The role of the therapeutic alliance in eating disorder treatment outcomes: a systematic review

Clinicians' power in the inpatient care of anorexia nervosa: A qualitative investigation of consumer perspectives

Medically compromised people with anorexia nervosa are cared for in inpatient settings where clinicians closely monitor health and safety. Clinicians are in a position of power, with the capacity to impose mandated weight gain to achieve medical stabilisation. Consumers are in a vulnerable position, compelled to temporarily relinquish autonomy and to accept coercive practices that often diminish the quality of the therapeutic relationship. Clinicians' position of power in mental healthcare has a dual potential for both healing and harm, and limited attention has been given to consumers' views of clinicians' power. The aim of this qualitative descriptive study was to investigate the consumer perspective of clinicians' power in the inpatient care of anorexia nervosa, establishing insight into the beneficence and maleficence of the power asymmetry. Ten women with anorexia nervosa in the community participated in semi-structured interviews online. The COREQ checklist was used to ensure accuracy and completeness of reporting. Thematic analysis revealed that abuses of power were common in the course of inpatient AN care, however life-saving measures were regarded as defensible. The perception of clinicians' power was determined by the strength of interpersonal relationships and clinicians' clinical competence. To mitigate the potential for harmful experiences, clinicians' use of power must be exercised with close consideration for consumer perspectives, with the integration of person-centred care and trauma-informed care principles.

Processes of change in family therapies for anorexia nervosa: a systematic review and meta-synthesis of qualitative data

OBJECTIVE

To synthesise young person and family member perspectives on processes of change in family therapy for anorexia nervosa (AN), including systemic family therapy and manualised family-based treatments, to obtain an understanding of what helps and hinders positive change.

METHOD

A systematic search of the literature was conducted to identify qualitative studies focussing on experiences of therapeutic change within family therapies for AN from the perspectives of young people and their families. Fifteen studies met inclusion criteria and underwent quality appraisal following which they were synthesised using a meta-synthesis approach.

RESULTS

Six overarching themes were generated: "A holistic focus on the young person's overall development"; "The therapeutic relationship as a vehicle for change"; "The therapist's confinement to a script and its impact on emotional attunement"; "A disempowering therapeutic context"; "Externalisation of the eating disorder (ED)"; and "The importance of family involvement". Positive change was helped by understanding and support given to the young person's overall development including their psychological, emotional, social and physical wellbeing, positive therapeutic relationships, relational containment within the family system and externalising conversations in which young people felt seen and heard. Positive change was hindered by inflexibility in the treatment approach, counter-effects of externalisation, negative experiences of the therapist, a narrow focus on food-intake and weight, as well as the neglect of family difficulties, emotional experiences, and psychological factors.

CONCLUSIONS

Positive change regarding the young person's eating-related difficulties ensued in the context of positive relational changes between the young person, their family members, the therapist and treatment team, highlighting the significance of secure and trusting relationships. The findings of this review can be utilised by ED services to consider how they may adapt to the needs of young people and their families in order to improve treatment satisfaction, treatment outcomes, and in turn reduce risk for chronicity in AN.

Direct and indirect effects of psychological well-being and therapeutic alliance on therapy outcome in eating disorders

Introduction

Outcome research in eating disorders (EDs) is commonly focused on psychopathological dysfunction. However, Ryff's model of psychological well-being (PWB) has shown promising-yet preliminary-results with ED patients. Additionally, despite substantial evidence highlighting the association between the therapeutic alliance and treatment outcome, findings in ED samples remain unclear. The present study aimed at exploring the direct effect of PWB dimensions and the early therapeutic alliance on ED patients' individual treatment responses, as well as the mediating role played by the early therapeutic alliance in the relationship between PWB dimensions and overall pre-post symptom change.

Methods

A sample of N = 165 ED patients assigned female at birth, who were receiving treatment in a residential program, completed the Psychological Well-Being Scale at treatment intake and the Working Alliance Inventory after the first four psychotherapy sessions. Patients also completed the Outcome Questionnaire-45.2 at the same time point and during the week prior to discharge.

Results

The PWB dimensions of autonomy, positive relations, and self-acceptance were associated with clinically significant change, while the dimensions of personal growth and self-acceptance were associated with reliable change. The early therapeutic alliance showed both direct and indirect effects on therapy outcome, predicting clinically significant and reliable symptom reduction. It also emerged as a significant mediator in the relationship between all PWB dimensions and overall symptomatic change.

Conclusion

The identification of individual, adaptive characteristics in ED patients that might influence their development of an early therapeutic alliance may help therapists to predict relationship ruptures and tailor their interventions to enhance treatment effectiveness.

Effects of Therapeutic Alliance in Interpersonal Psychotherapy Among Adolescent Girls With Loss-of-Control Eating

OBJECTIVE

Interpersonal psychotherapy (IPT) has been proposed for prevention of excess weight gain among adolescents with loss-of-control (LOC) eating. Mixed findings from a trial testing this conjecture warrant elucidation of potential outcome predictors. The therapeutic alliance (adolescent-facilitator emotional bond and task collaboration) may be important for IPT but has received little attention in weight-related interventions. This study evaluated associations of adolescent-reported therapeutic alliance during IPT with weight- and eating-related outcomes.

METHODS

Secondary analyses of a randomized controlled trial were conducted to compare group IPT to health education (HE) for preventing excess weight gain among 113 girls (ages 12-17) with body mass index (BMI) at the 75th to 97th percentile and LOC eating. BMI and LOC eating were measured at baseline, 12 weeks (postintervention), and 1 year. Multilevel modeling was used to test associations between change in therapeutic alliance (from session 1 to session 12) and changes in weight- and eating-related outcomes (from postintervention to 1 year). Analyses were controlled for therapeutic alliance after session 1 and for baseline and postintervention outcome values; group assignment (IPT vs. HE) was a moderator.

RESULTS

Increases in emotional bond were associated with decreased weight and with greater decreases in number of LOC eating episodes at 1 year in the IPT group (p<0.05) and with weight gain in the HE group (p<0.05). Greater task collaboration was related to greater weight gain at 1-year follow-up, regardless of group assignment (p<0.05).

CONCLUSIONS

The association of therapeutic alliance during IPT with weight and LOC eating outcomes among adolescent girls merits further investigation.

Critically appraising and utilising qualitative health research evidence in nutrition practice

BACKGROUND

Evidence-based decision-making and practice recommendations are commonly based on findings from quantitative studies or reviews. In the present study, we provide an overview of how to incorporate findings from qualitative research into the evidence-based decision-making process.

METHODS

To illustrate how qualitative evidence can be integrated into the decision-making process, we have outlined a clinical nutrition scenario and the process for sourcing credible evidence to inform decision-making. A qualitative health research study was selected and appraised using the Critical Appraisal Skill Programme (CASP) appraisal tool for qualitative research. Based on the results of the critical appraisal, the study quality is considered, and we discuss whether the qualitative evidence can be applied to practice.

RESULTS

A detailed description of how the qualitative findings can be used conceptually and instrumentally in practice to address the clinical nutrition scenario is provided.

CONCLUSIONS

Developing skills in critically appraising findings from qualitative studies will increase awareness and utilisation of this type of evidence in practice and policy, with a goal to ensure that patient/client perceptions are considered, leading to enhanced person-centred care or systems.

