Collaborative Care Skills Training workshops: helping carers cope with eating disorders from the UK to Australia

Skills-based online self-help program for carers of people with an eating disorder (SupportED): A case series evaluation

OBJECTIVE

To investigate the acceptability, feasibility, and preliminary effectiveness of "SupportED," a novel, online, self-paced skills-based program for carers/support people of those with lived and/or living experience of an eating disorder (ED).

METHOD

Carers of a loved one with an ED were invited to undertake a five-module skills-based (one core module, four optional modules) online program at their own pace. Modules cover general information about EDs, communication, practical skills, treatment engagement, and recovery. Participants completed demographics and were assessed using EDSIS, CASK, and DASS-21 for caregiver burden, skills, and distress, respectively, at program completion and 3-month follow-up. Feedback on the program and modules was also collected.

RESULTS

Most carers (65%; 82/126) completed the core module of the program, which is on par with other online learning programs. Nearly half of program completers responded to the 3-month follow-up (n = 39). On average, carers rated the program as relevant and useful and found the information validating and easy to understand, albeit a few carers found the program time-consuming and technically challenging. Intent-to-treat (ITT) linear mixed models demonstrated the preliminary effectiveness of the program for improving carer burden and skills, although the change in carer distress was non-significant.

CONCLUSIONS

Results of this case series evaluation suggest SupportED is an acceptable and feasible program for carers and may improve burden and support skill development. Although the online, self-paced format was highly rated, small improvements to improve acceptability were suggested. Reasons for a lack of impact on carer distress are discussed.

PUBLIC SIGNIFICANCE

This article describes a case series evaluation of "SupportED," an online skills-based support program for families, carers, and supporters of people with lived experience of an eating disorder. This is the first online carer support program that is designed to be inclusive of all carer types (e.g., partners, siblings) for all eating disorder presentations. Findings suggest the program's suitability and helpfulness for reducing carers' load and bolstering skills and knowledge.

Psychotherapies for eating disorders: findings from a rapid review

BACKGROUND

Psychotherapy is considered central to the effective treatment of eating disorders-focusing on behavioural, psychological, and social factors that contribute to the illness. Research indicates psychotherapeutic interventions out-perform placebo, waitlist, and/or other treatments; but, outcomes vary with room for major improvement. Thus, this review aims to (1) establish and consolidate knowledge on efficacious eating disorder psychotherapies; (2) highlight select emerging psychotherapeutic interventions; and (3) identify knowledge gaps to better inform future treatment research and development.

METHODS

The current review forms part of a series of Rapid Reviews published in a special issue in the Journal of Eating Disorders to inform the development of the Australian-government-funded National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2023, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, and population studies). Data pertaining to psychotherapies for eating disorders were synthesised and outlined in the current paper.

RESULTS

281 studies met inclusion criteria. Behavioural therapies were most commonly studied, with cognitive-behavioural and family-based therapies being the most researched; and thus, having the largest evidence-base for treating anorexia nervosa, bulimia nervosa, and binge eating disorder. Other therapies, such as interpersonal and dialectical behaviour therapies also demonstrated positive treatment outcomes. Emerging evidence supports specific use of Acceptance and Commitment; Integrative Cognitive Affective; Exposure; Mindfulness; and Emotionally-Focused therapies; however further research is needed to determine their efficacy. Similarly, growing support for self-help, group, and computer/internet-based therapeutic modalities was noted. Psychotherapies for avoidant/restrictive food intake disorder; other, and unspecified feeding and eating disorders were lacking evidence.

CONCLUSIONS

Currently, clinical practice is largely supported by research indicating that behavioural and cognitive-behavioural psychotherapies are most effective for the treatment of eating disorders. However, the efficacy of psychotherapeutic interventions varies across studies, highlighting the need for investment and expansion of research into enhanced variants and novel psychotherapies to improve illness outcomes. There is also a pressing need for investigation into the whole range of eating disorder presentations and populations, to determine the most effective interventions.

