Factors influencing the utilization of empirically supported treatments for eating disorders

Implementing service transformation for children and adolescents with eating disorders across England: the theory, politics, and pragmatics of large-scale service reform

BACKGROUND

Eating disorders are among the most serious mental health problems affecting children and young people and without appropriate treatment often have a protracted course with high levels of morbidity and mortality. While considerable progress has been made in recent years in developing effective evidence-based outpatient treatments, these are not always readily available. In England, until recently, the usual care pathway for young people with an eating disorder was referral from primary care to local generic Child and Adolescent Mental Health Services with varying levels of expertise in eating disorders and a mix of outpatient treatments available. Poor treatment progress or physical deterioration would usually result in inpatient admission. Admission rates were high, with children and young people with an eating disorder accounting for nearly a quarter of all child and adolescent psychiatric hospital admissions. Inpatient treatment is costly and has high relapse rates with some evidence that it may contribute to poorer long-term outcomes in eating disorders. Accumulating clinical and research evidence that early expert outpatient treatment can significantly reduce the need for inpatient care indicates,+ that investing in dedicated community-based eating disorders services is likely to be both clinically and economically beneficial.

OVERVIEW OF PAPER

This paper describes a large-scale transformation programme following a major government investment (initially £30 million/year, since then increased to over £50 million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community-based eating disorders services for children and young people.

Disordered eating in collegiate English equestrian athletes in aesthetic and nonaesthetic disciplines

Little is known about the rates of disordered eating behaviors in the athletes who compete in the disciplines that comprise collegiate English Equestrian sports. Importantly, in some subdisciplines, riders' scores depend upon judges' assessment of their appearance while riding, rather than upon solely objective measures such as time to complete a course. The purpose of the present research was to 1) assess the current rate of disordered eating behaviors in college equestrian athletes, 2) test whether certain disciplines of English riding (i.e., those that focus on aesthetics or non-aesthetics) at the collegiate level have higher rates of disordered eating behaviors, and 3) test whether these athletes face different pressures for appearance and weight if they specialize in aesthetic riding disciplines. English equestrian student athletes from across the United States (N = 330; 97 % female) and from the following disciplines were surveyed: equitation (aesthetic), dressage (aesthetic), hunters (aesthetic), jumpers (non-aesthetic), and eventing (non-aesthetic). The results suggest a high prevalence of disordered eating in the sport (35 % met cut off for disordered eating using the EAT-26). Findings suggest similar rates of disordered eating behaviors between the aesthetic and non-aesthetic disciplines. Findings also indicate that student athletes in aesthetic disciplines were much more likely to say that they were weighed by coaches and pressured to lose weight. Thus, the current study lends empirical support to the notion that coaches can be a source of pressure for these athletes. Issues of addressing disordered eating in coaching and future research are discussed.

Challenging rigidity in Anorexia (treatment, training and supervision): questioning manual adherence in the face of complexity

BACKGROUND

Anorexia Nervosa is a debilitating illness. While there have been many advancements to treatment protocols and outcomes for people with eating disorders, the field acknowledges there remains considerable room for improvement. This timely Special Edition of the Journal of Eating Disorders has invited those of us in the field to consider a range of topics in aid of this task, including potential modifications and implementation of evidence-based practice, specific and common psychotherapy factors, treatment manuals, adherence and individualising treatment approaches for individuals and families. BODY: In this paper, we briefly outline the key manualised treatments currently available to treat children, adolescents and adults with Anorexia Nervosa, considering the benefits, potential reasons for adaptations and limitations. We then review the current evidence for training strict adherence to treatment manuals which is often a key focus in training and supervision, questioning the association of increased treatment adherence with improved therapeutic outcome. We then summarise some key evidence behind other therapeutic factors which have been demonstrated to affect outcome regardless of which manual is implemented, such as readiness to change and therapeutic alliance.

CONCLUSION

The paper concludes with implications and considerations for future research, clinical guidelines, training and supervision, highlighting the need to consider the therapeutic relationship and processes alongside manual content to conduct best evidence-informed practice.

