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Putting the ‘B’ back into CBT for eating disorders. Glenn Waller. Vincent Square Eating Disorders Service, London and Institute of Psychiatry, King’s College, London. Unhappy families. CBT is not a monolith A family of therapies (Fairburn, 2011) Varying degrees of relatedness
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Putting the ‘B’ back into CBT for eating disorders Glenn Waller Vincent Square Eating Disorders Service, London and Institute of Psychiatry, King’s College, London BABCP - Guildford 2011
Unhappy families • CBT is not a monolith • A family of therapies (Fairburn, 2011) • Varying degrees of relatedness • and sometimes getting on like families do around mid-afternoon on Christmas day • In the eating disorders, only a few members of that family have evidence in support of their effectiveness • Bulik (1995); Fairburn (2008); Fairburn et al. (1993); Ghaderi (2006); Gowers & Green (2009); Waller et al. (2007) BABCP - Guildford 2011
Unhappy families • Other CBT and non-CBT approaches are commonly chosen by services, therapists and patients • for reasons other than being evidence-based • lots of clinical expertise, but coming to different conclusions • remember: no reliability = no validity • and the Dodo Bird Hypothesis looks pretty weak • The core distinguishing element in evidence-based CBT for the eating disorders is… • Behavioural change BABCP - Guildford 2011
Recommended manuals • Manual use is associated with better adherence to CBT procedures, by the way… BABCP - Guildford 2011
The central role of behavioural change • Evidence-based practice in CBT for the eating disorders is centred on the behavioural element • always necessary: sometimes sufficient • Little or no evidence that purely cognitive approaches are effective • Behaviour change predicts outcome and relapse • lets us tell patients when they are at risk of failing to benefit from CBT • Where did the ‘B’ go, and why? BABCP - Guildford 2011
A common assumption in ‘CBT’ • Start with the cognitions and the emotions • Behavioural change and physiological recovery will follow BABCP - Guildford 2011
What is needed for evidence-based CBT? • Start with the behavioural and biological • Making mood more stable and cognitions more flexible BABCP - Guildford 2011
What am I ranting about? • Cognitive behavioural therapies that are delivered without a core behavioural element • cognitive therapies • many ‘third wave’ therapies • not even going to consider non-CBT approaches here • But far, far more egregious • badly delivered ‘evidence-based’ CBT • All demanding that the patient tries to change with their physiology in knots • starvation effects on cognitions • serotonin deprivation effects on emotions BABCP - Guildford 2011
A preview of some nasty, nasty numbers • Survey of eating disorder CBT practitioners • including BABCP members (thank you) • courtesy of Hannah Stringer and Caroline Meyer • What core CBT behaviour-based procedures are used by what proportion of clinicians? BABCP - Guildford 2011
What core, evidence-based CBT procedures are used? • In short • No procedure is used routinely by even half of clinicians using CBT with eating disorders • Behavioural interventions are treated as optional • and clinicians are opting out… • And a substantial minority of clinicians doing ‘CBT’ for the eating disorders appear to use no CBT procedures at all • including cognitive restructuring BABCP - Guildford 2011
Roadblocks to behavioural procedures? • Our patients have their own safety behaviours, which maintain the eating disorder BABCP - Guildford 2011
Roadblocks to behavioural procedures? • As clinicians, we have our own safety behaviours, which stop us pushing for change BABCP - Guildford 2011
Roadblocks to behavioural procedures? • Finally, our own safety behaviours interact with those of our patients (accommodation) BABCP - Guildford 2011
Formulation • Case formulations that ignore the behavioural element of maintenance • and their impact on physiology • Too much exclusive focus on emotion, cognition, metacognition, schema modes, etc. • For example, do your formulations include: • ‘compensation’ → behaviour • starve → binge, rather than vice versa • safety behaviours and their full outcomes • e.g., body checking; vomiting • likely impact of starvation on cognitions and emotions • and hence on further behaviours BABCP - Guildford 2011
Measurement of outcomes • Outcomes are not routinely measured • or do I just know a disproportionate number of disappointing clinicians? • on the plus side, it is not hard to change that practice • Clinicians respond to (or generate) therapy-interfering behaviours by accommodating them • remember how few weigh their patients… • many seem unconcerned about diaries, weighing, etc. • And if measured, outcomes are routinely ignored… • “I don’t know why my patient is still bingeing…” BABCP - Guildford 2011
Comorbidity and risk • Commonly see CBT clinicians ignoring key risky behaviours and comorbidity • Without bringing such things into treatment, do not expect to address the eating disorder • the patient is likely to be unable to do so BABCP - Guildford 2011