Family connections in the treatment of relatives of people with eating disorders and personality disorders: study protocol of a randomized control trial

BACKGROUND

Eating disorders (EDs) are serious disorders that significantly affect not only the lives of patients, but also those of their family members who often experience high levels of burden, suffering and helplessness. If, in addition to ED, the patient has a personality disorder (PD), the psychological distress experienced by family members can be devastating. However, few treatments have been developed for family members of people with ED and PD. Family Connections (FC) is a programme that has been shown to be effective for family members of people with borderline personality disorder. The overall aims of this work are: (a) to adapt FC for application to family members of patients with BPD-PD (FC: ED-PD); (b) to analyse, in a randomised controlled clinical trial, the efficacy of this programme in a Spanish population, compared to a control condition consisting of treatment as usual optimised treatment (TAU-O); (c) to analyse the feasibility of the intervention protocol; (d) to analyse whether the changes that may occur in relatives are related to improvements in the family climate and/or improvements observed in patients; and (e) to analyse the perceptions and opinions of relatives and patients about the two intervention protocols.

METHODS

The study uses a two-arm randomised controlled clinical trial with two experimental conditions: adaptation of FC programme (FC: ED-PD) or Treatment as usual optimised (TAU-O). Participants will be family members of patients who meet DSM-5 criteria for ED and PD or dysfunctional personality traits. Participants will be assessed before and after treatment and at one-year follow-up. The intention-to-treat principle will be used when analysing the data.

DISCUSSION

The results obtained are expected to confirm the effectiveness of the programme and its good acceptance by family members. Trial registration ClinicalTrials.gov Identifier: NCT05404035. Accepted: May 2022.

A systematic review of the impact of carer interventions on outcomes for patients with eating disorders

PURPOSE

Eating disorder (ED) prevalence and illness severity is rapidly increasing. The complicated interplay of factors contributing to the maintenance of EDs, including family/carer influences, highlights the importance of carer interventions within ED treatment. Carer interventions demonstrate positive outcomes for carers themselves, though are also hypothesised to benefit the patient indirectly. A systematic review was conducted to greater understand the impact of carer interventions on ED patient outcomes.

METHODS

Eight databases, including CINAHL, MEDLINE and PsychINFO, were systematically searched. Intervention studies for parent(s)/carer(s) of a patient with an ED were included, provided they reported outcomes for the patient. No publication date restrictions were set. Included studies were quality appraised.

RESULTS

Twenty-eight studies met inclusion for the review; all of which varied in intervention type, duration, content and setting. Patient diagnosis and treatment setting were mixed across studies, though the majority focused on Anorexia Nervosa within outpatient settings. Intervention content broadly included consideration of relationship issues and interactional patterns, psychoeducation, skill development, behavioural management, and peer support. Therapeutic models utilised were diverse, including but not limited to: family, interpersonal, cognitive, and psychodynamic approaches.

CONCLUSION

Several carer interventions showed positive outcomes for patients with EDs, with small group treatment formats being commonly used and proving effective through intervention content alongside a peer support element. Separate family therapy was suggested to be of equal efficacy, if not better, than family therapy alongside the patient. Recommendations for clinical practice and future research are considered.

LEVEL OF EVIDENCE: 1

Systematic review, evidence mostly obtained from randomised controlled trials.

Occupational therapy interventions for adult informal carers and implications for intervention design, delivery and evaluation: A systematic review

Introduction

Informal carers provide vital support for patients, reducing strain on health and social care services. However, caring can detrimentally affect carers’ health and wellbeing, thus policy advocates for improved carer support. Objective: to establish the published international evidence base regarding interventions for carers delivered by occupational therapists.

Method

English language studies published January 2010–January 2021 were identified against predetermined inclusion/exclusion criteria via searches of MEDLINE, EMBASE, CINAHL, PsychINFO, OTSeeker, Scopus, Web of Science and the Cochrane Library. Supplemental strategies: database alerts, hand-searching, searching of included papers’ reference lists and citations, and contacting key authors. Two reviewers completed critical appraisal and produced a textual narrative synthesis of data using a convergent integrated method.