Differences between Australian adolescents with eating disorder symptoms who are in treatment or not in treatment for an eating disorder

BACKGROUND

Mental health problems frequently occur during adolescence, however, few adolescents seek treatment for these problems, especially for eating disorders. The current study aimed to quantify how adolescents in a clinical sample (ie, those receiving treatment for an eating disorder), differ in terms of psychological factors (eating disorder symptoms and psychological distress), compared to adolescents with eating pathology in a community sample (ie, those not receiving treatment).

METHOD

Data were used from a community sample of adolescents with eating disorder pathology who have not sought treatment (n = 1011) and a clinical sample of adolescents presenting at eating disorder services for treatment (n = 153). Participants reported demographics and completed questionnaires assessing weight/shape concerns, disordered eating and psychological distress.

RESULTS

Adolescents with a lower BMI, more frequent purging and higher weight/shape concerns were more common in the clinical sample, while those engaging in more frequent driven exercise were less common in the clinical sample. The samples did not differ in severity of psychological distress.

CONCLUSIONS

The findings highlight the need for increasing mental health literacy about the role of BMI and driven exercise in eating disorder symptom presentation to increase early detection of these disorders among adolescents.

Workforce Diversity in Eating Disorders: A Multi-Methods Study

Despite growing recognition of the importance of workforce diversity in health care, limited research has explored diversity among eating disorder (ED) professionals globally. This multi-methods study examined diversity across demographic and professional variables. Participants were recruited from ED and discipline-specific professional organizations. Participants' (n = 512) mean age was 41.1 years (SD = 12.5); 89.6% (n=459) of participants identified as women, 84.1% (n = 419) as heterosexual/straight, and 73.0% (n = 365) as White. Mean years working in EDs was 10.7 years (SD = 9.2). Qualitative analysis revealed three themes resulting in a theoretical framework to address barriers to increasing diversity. Perceived barriers were the following: "stigma, bias, stereotypes, myths"; "field of eating disorders pipeline"; and "homogeneity of the existing field." Findings suggest limited workforce diversity within and across nations. The theoretical model suggests a need for focused attention to the educational pipeline, workforce homogeneity, and false assumptions about EDs, and it should be tested to evaluate its utility within the EDs field.

Eating disorders "mental health literacy": a scoping review

Background: While it is apparent that much has been learned about "mental health literacy" (MHL) relating to certain mental health problems, such as depression, in recent years, what has been learned about MHL relating to eating disorders (ED-MHL) is unclear.Aims: A scoping review was conducted to inform the current state of knowledge in this field.Methods: A systematic search of relevant literature published between 1997 and 2017 was followed by a narrative synthesis of the findings.Results: The number of eligible studies increased from 32 in 1997-2001 to 98 in 2012-2017 (total = 264). Most studies originated from North America or Europe, recruited individuals with EDs receiving treatment or college students and included both female and male or only female participants. The majority of studies examined MHL relating to anorexia nervosa or bulimia nervosa and examined attitudes which facilitate recognition and appropriate help-seeking and knowledge and beliefs about professional help available.Conclusion: Interest in ED-MHL is increasing and there is now a considerable body of research addressing some aspects of ED-MHL in a range of study populations. Notable gaps in the literature exist, including a paucity of information about ED-MHL relating to EDs other than anorexia nervosa and bulimia nervosa, ED behaviour in males and the use of self-help interventions. We hope the findings will provide an incentive to further research in these and other aspects of ED-MHL.

Attitudes Toward Family-Based Treatment Impact Therapists' Intent to Change Their Therapeutic Practice for Adolescent Anorexia Nervosa

Community-based clinicians who treat patients with eating disorders rarely use empirically-supported treatments, and research demonstrates that clinicians make significant modifications when implementing family-based treatment (FBT) for anorexia nervosa. This study examined clinician attitudes toward FBT and explored the extent to which attitudes predicted intent to shift practices following training in FBT. Clinicians (N = 129) completed a standardized training in FBT for AN, either a two-day introductory training (n = 99) or a one-day "advanced" training (n = 30). Linear regressions were used to examine the association between therapists' attitudes toward FBT and their intent to use strategies consistent with FBT in the future, adjusting for pre-training use of strategies. Providers reported very positive attitudes toward evidence-based practices in general and moderately positive attitudes toward FBT. There were no significant differences between "novice" and "advanced" providers on attitudes toward evidence-based practices or FBT (ps > .10). For the subset of providers attending their first training in FBT, more positive attitudes toward FBT significantly predicted greater intent to use FBT-consistent strategies (p = .004), and more positive attitudes toward evidence-based practice significantly predicted lesser intent to use FBT-inconsistent strategies (p = .009). This study suggests that both general attitudes toward evidence-based practice and specific attitudes toward FBT may impact implementation. Future research might examine whether a brief intervention to improve attitudes toward FBT might increase the likelihood of seeking expert consultation post-training.

