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

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
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 families1
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
Recommended manuals

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

BABCP - Guildford 2011

The central role of behavioural change
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
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
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
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
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
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
Roadblocks to behavioural procedures?

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

BABCP - Guildford 2011

Roadblocks to behavioural procedures1
Roadblocks to behavioural procedures?

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

BABCP - Guildford 2011

Roadblocks to behavioural procedures2
Roadblocks to behavioural procedures?

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

BABCP - Guildford 2011


  • 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
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
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


  • 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


  • 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
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
Skill 1: Eating the alliance with my patient?

  • 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 the alliance with my patient?

  • 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
Eating: What goes wrong in the clinic? the alliance with my patient?

  • 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
Skill 2: Exposure the alliance with my patient?

  • 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
Examples of exposure the alliance with my patient?

  • 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 exposure1
Examples of exposure the alliance with my patient?

  • 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
Other times when we use exposure the alliance with my patient?

  • 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
Exposure: What goes wrong in clinic? the alliance with my patient?

  • 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
Skill 3: Behavioural experiments the alliance with my patient?

  • 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
Going through the steps the alliance with my patient?







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



BABCP - Guildford 2011

Behavioural experiments what goes wrong in the clinic
Behavioural experiments: the alliance with my patient?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
Skill 4: Motivation the alliance with my patient?

  • 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
Actions speak louder than words the alliance with my patient?

  • 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
Motivation: What goes wrong in the clinic? the alliance with my patient?

  • 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
I’ve started…so should I just carry on? the alliance with my patient?

  • 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
Sometimes, we work with systems… the alliance with my patient?

  • 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 systems1
Sometimes, we work with systems… the alliance with my patient?

  • 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 systems2
    Sometimes, we work with systems… the alliance with my patient?

    • 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 systems3
    Sometimes, we work with systems… the alliance with my patient?

    • 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
    To conclude the alliance with my patient?

    • 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
    To summarise… the alliance with my patient?

    • 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 the alliance with my patient?

    • 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