Treatment • So what behavioural elements do we need to bring (back) into treatment? • eating • exposure with response prevention • behavioural experiments • behavioural approaches to motivation • Each has a vital role in the core eating pathology • but is also valuable in addressing concurrent problems • e.g., eating to reduce mood problems • e.g., exposure to address anxiety features BABCP - Guildford 2011
Treatment • Other behavioural methods can be of use, but have less of a central impact in the eating disorders • e.g., behavioural activation, habit reversal, skills training • No evidence that the role of behavioural interventions differs across different eating disorders • But first, a quick aside • the therapeutic relationship • because if I don’t mention it, you will be thinking it… BABCP - Guildford 2011
Micro-class: But won’t all this behavioural stuff screw up the alliance with my patient? • Empirical evidence base • The therapeutic relationship has only a weak impact on the outcome of therapies • Even less impact on structured therapies, such as CBT • The therapeutic relationship can be driven by behavioural change, rather than vice versa • Patients doing evidence-based CBT for eating disorders report a strong working alliance • similar to the findings in DBT • [See summaries in: Crits-Cristoph et al.,1991; Evans et al., in press; Waller et al., in press] BABCP - Guildford 2011
Skill 1: Eating • This element seems to be surprisingly neglected • while it is included in exposure and in behavioural experimentation, remember that it is a skill • Need to teach the patient basic rules and how to operationalize them in their lives • Tools needed: • a healthy eating plan • a Department of Health plate • knowledge of the number of calories needed to gain weight… BABCP - Guildford 2011
Eating • What sort of food to eat? • food groups rather than specifics • never be fazed by specific food preferences (but challenge the general ones…) • How much to eat? • rigidity of rules tends to cause fights, but common purposes tend to get alliance • And always be ready to answer the ‘Why’ question BABCP - Guildford 2011
Eating: What goes wrong in the clinic? • Someone else’s job • this is not difficult in most cases • it does not require a dietitian to do hand-holding • dietitians are better dedicated to specialist cases • “We will do that after the cognitive work” • see earlier point about handicapping the patient • Finding the balance between rigidity and lack of rules • it is called ‘individualisation…’ • it is not a bad thing BABCP - Guildford 2011
Skill 2: Exposure • Exposure with response prevention (ERP) • Two elements, each of which is essential • elevation of anxiety • cannot learn if there is no anxiety • avoidance of safety behaviours • to reduce escape/avoidance conditioning • Can be augmented by cognitive techniques • e.g., cognitive challenges; mindfulness; distraction • But cannot be replaced by those techniques BABCP - Guildford 2011
Examples of exposure • Change in pattern and content of eating • Needs to start early in treatment • evidence that this is of benefit in bulimia (Wilson et al., 1999) • early weight change in underweight patients • Start with structure and content • roll out content across the day • challenges the patient’s beliefs about the perils of eating early • Individuals differ in response to food • so work with the individual and changes in symptoms (e.g., binges, weight) BABCP - Guildford 2011
Examples of exposure • Reduction in body-related behaviours • Checking, avoidance, comparison and display • all function as safety behaviours • reduction in anxiety, followed by feeling worse • ERP - not using the behaviour, tolerating the anxiety, and learning that mood improves in time • e.g., exposure to mirror image BABCP - Guildford 2011
Other times when we use exposure • Body image work • mirror work • Fill in the diary when you get the urge to binge • make bingeing an active choice • Reducing compensatory behaviours • waiting for 30-40 minutes after eating to allow the anxiety to subside • Eating ‘forbidden’ foods • etc., etc. BABCP - Guildford 2011
Exposure: What goes wrong in clinic? • Needs to be a skill that generalises • needs to be carried outside into the real world • patient’s responsibility • Clinicians trying to defend the patient from the anxiety involved • clinician safety behaviour • need to find that anxiety-based ‘bite’ point • Too much, too soon • make it progressive • systematic desensitization works better than flooding… BABCP - Guildford 2011
Skill 3: Behavioural experiments • Aim to test out beliefs in a systematic way, rather than simply change behaviour • Use of planned behavioural change to: • test existing beliefs about the self, others and the world • develop and test more adaptive beliefs • Commonly used to address eating, weight and shape cognitions • also valuable in working with cognitions regarding interpersonal issues and failure BABCP - Guildford 2011
Going through the steps 1 2 7 8 6 5 • If you have not taken all these steps, it is not likely to work… 3 4 BABCP - Guildford 2011
Behavioural experiments: What goes wrong in the clinic? • Failure to keep other variables static • e.g., agree to stick to eating plan rather than compensating • Not planning a ‘safe’ time to start the experiment • Not agreeing a time frame • Not planning where to go afterwards • Not allowing for the full range of outcomes • be Socratic BABCP - Guildford 2011
