Putting the b back into cbt for eating disorders
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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

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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

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Recommended manuals

  • Manual use is associated with better adherence to CBT procedures, by the way…

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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?

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A common assumption in ‘CBT’

  • Start with the cognitions and the emotions

  • Behavioural change and physiological recovery will follow

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What is needed for evidence-based CBT?

  • Start with the behavioural and biological

  • Making mood more stable and cognitions more flexible

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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

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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?

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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

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Roadblocks to behavioural procedures?

  • Our patients have their own safety behaviours, which maintain the eating disorder

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Roadblocks to behavioural procedures?

  • As clinicians, we have our own safety behaviours, which stop us pushing for change

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Roadblocks to behavioural procedures?

  • Finally, our own safety behaviours interact with those of our patients (accommodation)

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  • 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

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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…”

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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

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  • 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

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  • 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…

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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]

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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…

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  • 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

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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

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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

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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)

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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

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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.

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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…

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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

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Going through the steps







  • If you have not taken all these steps, it is not likely to work…



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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

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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

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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

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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”

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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?

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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

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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

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    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

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    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

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    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

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    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

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    • 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.

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