Therapeutic alliance with psychotherapist versus dietician: a pilot study of eating disorder treatment in a multidisciplinary team during the COVID-19 pandemic

Little is known about the therapeutic alliance (TA) formed with different professionals in multidisciplinary eating disorder (ED) treatment, particularly in the context of online treatment during the COVID-19 pandemic. We aimed to conduct a pilot study during the COVID-19 pandemic examining characteristics of patients' TA with their dieticians and psychotherapists, associations between patients' and therapists' views of the TA, and relationships between psychological characteristics and TAs. Sixty-three patients with EDs and their treating psychotherapists and dieticians were surveyed during the COVID-19 pandemic using the Working Alliance Inventory (WAI-S). Spearman correlation tests were used to examine associations between variables. Positive associations were found between the TAs examined. Concordance was stronger in patient-dietician dyads than in patient-psychotherapist dyads. Severe ED psychopathology was associated with weaker TA (bond subscale). General psychopathology was associated with weaker TA with the dietician (task subscale). Given that several differences were found between the TAs of treatment dyads, further longitudinal studies are needed to validate our pilot findings and to investigate multidisciplinary TAs and their impact on treatment outcomes in online ED treatment settings during the COVID-19 pandemic, as well as in other treatment settings (e.g., in-person settings). This study will contribute to a deeper understanding of the dynamics of TAs in multidisciplinary ED treatment and inform the development of more effective interventions.

An exploration of patient experiences of transitioning to a remote day programme following inpatient treatment in an adult eating disorder service

WHAT IS KNOWN ON THE SUBJECT?: Traditionally, treatment for eating disorders (EDs) has been provided on an inpatient or outpatient basis, but more recently other levels of treatment provision to include, day care (DC) and community outreach programmes, have been developed. There is limited research exploring the experience of patients who have transitioned from inpatient ED treatment to a remote DC treatment. This lack of knowledge can impact mental health nurses' understanding of what that experience is like for patients and hence may influence the efficacy of collaboration and inclusion between patients and nurses. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This research addresses this dearth of knowledge and adds to our understanding of patients' experiences of attending a remote DC programme following a period of inpatient treatment for an ED. This is an important study for nurses and other mental health professionals working with people in ED treatment, as it highlights the specific challenges and anxieties of transitioning from inpatient to a remote DC programme and the individualized supports advisable during this process. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This research provides a basis on which nurses can understand and address the challenges experienced by patients after transitioning to a less intensive supportive ED programme. The understanding of these experiences will enhance the therapeutic alliance between the nurse and patient, which will in turn support the patient in increasing agency as they progress through their recovery. This research provides a foundation on which to develop specific supports that need to be in place to help patients manage the anxieties they experience as they transition to a less intense and remote treatment. Findings from these lived experiences can be used to support the development of similar DC programmes for EDs in other settings.

ABSTRACT

INTRODUCTION: Day care (DC) treatment for people with an eating disorder (ED) provides for an easier transition from hospital to home, along with a treatment milieu where patients can maintain occupational and social functioning and allow for the transfer of newly acquired skills to everyday life.

AIM

To explore patients' experiences of attending a remote day programme following intense inpatient treatment in an adult ED service.

METHOD

A qualitative descriptive methodology informed the study. In-depth semi-structured interviews were conducted with 10 consenting patients. A thematic analysis framework was used to guide the process of data analysis.

RESULTS

Three themes reflected participants' experiences: 'Moving On: Preparing for Change', 'Navigating a New Support System' and 'Increasing Agency'.

DISCUSSION

An underlying issue for participants was an ongoing but changing experience of anxiety. While anticipatory anxiety is evident in preparing for discharge, this is replaced with a real-time anxiety as they endeavour to negotiate an effective support network.

IMPLICATIONS FOR PRACTICE

The findings from this study provide a basis on which mental health nurses can develop timely and effective treatment and support systems with patients who are transitioning from a high support inpatient ED programme to a less intensive ED remote DC programme.

Professional Quality of Life Among Professionals Working with People with Eating Disorders: The Interplay Between Meaning in Work, Optimism, and Career Duration

Purpose

Scientific literature findings reflect the challenges experienced by healthcare professionals (HCPs) whose work is dedicated to helping clients with eating disorders (EDs) in various treatment centers (wards). These challenges can affect the professional quality of life (comprised of compassion satisfaction, burnout, and secondary traumatic stress) of HCPs. The present study delved into this relationship and explored the moderating role of dispositional optimism and the role of career duration in ED wards in the link between meaning in work and professional quality of life.

Methods

Two hundred HCPs working in ED wards in Israel were recruited through their professional social networks. Participants completed self-report questionnaires related to socio-demographic and work data, professional quality of life, meaning in work, and dispositional optimism.

Results

Career duration in ED wards was negatively associated with secondary traumatic stress, while dispositional optimism and meaning in work were positively associated with compassion satisfaction and negatively associated with burnout and secondary traumatic stress. With respect to the moderation effect of dispositional optimism and EDs ward career duration, the findings revealed that the positive relationship between meaning in work and compassion satisfaction weakened as dispositional optimism scores increased. Additionally, the negative relationship between meaning in life and burnout was significant only when the career duration in EDs wards was less than 12.31 years.

Conclusion

HCPs working in ED wards could draw on the findings to improve their professional quality of life, especially through enhancing meaning in work. Attention should be paid especially toward HCPs with many years (>12.31) of experience in the ED wards.

Validation of the Working Alliance Inventory- Short Form for Patient (WAI-S-P) in Peruvian Adults

Background

Although the importance of the therapeutic alliance in the treatment process and health outcomes is recognized, so far, there has been no evaluation in the Peruvian context that considers possible individual differences that could influence this assessment.

Purpose

This study assessed the psychometric properties of the WAI-S-P in a sample of individuals from Peru who are receiving psychological therapy. Furthermore, a network analysis was conducted to investigate the direct relationships between the therapeutic alliance and several relevant sociodemographic variables.

Methods

The short version of the Working Alliance Inventory was used in a sample of 241 participants (Mage=32.58, SD=12.67) that had attended less than 6 sessions. Three models were considered, including a three-factor and a two-factor correlated model, as well as a bifactor model. In addition, a network of partial associations was created including the overall therapeutic alliance, sex, age, and number of psychotherapeutic sessions.

Results

The bifactor model, with an overall therapeutic alliance factor and two specific factors ("contact" and "contract"), better fit the data. Invariance of the structure by sex and age showed equitable measurement. On the other hand, network analysis revealed a positive correlation between total session attendance and therapeutic alliance. Men reported higher therapeutic alliance, while women had higher total session attendance.

Conclusion

The results of this study suggest that the therapeutic alliance is better represented by a bifactor model and demonstrates invariance across sex and age in Peruvian adults. Additionally, findings indicate that differences in life experiences and the sex of patients may need to be verified in future studies to better understand nuanced needs in forming therapeutic alliances at least in the early stages of session attendance.

Health Professionals' Experiences Supporting People With Type 1 Diabetes Mellitus Who Deliberately Restrict and/or Omit Insulin for Weight, Shape, and/or Appearance: A Meta-synthesis

OBJECTIVES

It has been reported that health professionals currently lack the required empathy, understanding, and knowledge about the deliberate restriction and/or omission of insulin to influence weight and/or shape, which may impact the quality of care provided. We sought to synthesize existing qualitative research pertaining to health professionals' experiences supporting individuals within this unique population.

METHODS

We conducted a meta-synthesis using a meta-aggregative approach. We searched 5 electronic databases. Eligible articles were qualitative or mixed-methods empirical studies with primary data reporting health professionals' experiences supporting people with type 1 diabetes restricting and/or omitting insulin for weight and/or shape control, written in English, from database inception to March 2022.

