage of being very easy to learn and deliver, even by inexperienced practitioners, making it very cost-effective.
Electronic support tools. Electronic support tools for therapists have the potential to enhance quality of care. First, checklists can help therapists ensure important points are covered in session and can also aid in decision-making. For instance, an electronic measurement-feedback system for routine outcome monitoring can be used. Meta-analytic work suggests that routine outcome feedback improves patient outcomes, at least in the short-term.19 Such monitoring can provide therapists with alerts that clients are “off track” indicating the current course of treatment may be ineffective. Furthermore, the detection of symptom improvements can reassure clients they are making progress and enhance the therapeutic alliance.
Electronic support tools can also be used to enhance adherence to therapy and facilitate transmission of information to the therapist. Recovery Record is a mobile app that can be used by patients with EDs to self-monitor meals, thoughts, emotions, and behaviors and share this information with the therapist.
Higher-level support and policy. For evidence-based care to dramatically increase, higher-level support is required. Improving Access to Psychological Therapies (IAPT) is a systematic way of organizing the delivery of evidence-based psychological treatment, according to the NICE guidelines, within England’s National Health Service. IAPT services are characterized by use of evidence-based treatments, routine outcome monitoring, and regular and outcomes-focused supervision.20 Routine outcome monitoring not only provides the patient and therapist with valuable information on symptom improvement, but it also provides information on whether this is a cost-effective approach. In the US, the Veterans Health Administration (VHA) is actively implementing a national initiative to disseminate and implement evidence-based treatments.21
IAPT and the VHA models involve centralized control of money from the top and their implementation is mandated. Such initiatives have a much greater likelihood of success in changing therapist behavior relative to relying on individual therapists to voluntarily receive training and modify their behavior.
Conclusion and future directions
The establishment of several evidence-based psychological treatments for EDs, including family-based treatment, CBT, and interpersonal psychotherapy, represent an enormous advance. However, only a minority of patients with EDs who access care receive one of these treatments. To address the research-practice gap and ensure that more people obtain high-quality, evidence-based care, the use of novel approaches are required.
What will be most effective in terms of meaningfully addressing the research-practice gap is higher-level support and policy, which has the greatest likelihood of generating widespread change. It is important to work with policy makers to develop research questions that will answer important policy-related questions. Such an approach may dramatically increase access to evidence-based care for patients with EDs.
There is an enormous treatment gap in the field of EDs, whereby the vast majority of patients with EDs (≥ 80%) receive no clinical care whatsoever.17 Moving forward, in addition to continuing to improve the quality of treatment for the minority of individuals with EDs who receive services, increased attention needs to be devoted to finding novel approaches to delivering treatment that can reach the vast number of individuals in need of care who currently receive no services at all.
Dr Fitzsimmons-Craft is Assistant Professor of Psychiatry, and Dr Wilfley is the Scott Rudolph University Professor of Psychiatry, Medicine, Pediatrics, and Psychological and Brain Sciences, Washington University School of Medicine, St. Louis, MO. The authors report no conflicts of interest concerning the subject matter of this article.
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