Results

38 papers were included, reporting 21 interventions. Most were dyadic, home-based interventions for carers of people living with dementia. Common intervention components included: assessment and goal-setting, skill training, education, coping strategies, equipment provision, environmental adaptation and signposting. Interventions improved outcomes for carers, however, intervention design and evaluation require careful consideration to maximise carer benefits and capture intervention effects.

Conclusion

Occupational therapist delivered carer interventions enhance support and improve carer outcomes. Intervention and evaluation designs should include careful selection of outcome measures, avoidance of increased carer burden in dyadic interventions and acknowledgement of known barriers and facilitators to both carer and therapist intervention engagement.

The experiential perspectives of parents caring for a loved one with a restrictive eating disorder in the UK

Background

Parents of a loved one with an eating disorder report high levels of unmet needs. Research is needed to understand whether clinical guidance designed to improve the experience of parents has been effective.

Aims

To establish parents’ experiential perspectives of eating disorder care in the UK, compared with guidance published by Beat, a UK eating disorders charity, and Academy for Eating Disorders, the leading international eating disorders professional association.

Method

A total of six focus groups (one online and five face-to-face) were held throughout the UK. A total of 32 parents attended. All participants were parents of a loved one with a diagnosis of anorexia nervosa or atypical anorexia nervosa (mean age 22 years; mean duration of illness 4.4 years). Focus groups were transcribed, and the text was analysed with an inductive approach, to identify emerging themes.

Results

Four key themes were identified: (a) impact of eating disorder on one's life, (b) current service provisions, (c) navigating the transition process and (d) suggestions for improvement.

Conclusions

Current experiences of parents in the UK do not align with the guidelines published by Beat and Academy of Eating Disorders. Parents identified a number of changes that healthcare providers could make, including improved information and support for parents, enhanced training of professionals, consistent care across all UK service providers, policy changes and greater involvement of families in their loved one's care. Findings from this project informed the design of a national web-survey on loved ones’ experience of care in eating disorders.

Exploring carer burden amongst those caring for a child or adolescent with an eating disorder during COVID-19

BACKGROUND

Carer burden amongst carers of youth with an eating disorder is substantial and if not addressed can lead to negative outcomes for the patient, carer and family. The Coronavirus Disease 2019 (COVID-19) pandemic has made caring for youth with an ED even more onerous and preliminary research is beginning to emerge demonstrating the profound negative impact the pandemic is having upon individuals with EDs and their carers. MAIN: In this review, we briefly summarize what is known about carer burden in families where a young person has an ED, consider the additional impact consequent to COVID-19 and highlight the need for interventions aimed at alleviating this. Pre-COVID-19 research identifies high levels of psychological and physical strain amongst those caring for a child with an ED. Themes are beginning to emerge as to why COVID-19 may further exacerbate carer burden: (1) reduced access to ED services; (2) increased physical vulnerability and exacerbation of psychiatric co-morbidity amongst youth with EDs; (3) increased practical demands placed on carers; and (4) social isolation and decreased social support.

CONCLUSION

The COVID-19 pandemic poses a specific threat to the mental health of youth with EDs and their carers. Given the salient role families play in caring for youth with an ED, attending to carer burden is imperative. Supporting carers through all phases of their child's ED journey by offering adaptive and flexible supportive services which accommodate time constraints, geographic barriers and possible COVID-19 spread is essential.

The value of including families in the treatment of anorexia nervosa

The aim of this paper is to consider family and wider carer involvement in the treatment of anorexia nervosa, and how this can be used to add value to services. We discuss widely adopted interventions involving the family that have been manualised and studied in trials that have outcome measures that are of relevance to illness costs. The therapeutic targets of these interventions range from a focus on feeding to the wellbeing of the whole family. The theoretical models that underpin interventions involving the family/wider carers include both intra and interpersonal processes, with the exception of family-based therapy, which in its original form holds an agnostic stance towards aetiology. Although formal evaluation of the cost effectiveness of these interventions is minimal, there is evidence that involving the family can reduce bed use and improve the wellbeing of both patients and family members. Moreover, for the most part, these interventions are acceptable to patients and carers. Finally, we consider how these approaches can be disseminated and scaled up more widely into services.