RESULTS

A final sample of 4 primary studies were included. The analysis indicated that in the absence of standardized screening and diagnostic tools, health professionals found it challenging to decide when behaviour became clinically significant. Health professionals were also challenged by complex perceptions and behaviours relating to their illness management and features of broader health-care systems and organizational factors.

CONCLUSIONS

Our findings have widespread multidisciplinary implications for health professionals and the broader health-care systems in which they work. We provide evidence-based clinical recommendations and suggestions for vital future research.

Collaborative care in eating disorders treatment: exploring the role of clinician distress, self-compassion, and compassion for others

BACKGROUND

Collaborative care is described as showing curiosity and concern for patient experiences, providing choices, and supporting patient autonomy. In contrast, in directive care, the clinician has authority and the patient is expected to adhere to a treatment plan over which they have limited influence. In the treatment of eating disorders, collaborative care has been shown to be more acceptable and produce better outcomes than directive care. Despite widespread patient and clinician preference for collaborative care, it is common for clinicians to be directive in practice, resulting in negative patient attitudes toward treatment and poor adherence. There is a need to understand factors which contribute to its use.

PURPOSE

This study examined the contribution of clinicians' experience of distress and how they relate to themselves and others in times of difficulty (self-compassion and compassion for others), to their use of collaborative support.

METHOD

Clinicians working with individuals with eating disorders from diverse professional backgrounds (N = 123) completed an online survey.

RESULTS

Whereas clinician distress was not associated with use of collaborative or directive support behaviours, self-compassion and compassion for others were. Regression analyses indicated that compassion for others was the most important determinant of collaborative care.

DISCUSSION

Relating to their own and others' distress with compassion was most important in determining clinicians' use of collaborative support. Understanding how to cultivate conditions that foster compassion in clinical environments could promote the delivery of collaborative care.

From symptoms to subjective and bodily experiences: the contribution of the Psychodynamic Diagnostic Manual (PDM-2) to diagnosis and treatment monitoring in eating disorders

PURPOSE

Atheoretical and descriptive conceptualizations of eating disorders (EDs) have faced substantial criticism due to their limited ability to assess patients' subjective characteristics and experiences, as needed to determine the most appropriate treatment options. The present article provides an overview of the clinical and empirical literature supporting the potential contribution of the Psychodynamic Diagnostic Manual (PDM-2) to both diagnostic assessment and treatment monitoring.

METHODS

Following a discussion of the most relevant shortcomings of current diagnostic models of EDs and a description of the rationale and structure of the PDM-2, evidence supporting the core PDM-2 dimensions of ED patients' subjective experiences (i.e., affective states, cognitive processes, relational patterns, somatic/bodily experiences and states) are examined, alongside their relevance to ED diagnosis and treatment.

RESULTS

Overall, the reviewed studies support the diagnostic importance of these patterns of subjective experiences in EDs, highlighting their potential role as either predisposing or maintaining factors to target in psychotherapy. A growing body of multidisciplinary evidence also shows that bodily and somatic experiences are central to the diagnosis and clinical management of ED patients. Moreover, there is evidence that a PDM-based assessment may enable closer monitoring of patient progress during treatment, with regard to both subjective experiences and symptom patterns.

CONCLUSIONS

The study suggests that current diagnostic frameworks for EDs would benefit from the addition of a person-centered perspective that considers not only symptoms, but also patients' full range of functioning-including their deep and surface-level emotional, cognitive, interpersonal, and social patterns-to improve patient-tailored interventions.

LEVEL OF EVIDENCE

Level V, narrative review.

The Treatment Experience of Anorexia Nervosa in Adolescents from Healthcare Professionals' Perspective: A Qualitative Study

Anorexia nervosa (AN) is a serious psychiatric illness with a high mortality rate and a poor outcome. AN in adolescents can be difficult to treat. The prognosis of patients with AN depends highly on how early specialized AN treatment starts. Therefore, the purpose of this study was to explore the experiences of healthcare professionals in treating adolescents with AN. A qualitative study approach was conducted. Through semi-structured interviews, 16 healthcare professionals, including 10 nurses, 3 dieticians and 3 physicians from the paediatric ward at a university-affiliated medical centre in central Taiwan, shared their experiences. Recorded interviews were transcribed and analyzed by content analysis. Five themes and ten subthemes were identified: 1. Building a trusting relationship first: (a) spending time to build trust with the client and (b) establishing a relationship with the client's parents; 2. The key to treatment success: (a) Clients' awareness of the illness and (b) parents' support for clients; 3. Consistency of team treatment goals: (a) maintaining stable vital signs and (b) achieving caloric intake; 4. Empowerment with knowledge about anorexia: (a) continuing education for healthcare professionals and (b) interdisciplinary collaborative care; and 5. Using different interaction strategies: (a) the hard approach and (b) the soft approach. In conclusion, the findings will provide important information for healthcare professionals to apply in monitoring the psychological and emotional states of adolescents with AN. The findings indicate that healthcare professionals should invite parents to participate in the treatment, support and guide them in their adolescent care, develop scales of family stress and support for AN in adolescents, develop interventions, and establish an early therapeutic alliance.

Influence of eating disorder psychopathology and general psychopathology on the risk of involuntary treatment in anorexia nervosa

PURPOSE

We explored associations between clinical factors, including eating disorder psychopathology and more general psychopathology, and involuntary treatment in patients with anorexia nervosa. Our intention was to inform identification of patients at risk of involuntary treatment.

METHODS

This was a retrospective cohort study combining clinical data from a specialized eating disorder hospital unit in Denmark with nationwide Danish register-based data. A sequential methodology yielding two samples (212 and 278 patients, respectively) was adopted. Descriptive statistics and regression analyses were used to explore associations between involuntary treatment and clinical factors including previous involuntary treatment, patient cooperation, and symptom-level psychopathology (Eating Disorder Inventory-2 (EDI-2) and Symptom Checklist-90-Revised (SCL-90-R)).

RESULTS

Somatization (SCL-90-R) (OR = 2.60, 95% CI 1.16-5.81) and phobic anxiety (SCL-90-R) (OR = 0.43, 95% CI 0.19-0.97) were positively and negatively, respectively, associated with the likelihood of involuntary treatment. Furthermore, somatization (HR = 1.77, 95% CI 1.05-2.99), previous involuntary treatment (HR = 5.0, 95% CI 2.68-9.32), and neutral (HR = 2.92, 95% CI 1.20-7.13) or poor (HR = 3.97, 95% CI 1.49-10.59) patient cooperation were associated with decreased time to involuntary treatment. Eating disorder psychopathology measured by the EDI-2 was not significantly associated with involuntary treatment.

CONCLUSIONS

Clinical questionnaires of psychopathology appear to capture specific domains relevant to involuntary treatment. Poor patient cooperation and previous involuntary treatment being associated with shorter time to involuntary treatment raise important clinical issues requiring attention. Novel approaches to acute anorexia nervosa care along with unbiased evaluation upon readmission could mitigate the cycle of repeat admissions with involuntary treatment.

LEVEL OF EVIDENCE

Level III, cohort study.