Delivery of Family-Based Treatment for Adolescent Anorexia Nervosa in a Public Health Care Setting: Research Versus Non-Research Specialty Care

Comparing evidence-based psychotherapy (EBP) to usual care typically demonstrates the superiority of EBPs, although this has not been studied for eating disorders EBPs such as family-based treatment (FBT). The current study set out to examine weight outcomes for adolescents with anorexia nervosa who received FBT through a randomized clinical research trial (RCT, n = 54) or non-research specialty care (n = 56) at the same specialist pediatric eating disorder service. Weight was recorded throughout outpatient treatment (up to 18 sessions over 6 months), as well as at 6- and 12-month follow-up. Survival curves were used to examine time to weight restoration [greater than 95% median body mass index (mBMI)] as predicted by type of care (RCT vs. non-research specialty care), baseline clinical and demographic characteristics, and their potential interaction. Results did not indicate a significant main effect for type of care, but there was a significant effect for baseline weight (p = .03), such that weight restoration was achieved faster across both treatment types for those with a higher initial %mBMI. These data suggest that weight restoration achieved in non-research specialty care FBT was largely similar to that achieved in a controlled research trial.

CLINICAL TRIAL REGISTRATION

http://www.anzctr.org.au/, identifier ACTRN12610000216011.

What do people really think about grief counseling? Examining community attitudes

To understand why bereaved people who are highly distressed significantly underutilize grief counseling and therapy, we surveyed adults (N = 156) to investigate community attitudes toward grief counseling. Overall attitude was positive and women reported a significantly more positive attitude than men; there were no associations between attitude and age, country of birth, previous counseling, or bereavement experience. After controlling for gender, beliefs and affects explained attitudes toward grief counseling; behavioral responses did not. Targeting beliefs about grief counseling may promote positive attitudes so that people most likely to benefit from intervention will be more likely to seek it.

To deliver or not to deliver cognitive behavioral therapy for eating disorders: Replication and extension of our understanding of why therapists fail to do what they should do

OBJECTIVE

This study investigated the extent to which therapists fail to apply empirically supported treatments in a sample of clinicians in The Netherlands, delivering cognitive behavioral therapy for eating disorders (CBT-ED). It aimed to replicate previous findings, and to extend them by examining other potential intra-individual factors associated with the level of (non-)use of core CBT-ED techniques.

METHOD

Participants were 139 clinicians (127 women; mean age 41.4 years, range = 24-64) who completed an online survey about the level of use of specific techniques, their beliefs (e.g., about the importance of the alliance and use of pretreatment motivational techniques), anxiety (Intolerance of Uncertainty Scale), and personality (Ten Item Personality Inventory).

RESULTS

Despite some differences with Waller's (2012) findings, the present results continue to indicate that therapists are not reliably delivering the CBT-ED techniques that would be expected to provide the best treatment to their patients. This 'non-delivery' appears to be related to clinician anxiety, temporal factors, and clinicians' beliefs about the power of the therapeutic alliance in driving therapy outcomes.

DISCUSSION

Improving treatment delivery will involve working with clinicians' levels of anxiety, clarifying the lack of benefit of pre-therapy motivational enhancement work, and reminding clinicians that the therapeutic alliance is enhanced by behavioral change in CBT-ED, rather than the other way around.

Cognitive behavioural therapy for eating disorders: how do clinician characteristics impact on treatment fidelity?