How are families included in the treatment of adults affected by eating disorders? A scoping review

OBJECTIVE

The involvement of families in the treatment of adults with eating disorders is recommended as a core component of comprehensive care, yet little is known about the optimal way to implement or routinely facilitate this. This article evaluates the recent evidence on the inclusion of families in treatment programs for adults with eating disorders.

METHOD

A systematic literature search was conducted to identify evidence of family inclusive treatment approaches for adults with eating disorders. A scoping review framework was applied to assess and synthesize findings.

RESULTS

Sixty-eight studies were identified. Substantial conceptual research contributing to the theoretical basis of current practice with families of adults with eating disorders and clinical applications in current use were identified. Most research used uncontrolled studies with few experimental designs, reflecting the standing of the extant literature. Common elements of existing approaches have been distinguished and shared core components of interventions identified.

DISCUSSION

Results confirmed that family members of adults were willing to be involved with eating disorder treatment services and appeared to respond to interventions of varying intensity and duration. The impact on individual patients, and effect on treatment outcomes, are yet to be established. The localized settings of existing studies, the homogenous nature of interventions used, and the limited diversity in research subjects, make it difficult to generalize from the results to the wide range of adult eating disorder presentations seen in practice. Suggestions for future research and further clinical developments are discussed.

Childhood Avoidant/Restrictive Food Intake Disorder: Review of Treatments and a Novel Parent-Based Approach

Avoidant/Restrictive food intake disorder (ARFID) is characterized by dietary restrictions that are not based on weight or shape concerns but that result in marked interference in feeding, growth, or psychosocial functioning (American Psychiatric Association, 2013; Eddy et al., 2019). The aim of the current article was to review available reports of treatment for childhood ARFID published since its inclusion in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), and to introduce a novel parent-based treatment for child ARFID through a case presentation. Empirical support for psychosocial treatments for child ARFID currently stems from two small-scale pilot randomized control trials, one pilot open trial, case reports, case series, and retrospective chart reviews. Treatment approaches for outpatient care generally apply family-based therapy, child-centered cognitive behavioral therapy, or parent-based behavioral approaches. SPACE-ARFID is a novel outpatient parent-based treatment that focuses on parental responses to child problematic eating habits. SPACE-ARFID aims to promote flexibility and adjustment in food related situations. The treatment helps parents to systematically reduce family accommodation, or changes that they make to their own behavior to help their child avoid or alleviate distress related to the disorder, while increasing supportive responses to the child's symptoms.

Cognitive Interpersonal Model for Anorexia Nervosa Revisited: The Perpetuating Factors that Contribute to the Development of the Severe and Enduring Illness

The cognitive interpersonal model was outlined initially in 2006 in a paper describing the valued and visible aspects of anorexia nervosa (Schmidt and Treasure, 2006). In 2013, we summarised many of the cognitive and emotional traits underpinning the model (Treasure and Schmidt, 2013). In this paper, we describe in more detail the perpetuating aspects of the model, which include the inter- and intrapersonal related consequences of isolation, depression, and chronic stress that accumulate in the severe and enduring stage of the illness. Since we developed the model, we have been using it to frame research and development at the Maudsley. We have developed and tested interventions for both patients and close others, refining the model through iterative cycles of model/intervention development in line with the Medical Research Council (MRC) framework for complex interventions. For example, we have defined the consequences of living with the illness on close others (including medical professionals) and characterised the intense emotional reactions and behaviours that follow. For the individual with an eating disorder, these counter-reactions can allow the eating disorder to become entrenched. In addition, the consequent chronic stress from starvation and social pain set in motion processes such as depression, neuroprogression, and neuroadaptation. Thus, anorexia nervosa develops a life of its own that is resistant to treatment. In this paper, we describe the underpinnings of the model and how this can be targeted into treatment.