Understanding dropout and non-participation in follow-up evaluation for the benefit of patients and research: evidence from a longitudinal observational study on patients with eating disorders

Treatment outcomes in eating disorders (EDs) are still an open field for clinicians and researchers. Besides difficulties in egosyntonic-linked treatment engagements, dropout is one of the most crucial elements that cause a reduction in the treatment efficacy. Thus, the aim of this study is to evaluate factors that could contribute to high dropout rates and non-participation in follow-up evaluation in patients with ED. This study used a large sample of patients from a specialized ED ward and day hospital (DH). A sample of 428 individuals was recruited for this study. Psychological and demographic data were collected at the time of hospitalization and discharge from the facilities. These data were used to explore a possible link between dropout and follow-up non-participation. Specially, the random forest was used to rank demographic and psychological features in importance and evaluate the top results with regression analyses for statistical significance. A dropout rate of 12.14% during inpatient and DH treatment was found. Anger-hostility and general psychopathology were found to be predictors of dropout during treatment, while the duration of the hospitalization predicted non-participation at the six-month follow-up. Specific psychological features should be considered before and during treatments for patients with EDs to reduce dropout rates. The duration of the hospitalization should also be evaluated as a relevant healthcare element that could affect engagement and, accordingly, outcome.

Learning clinical skills: an ecological perspective

The pedagogy underpinning clinical psychology training is often reliant upon the acquisition and transmission of knowledge and the practice of skills. The dominant paradigm in the training of clinical psychologists emphasises competence-based training drawing upon a scientist practitioner model of practice, often underpinned by knowledge of evidence-based interventions. Little has changed over the past 40 years. Training is predicated upon the assumption that effective therapy is attributed to the therapist's skills to implement specific therapeutic processes and her or his capacity to form an effective working alliance with the client or patient. We provide an argument for an alternative paradigm in which ecological principles are privileged with a view to enhancing clinical training of psychologists in health settings responsive to the trainee as well as the broader societal context in which they practice, by adopting a pedagogy which prioritizes the relationship between the person and the environment. The proposed approach brings an ecological set of assumptions to the learning experience in clinical contexts. Key principles, drawn from an ecological perspective includes: affordances, the emergence of self-organisation in clinical learning, constraints and rate limiters. The approach is supported by examples applied to clinical learning contexts. Implications for clinical training are discussed. The ways in which an ecological approach may contribute to more effective learning outcomes through the use of representative learning contexts may inform learning design, how learning is actioned in clinical psychology as well as future research on the pedagogy of clinical training.

Alliance matters: but how much? A systematic review on therapeutic alliance and outcome in patients with anorexia nervosa and bulimia nervosa

PURPOSE

Patients with eating disorders (ED) pose a high-risk group regarding relapse. The understanding of factors contributing to a better outcome is much-needed. Therapeutic alliance (TA) is one important, pantheoretical variable in the treatment process, which has shown to be connected with outcome. This review looks into a possible predictive effect of TA on outcome as well as related variables.

METHODS

A systematic review with pre-determined inclusion criteria following the PRISMA guidelines was conducted for studies published since 2014. Three previous reviews including studies up until 2014 were analyzed for studies matching our inclusion criteria. A total of 26 studies were included.

RESULTS

The results were heterogeneous between different patient groups. Regarding the predictive effect of TA, in adolescent samples, the TA of either the patients or their parents seems to impact outcome as well as completion. For adults, results are mixed, with a tendency to a greater impact of TA for anorexia nervosa (AN) patients, while some samples of adult bulimia nervosa (BN) patients did not find any relation between TA and outcome.

CONCLUSION

The effect of TA on clinical outcome depends on the patient group. TA has a greater impact on adolescents, irrespective of diagnosis, and on adults with AN. The examined studies have different limitations which include small sample sizes and questionable study design. The examination of motivation as a potential influencing factor is recommended.

LEVEL OF EVIDENCE

Level I, systematic review.

Clinicians' perspectives on supporting individuals with severe anorexia nervosa in specialist eating disorder intensive treatment settings during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has significantly affected intensive treatment settings (i.e., inpatient [IP] and day patient [DP]) in specialist eating disorder services. However, the impact on clinicians working in these services is largely unknown. We therefore explored the perspectives of those supporting individuals with severe anorexia nervosa (AN) in intensive treatment settings during the pandemic.

METHODS

Between May 2020 and June 2021, we interviewed clinicians (n = 21) who delivered IP and/or DP treatment to patients with severe AN in four specialist eating disorder services in the United Kingdom. Data relating to experiences during COVID-19 were analysed using reflexive thematic analysis.

RESULTS

We identified six themes: Disruptions to Routine Treatment; Introduction of Virtual Treatment; Separation from Treatment, Others and the World; Impact on Recovery; Impact on Staff; and Pressure on Referral Pathways. COVID-19 posed significant challenges to IP and DP services: forcing closures, operating with restrictions and virtual treatment, and impacting delivery of essential treatment components, referral pathways, clinician wellbeing, risk management, and patient isolation and recovery trajectories. Opportunities arose, in particular in DP services offering virtual support.

CONCLUSIONS

COVID-19 challenged the continuation of multidisciplinary treatment. The findings underline the necessity for medical, psychological, practical, and nutritional support, as well as carer involvement and fostering social connections to remain at the forefront of intensive treatment for severe AN. They also emphasise the uncertainty surrounding which intensive treatment may be best suited to which patient when, particularly within the context of virtual DP support.

Narrative and Bodily Identity in Eating Disorders: Toward an Integrated Theoretical-Clinical Approach

Eating disorders (EDs) can be viewed as “embodied acts” that help to cope with internal and external demands that are perceived as overwhelming. The maintenance of EDs affects the entire identity of the person; the lack of a defined; or valid sense of self is expressed in terms of both physical body and personal identity. According to attachment theory, primary relationships characterized by insecurity, traumatic experiences, poor mirroring, and emotional attunement lead to the development of dysfunctional regulatory strategies. Although the literature shows an association between attachment style or states of mind, trauma, behavioral strategies, and various EDs, the debate is still ongoing and the results are still conflicting. Therefore, we believe it is important to examine and treat EDs by understanding which narrative trajectory intercepts distress in relation to narrative and embodied self-concept. Drawing on clinical observation and a narrative review of the literature, we focus on the construction and organization of bodily and narrative identity. Because bodily representations are the primary tools for generating meaning, organizing experience, and shaping social identity from the earliest stages of life, we focus on the role that bodily interactions and sensorimotor and proprioceptive patterns have played in the development of EDs. We consider the role that lack of attunement, insecure attachment, and relational trauma play in mentalizing, affecting self-representation and emotion regulation strategies. The paper also considers a semantic mode of trauma in EDs that involves a top-down pathway through beliefs and narratives about oneself based on lack of amiability, on devaluation, and on humiliation memories. Finally, we would like to highlight the proposal of an integrated model with multiple access model to psychotherapy that takes into account the complexity of ED patients in whom aspects related to dysregulation, body image disintegration, and post-traumatic symptoms are associated with a suffering sense of self and a retraumatizing narrative.

Nurses' perceptions on and experiences in conflict situations when caring for adolescents with anorexia nervosa: A qualitative study

Anorexia nervosa (AN), which primarily affects adolescent girls and young women, is characterized by excessive dieting, leading to severe weight loss and a pathological fear of becoming overweight, or unhealthy behaviours that hinder weight gain. Caring for patients who have AN is particularly challenging for nursing staff, who are on the front line and have the closest contact with patients. However, little is known about how nursing staff care for adolescent patients with AN in Taiwan. This study aimed to explore nurses' perceptions on and experiences in conflict situations in caring for adolescents with AN. A qualitative study approach was conducted. Through semi-structured interviews, ten nursing staff from the paediatric ward at a university-affiliated medical centre in central Taiwan shared their experiences. Recorded interviews were transcribed and analysed by content analysis. This analysis identified three themes with eight subthemes: (i) struggling to develop therapeutic relationships, (ii) selective focusing, and (iii) difficulty changing minds. The findings of this study indicated a need for ongoing support for nursing staff, the development of therapeutic relationships with adolescent patients with AN, extensive nursing staff preparation, and the development of in-service training programs to enable nursing staff to care for these patients with greater understanding.