Skill 4: Motivation • Motivation is all about discussion, isn’t it? • a verbal run around the stages of change model before CBT begins • very commonly used (over 50%) • Unfortunately, that verbally-based approach does not really work in the eating disorders • a very, very consistent evidence base (Waller, in press) • Motivation as a manifesto • a statement to get something: not a statement of intent • Worth trying a more behaviourally-based approach BABCP - Guildford 2011
Actions speak louder than words • To start with, build patient and clinician optimism • through early, controllable symptom change • and working with therapy-interfering behaviours • And then, start responding to the patient’s real motivation • motivation as a manifesto • Disengagement • Disability training BABCP - Guildford 2011
Motivation: What goes wrong in the clinic? • Believing in the manifesto, rather than attending to what is actually happening • Clinician reducing demands of therapy • encouraging the patient to engage in change or not? • avoiding emotional arousal in the room • Clinician ‘masterly inactivity’ • “something is bound to happen if I just wait…” • Clinician ‘masterly hyperactivity’ • “if I do everything all at once, something will work” BABCP - Guildford 2011
I’ve started…so should I just carry on? • OK, so I have been doing it all wrong so far • So should I just give up with the patients I am already seeing, and change for all new patients? BABCP - Guildford 2011
Sometimes, we work with systems… • Helping colleagues • Supervision as a skill to enhance behavioural interventions • focus clinicians on good symptom outcomes and the skills needed to achieve them • responsibility for doing as well as anyone else can • Dealing with supervision-interfering behaviours BABCP - Guildford 2011
Sometimes, we work with systems… • Helping teams • Focus the team on the possibility of change • give reasonable targets • Stress the recording of objective outcomes • behaviours, weight, eating attitudes • Get the team to talk about cases openly • including successes • Encourage appropriate turnover of patients • including disengagement where appropriate BABCP - Guildford 2011
Sometimes, we work with systems… • And if the team members want to try something else, then discuss it as a team • Ask three key questions • Have you tried the evidence-based route properly? • Can you explain the theory behind this? • How are you going to structure this experiment? • anticipated outcome • time frame • report back to the team BABCP - Guildford 2011
Sometimes, we work with systems… • Helping carers • Focus on reducing carer stress and stuckness • Work with carers on self-blame • Change behaviours to reduce levels of accommodation BABCP - Guildford 2011
To conclude • There are evidence-based CBT approaches… • …and there are other CBT approaches • Evidence-based CBT is behavioural at its core… • …but it is uncommon in everyday practice • Evidence-based CBT works just as well in non-research settings… • …and other CBT approaches work just as badly BABCP - Guildford 2011
To summarise… • Getting patients to do evidence-based CBT is much easier than clinicians seem to assume • just be an optimistic realist • and use the skills that I have been idly chatting about • no magic skills • The final behavioural task of the session • you know the skills needed to help patients… • you know that this approach works • you know why we use ineffective approaches at times • Choose • for every new patient and for every existing patient BABCP - Guildford 2011
References • Crits-Christoph, P., Baranackie, K., Kurcias, J.S., Beck, A. T., Carroll, K., Perry, K., Luborsky, L., McLellan, A.T., Woody, G.E., Thompson, L., Gallagher, D., & Zitrin, C. (1991). Meta-analysis of therapist effects in psychotherapy outcome studies. Psychotherapy Research, 1, 81-91. • Evans, J., & Waller, G. (in press). The therapeutic alliance in cognitive behavioural therapy for adults with eating disorders. In J. Alexander & J. Treasure (Eds.). A collaborative approach to eating disorders. London: Routledge. • Fairburn, C.G. (2008). Cognitive behaviour therapy and eating disorders. New York: Guilford. • Gowers, S. G. & Green, L. (2009). Eating disorders: Cognitive behaviour therapy with children and younger people. London, UK: Routledge. • Safer, D.L., & Hugo, E.M. (2006). Designing a control for a behavioral group therapy. Behavior Therapy, 37, 120–130. • Tang, T.Z., & DeRubeis, R.J. (1999). Sudden gains and critical sessions in cognitive-behavioral therapy for depression. Journal of Consulting and Clinical Psychology, 67, 894−904. • Waller, G., Cordery, H., Corstorphine, E., Hinrichsen, H., Lawson, R., Mountford, V., & Russell, K. (2007). Cognitive-behavioral therapy for the eating disorders: A comprehensive treatment guide. Cambridge, UK: Cambridge University Press. • Waller, G., Evans, J., & Stringer, H. (in press). The therapeutic alliance in the early part of cognitive-behavioral therapy for the eating disorders. International Journal of Eating Disorders. BABCP - Guildford 2011