Efficacy of a brief group intervention for carers of individuals with eating disorders: A randomized control trial

OBJECTIVE

Interventions for carers of individuals with eating disorders are often time and resource intensive, which may be a barrier for service providers or attendees. This study aimed to evaluate the efficacy of a very brief, two-session psychoeducation and communication skills-based intervention for carers of individuals with eating disorders.

METHOD

Carers (N = 44) were randomized to attend two 2.5 hr sessions delivered 1 week apart or waitlist control. Carer burden, self-efficacy, skills, knowledge, expressed emotion (emotional overinvolvement and critical comments), distress (anxiety and depression), and accommodating and enabling behaviors were assessed at preintervention and postintervention and 1-month follow-up.

RESULTS

Carer burden, self-efficacy, skills, knowledge, and one component of expressed emotion (critical comments) improved significantly more in the treatment group compared to the waitlist. Changes in anxiety, depression, and accommodating and enabling behaviors did not significantly differ between groups.

DISCUSSION

These results demonstrated that substantial improvements can be made from a very brief carers' intervention. More intensive and targeted interventions might be required to address carers' emotional symptoms and to reduce accommodating and enabling behaviors.

Parenting skills after participation in skills-based training inspired by the New Maudsley Method: a qualitative study in an outpatient eating disorder setting

BACKGROUND

Eating disorders affect the whole family and it is recommended that parents play an important role in their adolescents' recovery. Being a parent to an adolescent with an eating disorder is often linked to feelings of guilt and hopelessness and at the same time parents often feel left alone with unmet needs when it comes to handling symptoms in family life. Little is known about parents' perspectives to skills-based training in adolescent eating disorder treatment. This knowledge is urgently required, since previous research has focused mainly on adult patients showing positive effects of skills-based training as a promising adjunct in eating disorder treatment.

OBJECTIVE

To examine parents' perception of their new skills after having participated in skills-based training inspired by the New Maudsley Method.

METHODOLOGY

A qualitative study using deductive dominant content analysis.

METHODS

In total, 21 parents participated in focus groups.

FINDINGS

Three categories were identified (i) Standing outside oneself and realise that one has become entangled in the illness, (ii) Understanding the daughter's inner life with the illness offers new opportunities in the relationship, (iii) Courage to find new ways of parenting. The parents experienced themselves more calm and confident in their ability to recognise and confront the eating disorder symptoms. They expressed increased communication skills, which improved their relationship with their child and gave access to her inner life.

CONCLUSION

Skills-based training serves as an important intervention and it may improve parental skills, reduce high expressed emotions and reduce anxiety, guilt and stress. Skills-based training may contribute to reinforcing parents to regain parenting authority and enable parents and adolescents to 'be on the same side' in the beating the eating disorder.

Treatment dropout in a family-based partial hospitalization program for eating disorders

Treatment dropout is a significant challenge in the treatment of eating disorders. In day hospital/partial hospitalization program settings, little is known about factors associated with treatment dropout. The purpose of the present study was to assess factors associated with treatment dropout in a partial hospitalization program for adolescents and young adults with anorexia nervosa. Patients and parents completed self-report and interview-based measures at baseline and at end of treatment in the partial hospitalization program. Few factors were found that differentiated the two groups. Those who dropped out had lower body weight at end of treatment, were less likely to have purged in the previous month, and had fathers who scored higher on the criticism subscale of expressed emotion. Patients who are purging may be seen as having more severe symptoms, thus possibly reducing the chances of parents prematurely discontinuing treatment. Parental criticism is a potentially modifiable factor in treatment. Further research is needed to identify effective ways to reduce parental criticism, and to identify additional modifiable factors associated with treatment dropout to reduce dropout rates in this population.Level IV: Evidence obtained from multiple time series with or without the intervention, such as case studies.