Rescripting-A grounded theory study of the contribution that fathers make to Family-Based Treatment when a young person has anorexia nervosa

AIM

To present a grounded theory of the contribution that fathers make to family-based treatment when a young person has anorexia nervosa.

BACKGROUND

Research indicates a potential to improve outcomes by involving both parents in the treatment of anorexia nervosa. However, fathers are underrepresented both within treatment and research. Family-based treatment requiring the involvement of both parents presents an opportunity to better understand the role of the father in treatment.

DESIGN

Classic grounded theory.

METHODS

Individual interviews conducted with fifteen fathers involved in family-based treatment. The COREQ checklist was followed.

RESULTS

Fathers valued being involved in family-based treatment and felt they had an important contribution to make. The analysis captures the overall contribution that fathers make and the impact of their involvement. Four categories; Being on the Outside, Finding a Way In, Finding a Way to Be and Finding a Way to Let Go and one core category Repositioning were generated from the data. A substantive theory of Rescripting, generated from categories and the core category, describes the way that participating in family-based treatment changes fathers and their role.

CONCLUSIONS

Fathers make an important and significant contribution to family-based treatment when a young person has anorexia nervosa. The findings inform clinicians about the importance of including fathers in the treatment of young people with anorexia nervosa. They highlight the importance of incorporating support mechanisms into family-based treatment to harness and maximise the paternal contribution.

RELEVANCE TO CLINICAL PRACTICE

Paternal contribution to family-based treatment can be maximised to improve outcomes for young people with anorexia nervosa.

"I'm truly free from my eating disorder": Emerging adults' experiences of FREED, an early intervention service model and care pathway for eating disorders

BACKGROUND

Eating disorders (EDs) typically start during adolescence or emerging adulthood, periods of intense biopsychosocial development. FREED (First Episode Rapid Early Intervention for EDs) is a service model and care pathway providing rapid access to developmentally-informed care for emerging adults with EDs. FREED is associated with reduced duration of untreated eating disorder and improved clinical outcomes, but patients' experiences of treatment have yet to be assessed.

OBJECTIVE

This study aimed to assess emerging adults' experiences of receiving treatment through FREED.

METHOD

This study triangulated qualitative data on participants' experiences of FREED treatment from questionnaires and semi-structured interviews. Participants were 106 emerging adults (aged 16-25; illness duration < 3 yrs) (questionnaire only = 92; interview only = 6; both = 8). Data were analysed thematically.

RESULTS

Most participants reported psychological and behavioural changes over the course of treatment (e.g. reduction in symptoms; increased acceptance and understanding of difficulties). Participants identified five beneficial characteristics of FREED treatment: i) rapid access to treatment; ii) knowledgeable and concerned clinicians; iii) focusing on life beyond the eating disorder; iv) building a support network; v) becoming your own therapist.

CONCLUSION

This study provides further supports for the implementation of early intervention and developmentally-informed care for EDs. Future service model development should include efforts to increase early help-seeking.

ANZAED practice and training standards for mental health professionals providing eating disorder treatment

INTRODUCTION

The Australia & New Zealand Academy for Eating Disorders (ANZAED) recently developed general principles and clinical practice standards recommended for mental health clinicians and dietitians providing treatment for people with eating disorders. Separate mental health practice and training standards were then devised as a foundation for strengthening the workforce and providing guidance to professional training programs and service providers on the minimal standards required for practice in the eating disorder field.

RECOMMENDATIONS

The present recommendations for mental health professionals providing eating disorder treatment describe the following practice and training standards: eating disorder treatment foundations (including co-ordination of services, establishing a positive therapeutic alliance, professional responsibility and knowledge of levels of care), assessment, diagnosis, intervention (including evidence-based intervention, managing psychiatric risk and managing co-morbid mental health problems), and monitoring and evaluation.

CONCLUSIONS

Further work is required to disseminate these standards to clinicians providing services across Australia to people with eating disorders, and to support adherence in the clinic room where they can translate to improved outcomes for clients. Pathways to supporting adherence include expert supervision of practice, incorporation in training and supervised practice in university settings, and support with checklists that can be used by consumers and referring professionals.

Expectations and Concerns of Older Adults With Cognitive Impairment About Their Relationship With Medical Providers: A Call for Therapeutic Alliances

We sought to understand the expectations and concerns of older adults with cognitive impairment with regard to their relationship with medical providers. In particular, we observed whether study participants were involved in therapeutic alliances. Medical providers and patients create therapeutic alliances when they agree on the goals of the treatment and share a personal bond. Whereas such alliances have been studied in cancer research, little is known about therapeutic alliances in dementia research. Data were gathered in a qualitative study of 27 older adults with cognitive impairment and analyzed with narrative analysis. We introduce four case studies that illustrate the effects of having or missing a therapeutic alliance. Whereas the participant in the first case benefited from a therapeutic alliance, the other cases are marked by different experiences of abandonment. Findings suggest that interventions should concentrate on ways to enhance the relationship between medical providers and patients with cognitive impairment.

The lived experience of working with people with eating disorders: A meta-ethnography

OBJECTIVE

Working with people with eating disorders (EDs) is known to elicit strong emotional reactions, and the therapeutic alliance has been shown to affect outcomes with this clinical population. As a consequence, it is important to understand healthcare professionals' (HCPs') experiences of working with this client group.

METHOD

A meta-synthesis was conducted of qualitative research on HCPs' lived experiences of working with people with EDs. The results from the identified studies were analyzed using Noblit and Hare's meta-ethnographic method. Data were synthesized using reciprocal translation, and a line of argument was developed.

RESULTS

Thirty-seven studies met the inclusion criteria. Reciprocal translation resulted in a key concept: "Coping with caring without curing." This was underpinned by the following third-order concepts: (a) "The dissonance and discomfort of being a helper struggling to help," (b) "Defending against the dissonance," and (c) "Accepting the dissonance to provide safe and compassionate care." These concepts were used to develop a line-of-argument synthesis, which was expressed as a new model for understanding HCPs' experiences of working with people who have an ED.

DISCUSSION

Although the conflict associated with being a helper struggling to help led some HCPs to avoid and blame people with EDs, others adopted a compassionate stance characterized by humanity, humility, balance, and awareness.

Effective nurse-patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance

Background

Therapeutic alliance is a core part of the nursing role and key to the attainment of positive outcomes for people utilising mental health care services. However, these relationships are sometimes difficult to develop and sustain, and nursing staff would arguably benefit from evidence-based support to foster more positive relationships.

Objectives

We aimed to collate and critique papers reporting on interventions targeted at improving the nurse–patient therapeutic alliance in mental health care settings.

Design

Systematic literature review.

Data sources

The online databases of Excerpta Medica database (Embase), PsycINFO, Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched, eligible full text paper references lists reviewed for additional works and a forward citation search conducted.

Review methods

Original journal articles in English language were included where they reported on interventions targeting the nurse–patient therapeutic relationship and included a measure of alliance. Data were extracted using a pre-determined extraction form and inter-rater reliability evaluations were conducted. Information pertaining to design, participants, interventions and findings was collated. The papers were subject to quality assessment.