BACKGROUND

Clinicians routinely report not practising evidence-based treatments with eating disorders. There has been limited research investigating the impact of adaptable clinician characteristics such as self-efficacy and therapeutic optimism in this area. This study evaluated if there is a relationship between clinician therapeutic optimism, self-efficacy and the provision of evidence-based practice in the treatment of bulimia nervosa and binge eating disorder.

METHOD

A survey developed for this study was administered to 100 psychologists who were recruited online via a range of organisations affiliated with psychology and/or eating disorders. The survey measured demographic factors, eating disorder treatment knowledge, treatment fidelity, the use of individual treatment components and a range of clinician characteristics including self-efficacy and therapeutic optimism.

RESULTS

Results demonstrated that clinician self-efficacy was positively associated with and predicted treatment fidelity. Therapeutic optimism had significant low correlations with treatment fidelity but did not predict treatment fidelity.

CONCLUSION

These findings would suggest that strengthening clinician self-efficacy is useful in improving evidence-based practice in the treatment of binge eating disorder and bulimia nervosa and may also have implications in the training of clinicians. The study also demonstrated that the use of a range of knowledge translation strategies are valuable in enhancing clinician adherence to evidence-based practice. Further research with direct measures of treatment fidelity is needed to clarify these findings.

Treatment Protocols for Eating Disorders: Clinicians' Attitudes, Concerns, Adherence and Difficulties Delivering Evidence-Based Psychological Interventions

There are several protocols in existence that guide clinicians in the implementation of effective, evidence-based psychological interventions for eating disorders. These have been made accessible in the form of treatment manuals. However, relatively few clinicians use those protocols, preferring to offer more eclectic or integrative approaches. Following a summary of the research that shows that these evidence-based approaches can be used successfully in routine clinical settings, this review considers why there is such poor uptake of these therapies in such settings. This review focuses on the role of service culture and on clinicians' own attitudes, beliefs and emotions. Possible means of enhancing uptake are considered, but these cannot be considered to be ideal solutions at present.

Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track

Therapist drift occurs when clinicians fail to deliver the optimum evidence-based treatment despite having the necessary tools, and is an important factor in why those therapies are commonly less effective than they should be in routine clinical practice. The research into this phenomenon has increased substantially over the past five years. This review considers the growing evidence of therapist drift. The reasons that we fail to implement evidence-based psychotherapies are considered, including our personalities, knowledge, emotions, beliefs, behaviours and social milieus. Finally, ideas are offered regarding how therapist drift might be halted, including a cognitive-behavioural approach for therapists that addresses the cognitions, emotions and behaviours that drive and maintain our avoidance of evidence-based treatments.

Weighing patients within cognitive-behavioural therapy for eating disorders: How, when and why

While weight, beliefs about weight and weight changes are key issues in the pathology and treatment of eating disorders, there is substantial variation in whether and how psychological therapists weigh their patients. This review considers the reasons for that variability, highlighting the differences that exist in clinical protocols between therapies, as well as levels of reluctance on the part of some therapists and patients. It is noted that there have been substantial changes over time in the recommendations made within therapies, including cognitive-behavioural therapy (CBT). The review then makes the case for all CBT therapists needing to weigh their patients in session and for the patient to be aware of their weight, in order to give the best chance of cognitive, emotional and behavioural progress. Specific guidance is given as to how to weigh, stressing the importance of preparation of the patient and presentation, timing and execution of the task. Consideration is given to reasons that clinicians commonly report for not weighing patients routinely, and counter-arguments and solutions are presented. Finally, there is consideration of procedures to follow with some special groups of patients.

Disseminating evidence-based psychological treatments for eating disorders

The research-practice gap is of concern in the treatment of eating disorders. Despite the existence of empirically supported treatments, few receive them. The barriers to wider dissemination and implementation of evidence-based treatment include clinician attitudes towards such treatments and the lack of sufficient numbers of suitably trained therapists to provide treatment. In this review we discuss these barriers in the context of the wider issue of the dissemination and implementation of psychological treatments and review the research with regard to the treatment of eating disorders. Particular emphasis is placed on examining recent efforts to expand the availability and reach of treatments by making treatment delivery and training more scalable. We highlight promising developments and areas where further research is needed.