Family accommodation in psychopathology: A synthesized review

Family accommodation describes changes that family members make to their own behavior, to help their relative who is dealing with psychopathology, and to avoid or alleviate distress related to the disorder. Research on family accommodation has expanded greatly in the past few years. The aim of this study was to provide a synthesized review of recent findings on family accommodation in psychopathology. Electronic databases were searched for available, peer-reviewed, English language papers, published between September 2015 and March 2018, cross-referencing psychiatric disorders with accommodation and other family-related terms. Ninety-one papers were identified and reviewed, of which 69 were included. In obsessive-compulsive disorder and anxiety disorders family accommodation has been linked to symptom severity, functional impairment, caregiver burden, and poorer treatment outcomes. Several randomized controlled trials explored the efficacy of treatments aimed at reducing family accommodation. A growing number of studies have reported family accommodation in eating disorders where it is associated with greater symptom severity and caregiver burden. Family accommodation has also been studied in other disorders, including autism spectrum disorders, tic disorders, and posttraumatic stress disorder. Research on family accommodation in psychopathology is advancing steadily, expanding across disorders. The study highlights the importance of addressing family accommodation in the assessment and treatment of various disorders.

Experience of caregiving and coping strategies in caregivers of adolescents with an eating disorder: A comparative study

Caring for a relative with an eating disorder (ED) is associated with heightened psychological distress, which, according to a stress-coping model, may be influenced by coping and appraisal. However, limited quantitative studies have assessed coping in ED caregivers. This cross-sectional study aims to assess 1) the differences in coping between caregivers of three groups: patients with an ED, patients with a substance use disorder, and healthy teens, and 2) the patient and caregiver variables associated with coping and appraisal of the caregiving experience. A one-way MANOVA was significant for caregiver group for mothers, but not fathers. Mothers of both patient groups used more self-sufficient problem focused coping than mothers of healthy teens. Patient caregivers did not significantly differ from caregivers of healthy teens in their use of avoidance. Mothers used social support strategies more than fathers. A positive experience of caregiving was significantly associated with the use of approach-oriented coping in ED caregivers and a negative experience of caregiving was significantly associated with avoidance in ED mothers. Older ED caregivers were less likely to use avoidance. Future interventions could help ED caregivers to recognize their coping preferences and how to appropriately use these strategies when faced with illness-related stressors.

Interventions for caregivers of someone with an eating disorder: a meta-analysis

OBJECTIVE

A variety of interventions have been developed for caregivers of people with an eating disorder either to help them cope with the burden and distress that commonly accompanies this role or to make them more effective at providing support. The aim of the study is to perform a meta-analysis of quantitative studies that have described the impact of these interventions on caregivers.

METHOD

Electronic databases were searched between September 2001 and September 2013. Thirteen studies were finally selected for inclusion. Pooled effect size estimates were summarized. Meta-regressions were used to determine whether type of intervention, team, measure used or risk of bias were effect modifiers of the relationship. We also summarized the content and form (amount of professional help) of the interventions.

RESULTS

Most interventions produced a moderate sized reduction in carer distress and a small/moderate reduction in carer burden and expressed emotion post treatment and these changes were maintained over follow-up.

DISCUSSION

Carer distress, burden and expressed emotion can be reduced by a variety of psychoeducational interventions and these changes are sustainable over time. The interventions themselves are easy to disseminate and deliver.

International training programs on eating disorders for professionals, caregivers, and the general public: A scoping review

This review identified and synthesized published training programs on eating disorders (ED) (anorexia nervosa or bulimia nervosa) for professionals, natural supporters of people with ED, or the public. A scoping review using the Arksey and O'Malley (2005) framework was conducted. Four data bases were searched, for all years, and manual searches from three additional sources were also conducted. Experts on ED were consulted for validation of the identified studies. A narrative synthesis was performed. A total of 20 evaluation studies from five countries were identified, and reviewed in relation to 14 ED training programs. Characteristics of the training programs, and study characteristics, were highly diverse, as shown on Table 1 which compiles results from the charted data. Evaluations were equally divided between training for healthcare and education professionals (9), and training for families or other carers of people with ED (10). One study evaluated ED training for the general public. We found that training orientation varies with the interests and needs of different trainee groups. While most studies assessed trainee outcomes, future research needs to give greater consideration to patient perspectives, and to the relationship between training and evaluation approaches, improved knowledge, and better care.