Results

Relatively few eligible papers (n = 8) were identified, highlighting the limitations of the evidence base in this area. A range of interventions were tested, drawing on diverse theoretical and procedural underpinnings. Only half of the studies reported statistically significant results and were largely weak in methodological quality.

Conclusions

The evidence base for methods to support nursing staff to develop and maintain good therapeutic relationships is poor, despite this being a key aspect of the nursing role and a major contributor to positive outcomes for service users. We reflect on why this might be and make specific recommendations for the development of a stronger evidence base, with the hope that this paper serves as a catalyst for a renewed research agenda into interventions that support good therapeutic relationships that serve both staff and patients.

Minding the adolescent in family-based inpatient treatment for anorexia nervosa: a qualitative study of former inpatients' views on treatment collaboration and staff behaviors

Background

For some young persons diagnosed with anorexia nervosa, treatment will inevitably involve phases where hospitalization is required. Inspired by the encouraging evidence-base for outpatient family-based treatment for adolescent anorexia nervosa, clinicians and program developers have started to incorporate outpatient family-based treatment principles into higher levels of care. During family-based inpatient treatment, collaborative efforts are largely directed toward the parents of the adolescent. Consequently, the therapeutic focus on the young person is more of an indirect one. With this study we aimed to understand how young persons with lived experience from a family-based inpatient treatment setting, where the adolescents were admitted together with their parents, viewed therapeutic aspects related to staff-patient collaboration and staff-related behaviors.

Methods

Thirty-seven semi-structured interviews of former adolescent inpatients were conducted. Participants’ post-treatment reflections were inductively analyzed by applying a thematic analytic framework.

Results

Based upon user perspectives from a treatment setting highly influenced by a family therapeutic approach, findings revealed that former inpatients prefer tailored treatment and a collaborative approach. Eight subthemes constituting two main themes emerged: 1) There are no ready-made solutions. Staff should facilitate collaboration by tailoring treatment toward the young person’s perspectives, and 2) Emphasizing skills that matter. Staff should display a non-judgmental stance, educate patients, stimulate motivation, enable activities and prevent iatrogenic effects during the stay.

Conclusions

This study adds valuable user perspectives to the ongoing work with adapting family-based frameworks into higher levels of care. Clinicians could benefit from viewing their practice from the standpoint of the young person’s post-treatment reflections. From their unique perspectives as having lived experience and hence, “insider knowledge” with a specific treatment situation, clinicians are reminded of the importance of being mindful on the young persons’ views.

Dynamics of nurses' authority in the inpatient care of adolescent consumers with anorexia nervosa: A qualitative study of nursing perspectives

Nurses caring for adolescent consumers with anorexia nervosa in the inpatient setting are challenged in a unique way, in that they are caring for people with whom they do not have a mutually held concept of well-being. Their efforts to ensure weight gain are frequently against the wishes of the consumer. This dissonance results in challenging interactions, where nursing care and authority may be undermined. This study investigated the dynamics of nurses' authority within this context. Interviews with nurses (n = 10) were conducted and analysed through thematic analysis. Nurses reported that consumers, compelled by the psychopathology of anorexia nervosa, often sought to challenge or undermine their authority. Some nurses experienced the opposition and conflict as demoralizing, whereas others were able to maintain confidence in the therapeutic merit of their care. Younger, inexperienced nurses in this study were particularly vulnerable to interactions that mitigated their authority, due to their tendency to engage in friend-like relationships. Nurses caring for adolescents with anorexia nervosa should be prepared to be confronted by interactions that overtly and surreptitiously undermine their capacity to exercise professional authority. It is important that nurses recognize the importance of maintaining their authority, and how it can be threatened in subtle and unexpected ways.

The Modum-ED Trial Protocol: Comparing Compassion-Focused Therapy and Cognitive-Behavioral Therapy in Treatment of Eating Disorders With and Without Childhood Trauma: Protocol of a Randomized Trial

Background: The combination of eating disorder (ED) and the experience of childhood trauma leads to significant impairment and suffering. To improve treatment, it is critically important to study treatment effects, and the mechanism of these effects. The overall aim of the current project is to; (1) build knowledge on how to best treat patients with ED with and without childhood trauma, (2) develop our understanding about how change happens for these patients. We will do this by comparing two treatment models in an inpatient setting; Compassion-Focused Therapy (CFT) and cognitive-behavioral therapy (CBT) for ED. This paper describes the development, design and implementation of the trial. Methods and Design: Patients included in this randomized controlled trial will satisfy DSM-5 criteria for ED and approximately half of the patients will in addition have a history of childhood trauma. A total of 144 patients who have received either CFT or CBT are followed up 1 year after completion of the treatment. The study will collect a rich dataset of outcome measures at four time points, and process and sub-outcome measures at 13 time points. All patients will be assessed with the same clinical instruments based on current state-of-the-art methods. The primary outcome will be change in the severity of ED features as measured by the global ED examination score, and having a global ED examination score less than one standard deviation above the community mean, while secondary outcomes will relate to treatment effects on trauma symptoms, general symptoms, and quality of life. Discussion: This trial will make an important contribution to the need for evidence of effective treatment for patients with ED with or without childhood trauma. Ethics and Dissemination: The project is approved by the South-Eastern Regional Committee for Medical and Health Research Ethics of Norway (REC;2014/836). Clinical Trial Registration: ClinicalTrials.gov, http://www.Clinicaltrials.gov/ct2/show/NCT02649114.

Therapeutic alliance in inpatients with severe anorexia nervosa

OBJECTIVE

Therapeutic alliance (TA) is a relevant aspect in anorexia nervosa (AN), but data on inpatients are lacking. We aimed to evaluate the influence of motivation to change, diagnostic subtypes, and duration of illness on TA at hospital discharge; we also investigated if baseline clinical characteristics were associated with discharge TA, and the TA-outcome association.

METHOD

We enrolled 137 adult inpatients with AN completing Eating Disorder Examination-Questionnaire, Beck Depression Inventory, State-Trait Anxiety Inventory, Anorexia Nervosa Stages of Change-Questionnaire, EuroQoL-Quality of Life Scale-Visual Analogue Scale, and Working Alliance Inventory-Short Revised.

RESULTS

Patients with different AN subtypes and duration of illness reported similar TA. Baseline depression, state anxiety, and motivation to change were statistically significantly associated with TA at discharge. After controlling for all these variables and duration of illness, only motivation to change remained statistically significant. Statistically significant correlations were also found between improvements in body mass index and quality of life and discharge TA.

CONCLUSIONS

Few data exist on TA in inpatients with AN and a long duration of illness. Our findings suggest that baseline motivation to change correlates with TA at discharge independently of other variables. Future studies should ascertain as to whether a causal link exists or not.

The improvement in neurocognitive functioning in anorexia nervosa adolescents throughout the integrative model of psychotherapy including cognitive remediation therapy

BACKGROUND

Patients with anorexia nervosa (AN) experience difficulties in neurocognitive functioning in the acute phase of illness which might be related to clinical presentation, but also in the apparently remitted state after weight recovery. Among the most commonly reported persistent deficits is cognitive inflexibility, which can be interpreted as a vulnerability trait or a "neuropsychological scar" reflecting the detrimental effect of prolonged semi-starvation in patients with a long duration of illness. Studies of adolescent samples with a relatively short clinical course may enable avoiding the effect of prolonged illness and help to determine whether neuropsychological deficits are trait or state dependent. The aim of this study is to assess cognitive functioning in adolescents with AN before and after the inpatient treatment programme, including cognitive remediation therapy (CRT).