Clinician adherence to guidelines in the delivery of family-based therapy for eating disorders

OBJECTIVE

Clinicians have been shown to drift away from protocol in their delivery of evidence-based treatments. This study explores this phenomenon in the delivery of family-based therapy (FBT) for eating disorders, and the clinician characteristics that might explain such therapist drift.

METHOD

The participants were 117 clinicians who reported using FBT for eating disorders. They completed an online survey, which included questions relating to clinician characteristics, caseload, and reported use of FBT manuals and core therapeutic tasks, as well as a measure of anxiety.

RESULTS

The use of core FBT tasks was higher than for other therapies, but there were still noteworthy gaps between recommended and reported practice. Approximately a third of clinicians reported delivering "FBT" that deviated very substantially from evidence-based protocols, often appearing to be on an individual therapy basis. Using an FBT manual to guide treatment delivery was associated with greater adherence to recommended techniques. Clinician caseload and anxiety were associated with differences in the use of specific FBT tasks.

DISCUSSION

Consistent with previous research regarding clinicians' use of other therapies, the delivery of FBT for the eating disorders is not homogeneous.

CONCLUSION

Further investigation of this phenomenon is needed to determine the impact of deviating from treatment protocols on the effectiveness of FBT for the eating disorders.

Clinicians' concerns about delivering cognitive-behavioural therapy for eating disorders

Despite research supporting the effectiveness of evidence-based interventions in the treatment of eating disorders, those interventions are under-utilised in routine clinical practice, possibly due to clinicians' concerns about delivering the relevant techniques. This study examined what elements of therapy clinicians worry about when delivering cognitive-behavioural therapy (CBT) for the eating disorders, and what clinician variables are associated with such concerns. The participants were 113 clinicians who used individual CBT with eating disorder patients. They completed a novel measure of concerns about delivering elements of CBT, as well as demographic characteristics and a standardised measure of intolerance of uncertainty. Clinicians worried most about body image work and ending treatment, but least about delivering psychoeducation. Their concerns fell into four distinct factors. Older, more experienced clinicians worried less about delivering the CBT techniques, but those with greater levels of prospective and inhibitory anxiety worried more about specific factors in the CBT techniques. Clinicians' capacity to tolerate uncertainty might impair their delivery of evidence-based CBT, and merits consideration as a target in training and supervision of CBT clinicians.

Mapping the evidence for the prevention and treatment of eating disorders in young people

ABSTRACT

Eating disorders often develop during adolescence and young adulthood, and are associated with significant psychological and physical burden. Identifying evidence-based interventions is critical and there is need to take stock of the extant literature, to inform clinical practice regarding well-researched interventions and to direct future research agendas by identifying gaps in the evidence base.

AIM

To investigate and quantify the nature and distribution of existing high-quality research on the prevention and treatment of eating disorders in young people using evidence mapping methodology.

METHOD

A systematic search for prevention and treatment intervention studies in adolescents and young adults (12-25 years) was conducted using EMBASE, PSYCINFO and MEDLINE. Studies were screened and mapped according to disorder, intervention modality, stage of eating disorder and study design. Included studies were restricted to controlled trials and systematic reviews published since 1980.

RESULTS

The eating disorders evidence map included 197 trials and 22 systematic reviews. Prevention research was dominated by trials of psychoeducation (PE). Bulimia nervosa (BN) received the most attention in the treatment literature, with cognitive behavioural therapy (CBT) and antidepressants the most common interventions. For anorexia nervosa (AN), family based therapy (FBT) was the most studied. Lacking were trials exploring treatments for binge eating disorder (BED) and eating disorder not otherwise specified (EDNOS). Relapse prevention strategies were notably absent across the eating disorders.

CONCLUSIONS

Despite substantial literature devoted to the prevention and treatment of eating disorders in young people, the evidence base is not well established and significant gaps remain. For those identified as being at-risk, there is need for prevention research exploring strategies other than passive PE. Treatment interventions targeting BED and EDNOS are required, as are systematic reviews synthesising BN treatment trials (e.g., CBT, antidepressants). FBTs for AN require investigation against other validated psychological interventions, and the development of relapse prevention strategies is urgently required. By systematically identifying existing interventions for young people with eating disorders and exposing gaps in the current literature, the evidence map can inform researchers, funding bodies and policy makers as to the opportunities for future research.