Collaborative Care: The New Maudsley Model

The aim of this article is to describe the rationale and practice of the New Maudsley collaborative care intervention for families of people with eating disorders. The intervention teaches carers the underpinning theory with practical examples on how to optimize their care giving, communication, and coping skills. This includes moderating high expressed emotion and reducing the tendency to accommodate and/or enable illness behaviors. Transcripts are used to give examples of this approach in action. The emerging evidence base indicates that this approach improves both carer and patient well-being and also is associated with a more efficient use of resources.

A systematic review of family caregiving in eating disorders

The objective of the study was to review systematically the available new evidence on family caregiving in eating disorders (ED), updating the study of Zabala, Macdonald, and Treasure (2009). Electronic databases were searched from October 2008 until May 2013. Selected studies included carers of people with ED and employed one or more measures of caregiving experience, accommodation and enabling behaviours, expressed emotion, and/or psychological distress. Twenty-nine studies were identified. Most of the studies examined these features in mothers of patients with anorexia. Only a few studies included a control group. The majority of studies found high levels of negative aspects of caregiving, accommodation and enabling behaviours, expressed emotion and psychological distress in carers of people with ED, although positive aspects and emotions were also reported. These features varied depending on some sociodemographic and clinical characteristics of carers and patients; moreover, interesting preliminary cultural and gender differences emerged. Progress has been made in research on family caregiving in ED and there is evidence that these factors can be associated with the outcome of ED. Theoretical, research and clinical implications of the findings are discussed.

Experienced Carers Helping Others (ECHO): protocol for a pilot randomised controlled trial to examine a psycho-educational intervention for adolescents with anorexia nervosa and their carers

Experienced Carers Helping Others (ECHO) is an intervention for carers of people with eating disorders. This paper describes the theoretical background and protocol of a pilot multicentre randomised controlled trial that will explore the use of two variants of ECHO for improving outcomes for adolescents with anorexia nervosa (AN) referred for outpatient care. Adolescent patients and their carers (typically parents and close others in a supportive role) will be recruited from 38 eating disorder outpatient services across the UK. Carers will be randomly allocated to receive 'ECHOc' guided self-help (in addition to treatment as usual), 'ECHO' self-help only (in addition to treatment as usual) or treatment as usual only. Primary outcomes are a summary measure of the Short Evaluation of Eating Disorders at 6- and 12-month follow-ups. Secondary outcomes are general psychiatric morbidity of AN patients and carer, carers' coping and behaviour, and change in healthcare use and costs at 6- and 12-month follow-ups. Therapist effects will be examined, and process evaluation of ECHOc will be completed. The findings from this pilot trial will be used in preparation for executing a definitive trial to determine the impact of the preferred variant of ECHO to improve treatment outcomes for AN.

Confirmatory factor analysis for two questionnaires of caregiving in eating disorders

Objective: Caring for someone diagnosed with an eating disorder (ED) is associated with a high level of burden and psychological distress which can inadvertently contribute to the maintenance of the illness. The Eating Disorders Symptom Impact Scale (EDSIS) and Accommodation and Enabling Scale for Eating Disorders (AESED) are self-report scales to assess elements of caregiving theorised to contribute to the maintenance of an ED. Further validation and confirmation of the factor structures for these scales are necessary for rigorous evaluation of complex interventions which target these modifiable elements of caregiving. Method: EDSIS and AESED data from 268 carers of people with anorexia nervosa (AN), recruited from consecutive admissions to 15 UK inpatient or day patient hospital units, were subjected to confirmatory factor analysis to test model fit by applying the existing factor structures: (a) four-factor structure for the EDSIS and (b) five-factor structure for the AESED. Results: Confirmatory factor analytic results support the existing four-factor and five-factor structures for the EDSIS and the AESED, respectively. Discussion: The present findings provide further validation of the EDSIS and the AESED as tools to assess modifiable elements of caregiving for someone with an ED.