METHODS

Forty-seven adolescent female inpatients with AN diagnosed according to DSM-5 and fifty healthy female adolescents matched for the education level and age were recruited. The patients underwent a multimodal treatment including a ten-week CRT. The standardized and cross-validated neuropsychological (Trail Making Test - TMT A and B, Color-Word Stroop Task - CWST, Ruff Figural Fluency Test - RFFT) and clinical measurements (Beck Depression Inventory - BDI, Eating Attitude Test - EAT-26, Yale-Brown Obsessive Compulsive Scale - Y-BOCS) were used to assess both clinical (in the acute phase and after partial weight recovery) and control subjects.

RESULTS

Initially, AN patients performed significantly worse compared to the controls, but afterwards, inpatient treatment improvement was noted on all examined measures. In a few subtests (TMT, CWST) performance of AN patients after the programme was still significantly poorer than in HC.

CONCLUSIONS

Cognitive inflexibility in adolescent AN patients, as measured with TMT, CWST, and RFFT tends to improve after therapy. Nevertheless, a few neuropsychological subtests which did not show complete normalization may warrant attention in subsequent studies. Further research including control intervention is needed to conclude whether CRT intervention affects the outcome.

Procedures and Protocols for Weight Assessment During Acute Illness in Individuals With Anorexia Nervosa: A National Survey

BACKGROUND

Weight assessment is a key component of nursing care for individuals with the acute illness of anorexia nervosa (AN). However, there is little data to guide protocols and procedures regarding weight assessment.

OBJECTIVE

To describe institutional practices regarding weight assessment of individuals during acute illness of AN.

DESIGN

Treatment facilities ( N = 24) completed a survey about written protocols and procedures regarding weight assessment and disclosure of weight to patients.

RESULTS

The majority of facilities ( n = 22; 92%) have written protocols for weight assessment. Weight assessments occurred mostly in the morning ( n = 23; 95.8%), in hospital gowns ( n = 21; 87.5%), and after voiding ( n = 14; 58.3%). Respondents described mixed practices for disclosing weight to patients.

CONCLUSION

Results indicate widespread variability in weight assessment and disclosure of weight. Further research is necessary to help develop evidence-based guidelines about weighing practices during acute illness for individuals with AN.

Predictors of premature termination from psychotherapy for anorexia nervosa: Low treatment credibility, early therapy alliance, and self-transcendence

OBJECTIVE

Failure to complete treatment for anorexia nervosa (AN) is- common, clinically concerning but difficult to predict. This study examines whether therapy-related factors (patient-rated pretreatment credibility and early therapeutic alliance) predict subsequent premature termination of treatment (PTT) alongside self-transcendence (a previously identified clinical predictor) in women with AN.

METHODS

56 women aged 17-40 years participating in a randomized outpatient psychotherapy trial for AN. Treatment completion was defined as attending 15/20 planned sessions. Measures were the Treatment Credibility, Temperament and Character Inventory, Vanderbilt Therapeutic Alliance Scale and the Vanderbilt Psychotherapy Process Scale. Statistics were univariate tests, correlations, and logistic regression.

RESULTS

Treatment credibility and certain early patient and therapist alliance/process subscales predicted PTT. Lower self-transcendence and lower early process accounted for 33% of the variance in predicting PTT.

DISCUSSION

Routine assessment of treatment credibility and early process (comprehensively assessed from multiple perspectives) may help clinicians reduce PTT thereby enhancing treatment outcomes.

Social support satisfaction in adults with eating disorders: Does stance matter?

Although the role of social support is clearly established in the recovery of youth with eating disorders, little is known about factors that contribute to support satisfaction and improved treatment outcome in adults. This study examined the contribution of patient factors and perceived support stance used by family and friends in determining social support satisfaction. Individuals meeting DSM-IV criteria for an eating disorder (n = 182) completed measures of eating disorder and psychiatric severity, interpersonal functioning, perceived support stance used by family and friends, and social support satisfaction. Correlations indicated that both patient factors (lower psychiatric distress and fewer interpersonal difficulties) and perceived support stance (higher concerned and lower directive support) were associated with patient support satisfaction. Multiple regression analyses indicated that perceived support stance accounted for greater variance in social support satisfaction than did patient factors. Patient age was associated with differences in preferred support stance: expressions of caring were most critical for younger patients, whereas not being criticized or told what to do was most significant for older patients. This research suggests that the stance used when offering support is vital to the care of individuals with eating disorders.

Identification des pratiques prometteuses dans le traitement de l’anorexie mentale

L’anorexie mentale inquiète, d’une part, car elle est associée à de nombreuses complications médicales et, d’autre part, car elle est liée à un mauvais pronostic. Face à ces constats, il est impératif que les traitements les plus efficaces soient offerts aux personnes présentant une anorexie mentale. Cet article vise à présenter une revue systématique de la littérature portant sur les modalités thérapeutiques prometteuses dans le domaine de l’anorexie mentale. Parmi celles-ci, notons le traitement ambulatoire, l’importance d’une équipe multidisciplinaire ainsi que différentes approches psychothérapeutiques, dont l’approche familiale.

The PED-t trial protocol: The effect of physical exercise -and dietary therapy compared with cognitive behavior therapy in treatment of bulimia nervosa and binge eating disorder

BACKGROUND

Sufferers from bulimia nervosa (BN) and binge eating disorder (BED) underestimate the severity risk of their illness and, therefore, postpone seeking professional help for years. Moreover, less than one in five actually seek professional help and only 50% respond to current treatments, such as cognitive behavioral therapy (CBT). The impetus for the present trial is to explore a novel combination treatment approach adapted from physical exercise- and dietary therapy (PED-t). The therapeutic underpinnings of these separate treatment components are well-known, but their combination to treat BN and BED have never been previously tested. The purpose of this paper is to provide the rationale for this new treatment approach and to outline the specific methods and procedures.

METHODS

The PED-t trial uses a prospective randomized controlled design. It allocates women between 18 and 40 years (BMI range 17.5-35.0) to groups consisting of 5-8 members who receive either CBT or PED-t for 16 weeks. Excess participants are allocated to a waiting list control group condition. All participants are assessed at baseline, post-treatment, 6, 12 and 24 months' post-follow-up, respectively, and monitored for changes in biological, psychological and therapy process variables. The primary outcome relates to the ED symptom severity, while secondary outcomes relates to treatment effects on physical health, treatment satisfaction, therapeutic alliance, and cost-effectiveness. We aim to disseminate the results in high-impact journals, preferable open access, and at international conferences.

DISCUSSION

We expect that the new treatment will perform equal to CBT in terms of behavioral and psychological symptoms, but better in terms of reducing somatic symptoms and complications. We also expect that the new treatment will improve physical fitness and thereby, quality of life. Hence, the new treatment will add to the portfolio of evidence-based therapies and thereby provide a good treatment alternative for females with BN and BED.

TRIAL REGISTRATION

Prospectively registered in REC the 16th of December 2013 with the identifier number 2013/1871 , and in Clinical Trials the 17th of February 2014 with the identifier number NCT02079935 .