Understanding the uptake of family-based treatment for adolescents with anorexia nervosa: therapist perspectives

OBJECTIVE

To explore and describe therapists' perceptions of the factors affecting their uptake of family-based treatment (FBT) for adolescents with anorexia nervosa (AN).

METHOD

Fundamental qualitative description guided the sampling and data collection in this study. A purposeful sample of 40 therapists providing treatment to youth with AN, completed an in-depth interview. Conventional content analysis guided the development of initial codes and categories, whereas constant comparison analytic techniques were used to compare and contrast therapist perceptions across contexts. Summative content analysis was used to provide counts of keywords, phrases, and themes.

RESULTS

Therapists face several barriers to the implementation of FBT, divided broadly into interventional, organizational, interpersonal, patient/family, systemic, and illness factors. Therapists support the implementation of evidence-based practices, including FBT for AN, but fidelity to this model is not practiced. Specific concerns about the intervention included weighing the patient, providing nutritional advice, and the family meal. Ninety-five percent of therapists requested further training in the FBT model.

DISCUSSION

Further investigation into the barriers and facilitating factors to the use of FBT is warranted. Understanding effective dissemination and training strategies is critical to ensuring patients receive the best possible care.

Theoretical and practical barriers to practitioners' willingness to seek training in empirically supported treatments

To identify barriers to the dissemination of empirically supported treatments (ESTs), a random sample of psychologists in independent practice (N=1291) was asked to complete measures of attitudes towards ESTs and willingness to attend a 3-hour, 1-day, or 3-day workshop in an EST of their choice. The strongest predictor of unwillingness to obtain EST training was the amount of time and cost required for the workshop, followed by objections to the need for EST training. Psychodynamic (compared to cognitive-behavioral) and more experienced practitioners agreed more strongly with the objections to ESTs overall, as did those whose graduate schools had not emphasized psychotherapy research. Results suggest that both practical and theoretical barriers are significant obstacles to EST dissemination.

Cost-effectiveness of guided self-help treatment for recurrent binge eating

OBJECTIVE

Adoption of effective treatments for recurrent binge-eating disorders depends on the balance of costs and benefits. Using data from a recent randomized controlled trial, we conducted an incremental cost-effectiveness analysis (CEA) of a cognitive-behavioral therapy guided self-help intervention (CBT-GSH) to treat recurrent binge eating compared to treatment as usual (TAU).

METHOD

Participants were 123 adult members of an HMO (mean age = 37.2 years, 91.9% female, 96.7% non-Hispanic White) who met criteria for eating disorders involving binge eating as measured by the Eating Disorder Examination (C. G. Fairburn & Z. Cooper, 1993). Participants were randomized either to treatment as usual (TAU) or to TAU plus CBT-GSH. The clinical outcomes were binge-free days and quality-adjusted life years (QALYs); total societal cost was estimated using costs to patients and the health plan and related costs.

RESULTS

Compared to those receiving TAU only, those who received TAU plus CBT-GSH experienced 25.2 more binge-free days and had lower total societal costs of $427 over 12 months following the intervention (incremental CEA ratio of -$20.23 per binge-free day or -$26,847 per QALY). Lower costs in the TAU plus CBT-GSH group were due to reduced use of TAU services in that group, resulting in lower net costs for the TAU plus CBT group despite the additional cost of CBT-GSH.

CONCLUSIONS

Findings support CBT-GSH dissemination for recurrent binge-eating treatment.

Treating Asian American women with eating disorders: multicultural competency and empirically supported treatment

Disordered eating and body dissatisfaction are occurring among Asian American women, but the vast majority of treatment literature is based on White Western women. Empirically supported treatments are increasingly encouraged for eating disorders, but therapists find little guidance for implementing them in a culturally sensitive manner. This paper reviews eating problems in Asian American women and explores concepts important to cultural competency in therapy. Examples of how cultural adaptations could be made to an empirically supported treatment are illustrated in a case scenario using aspects of C. G. Fairburn's Enhanced Cognitive Behavioral Therapy for Eating Disorders (2008).