Cognitive Remediation Therapy for Adolescents with Anorexia Nervosa-Treatment Satisfaction and the Perception of Change

Cognitive remediation therapy (CRT) has recently been developed for children and adolescents with anorexia nervosa (AN). It focuses on decreasing rigid cognitions and behaviors, as well as increasing central coherence. Overall, CRT has been proven feasible for young individuals with AN, but little is known regarding the specifics of its feasibility, and the perception of change associated with the intervention. Consequently, the aim of the current study was to explore service users’ perspective on CRT with a specific focus on treatment delivery, treatment content, and perceived change. Twenty adolescents (age 13–18) with AN participated in a 10-session course of CRT. A 20-item treatment evaluation questionnaire was administered at the end of treatment, focusing on four aspects of the intervention: (1) general attitudes towards treatment, (2) treatment specifics, (3) the perception of change and (4) the patient-therapist relation. The main findings suggest high levels of treatment satisfaction, but somewhat limited perceptions of change. The current study is one of the most detailed accounts of adolescents’ perspective on CRT published on eating disorders, and highlights several important aspects of the treatment viewed through the eye of the receiver.

A 10-year follow-up study of completers versus dropouts following treatment with an integrated cognitive-behavioral group therapy for eating disorders

BACKGROUND

Cognitive-behavioral therapy (CBT) has been recommended for the treatment of eating disorders, and group therapy is known to have certain advantages over individual therapy. The aim of the current study was to compare the 10-year prognosis of patients who completed integrated group CBT with those who dropped out and to examine the effect of completion of group CBT on the prognosis.

METHODS

The participants were 65 adult patients with eating disorders. All patients were women and Japanese. The average age (19-37) of the patients was 25.1 ± 3.8 years, and the average body mass index (BMI) was 17.7 ± 2.0. We conducted integrated group CBT with the patients and compared eating disorder symptoms, mood states, coping styles, and self-esteem before and after therapy. Furthermore, we compared clinical features and the 10-year prognosis of patients who completed the treatment and those who dropped out.

RESULTS

After 10 sessions of group therapy, Eating Attitudes Test scores, Profile of Mood States depression scores, and Coping Inventory for Stressful Situations emotion-oriented scores decreased, while Rosenberg's Self-Esteem Scale scores increased. Regarding the results of the 10-year follow up, the completer group had more patients with a good prognosis. In contrast, the dropout group had more patients with a poor prognosis.

CONCLUSIONS

Those who completed the integrated group CBT had a good prognosis. Group therapy gives the patients an opportunity to form peer relationships, and helps them to develop communication and socialization skills. Furthermore, in the group therapy sessions, the patients develop self-awareness by listening to other members of the group and they also develop interpersonal relationships. This effect may be temporary, but experience of group therapy may provide hope for the patient and increase the chance of the patient continuing treatment.

TRIAL REGISTRATION

Retrospectively registered in University Hospital Medical Information Network in Japan: No. 000028868 (May 19th, 2017).

Therapeutic alliance, expressed emotion, and treatment outcome for anorexia nervosa in a family-based partial hospitalization program

Adolescent therapeutic alliance has been found to be associated with improvements in eating disorder cognitions and with early weight gain. The current study assessed patient and parent therapeutic alliance, correlates of parent alliance, and relationship between alliance and treatment outcome. Fifty-six patients with anorexia nervosa completed measures of therapeutic alliance and eating disorder symptoms. Patients' parents completed measures of therapeutic alliance, expressed emotion, and psychopathology. Patients' alliance predicted cognitive and behavioral symptomatology at end of treatment (β=-0.39, p=0.001), though it was not related to changes in weight (β=0.12, p=0.377). Maternal hostility was associated with lower maternal alliance (r=-0.34, p=0.05). Findings suggest that maternal hostility should be addressed in treatment, and that patient alliance may be important in achieving psychological recovery from disordered eating.

Personality predicts drop-out from therapist-guided internet-based cognitive behavioural therapy for eating disorders. Results from a randomized controlled trial

Internet-based guided self-help cognitive behavioural therapy (ICBT) seems a promising way of delivering eating disorder treatment. However, treatment drop-out is a common problem and little is known about the correlates, especially in clinical settings. The study aimed to explore prediction of drop-out in the context of a randomized controlled trial within specialized eating disorder care in terms of eating disorder symptomatology, personality traits, comorbidity, and demographic characteristics. 109 outpatients diagnosed with bulimia nervosa or similar eating disorder were randomized to two types of ICBT. Participants were assessed with several clinical- and self-ratings. The average drop-out rate was 36%. Drop-out was predicted by lower scores in the personality traits Dutifulness and Assertiveness as measured by the NEO Personality Inventory Revised, and by higher scores in Self-affirm as measured by the Structural Analysis of Social Behaviour. Drop-out was also predicted by therapist factors: one therapist had significantly more drop-outs (82%) than the other three (M = 30%). Theoretical and clinical implications of the impact of the predictors are discussed.

Nursing Care Considerations for the Hospitalized Patient with an Eating Disorder

Eating disorders are chronic psychiatric illnesses with significant medical complications, psychological distress, and psychiatric comorbidity. Although many patients are treated on an outpatient basis, inpatient care for the more severely ill hospitalized patient can be challenging given the severity of illness and concurrent issues requiring intervention. This article provides an overview of the clinical characteristics of eating disorders typically seen for inpatient care, focusing primarily on anorexia nervosa and bulimia nervosa, and the associated key areas for nursing assessment, diagnoses, and plan of care during hospitalization.

The Tree Theme Method® (TTM), an occupational therapy intervention for treating depression and anxiety: study protocol of a randomized controlled trial

Background

Depression and anxiety disorders are increasing among the general population in the Western world. Individuals may need several kinds of treatment in order to maintain health, such as cognitive behavioural therapy (CBT) and drug treatment. However, having an everyday life that “works” is also important, suggesting a need for interventions based on activities that facilitate a satisfying everyday life. There is still lack of such evidence-based interventions. The Tree Theme Method^® (TTM) is an occupational therapy intervention designed for a client-centred context in which an individual develops strategies to become an actor in his or her everyday life. Previous studies of the TTM have focused on process evaluation; therefore, further studies are needed to evaluate the method’s effects. The aim of this paper is to outline an intervention that can evaluate the effects of the TTM in terms of psychological symptoms, as well as everyday occupations and well-being, in patients suffering from depression and anxiety.

Methods/Design

This randomized clinical trial includes patients from three Swedish counties randomized to either intervention or treatment as usual. Men and women aged 18–65 years who have been diagnosed with either depression or anxiety are eligible for inclusion. Data collection is carried out at baseline, and outcomes are assessed at the end of intervention, as well as at 3 months and 12 months after intervention ends. The outcomes measured are psychological symptoms, everyday activities, and health-related factors.

Discussion

Depression and anxiety may create difficulties for individuals in the activities of their everyday lives to the extent that they require diagnosis and intervention. Despite this reality, evidence-based interventions that focus on everyday activities are lacking. Therefore, it would be useful to design a specific method for occupational therapy intervention that does precisely that. This study provides insight into the effects of the TTM, comparing it to occupational therapy treatment as usual.

Trial registration

ClinicalTrials.gov: NCT01980381; registered November 2013.

Family therapy for adolescent anorexia nervosa

PURPOSE OF REVIEW

Research into the efficacy and practice of family therapy for the treatment of adolescent anorexia nervosa has been ongoing for the past 4 decades. Research results continue to highlight the effective role of family therapy for the treatment of anorexia in adolescents. This review aims to present findings and opinions from relevant articles published over the past 12 months, related to the treatment of adolescent anorexia, utilizing family therapy and multi-family therapy.

RECENT FINDINGS

A number of recent articles continue to explore family therapy for adolescent anorexia, with particular emphasis being placed on attempting to pinpoint those elements of the approaches that may hold significance in relation to recovery from this dangerous illness and the development of new interventions that draw on the evidence to date for a family approach to the treatment of anorexia.

SUMMARY

Ongoing research is needed to identify the active ingredients of family therapy for anorexia.