norfolk community eating disorders research updates

Norfolk CommunityEating DisordersServiceResearch Updates

Dr MadeleineTathamConsultant ClinicalPsychologist

Julie DoddAssistant Psychologist

Overview•CBT-T

•Keeping Myself Safe Group

•Attitudes and concerns regarding CBTmanuals

Background

• Vikki Mountford

• Hannah Turner

• Madeleine Tatham

• Glenn Waller

1. CBT-T

• Need for cost effective, faster, evidence-basedtreatments

• Delivered by wide range of (non-specialist) mentalhealth providers?

Pilot Project• 10 week CBT protocol

• 2 x Band 5s

• 2 day training delivered by lead author

• Weekly supervision by lead author to ensure fidelity

• Case management by Consultant ClinicalPsychologist

Broadstructure ofCBT-T

Psychoeducation and cognitive restructuring

Changing eating - exposure

Changing eating – Behavioural experiments

Maintaining alliance and motivation (reinforcement for change)

Body image work (avoidance = exposure;checking and comparison = behaviouralexperiments; mind-reading = surveys)

Reducing bingeing and purging - exposure work

Reducing emotional triggers tobulimic behaviours

Monitoring risks and safety

Measurement of outcome, discussion with patient, response to no change

Engage; assessmaintaining factors

Relapse prevention

Measures•EDE-Q•GAD7•PHQ9•WAI-SR•PBQ

•and ED10

ED10 – development of a new measure• Session by session measure

• 10 core attitudinal and behavioural items

• Good internal consistency and test-retest reliability

• r=.889 with EDE-Q

• track changes to determine importance of earlyresponse to therapy

And beyond......

• Is it effective and if so, who for?

• Mediators and moderators of change

• Therapeutic alliance

• Long-term follow up

2. Keeping Myself Safe Group

•Move away from MET

•Psychoeducation and therapeuticstance

Rationale and aims• Manage RTT targets

• Fostering early engagement following assessment

• Reducing isolation and shame

• Provide psychoeduation about ED symptoms andassociated health risks

• Promoting responsibility and autonomy for self-care

• Developing an individualised self-care plan (includingengaging with physical monitoring)

Group Format•4 Group Sessions and anindividual follow up

•Our stance

•Overview

•Keeping myself safer plan and GPsummary

•Overcoming obstacles

•What has gone well?/ difficulties?

Impact....?• Self-reported increases in likelihood of attendingphysical monitoring.

• Increased belief ratings re the importance of self-care

• Increased confidence to engage in proactive self-care activitiesAND

• Anecdotal observations regarding improvement insymptoms.........

I.e. symptom change2012 - 2013 2013-2014

0

1

2

3

4

5

6

No.

of s

ympt

oms

per w

eek

Eating Disorder Symptomatology

Binges Vomitting Laxatives

0

1

2

3

4

5

6

No.

of s

ympt

oms

per w

eek

Eating Disorder Symptomatology

Binges Vomitting Laxatives

And BMI.....2012-2013 2013-2014

16.6

16.21

15.8

17.817.95

Diagnosticcut off

14.5

15

15.5

16

16.5

17

17.5

18

18.5

Assessment Start Session 6 End Follow up

BM

I

BMI (AN only)

16.3

17.3

16.7

17.01

17.4Diagnostic

cut off

14.5

15

15.5

16

16.5

17

17.5

18

18.5

Assessment Start Session 6 End FU 1

BM

I

BMI (AN only)

Research in progress......• Impact of psychoeduational group on symptomswhilst awaiting treatment?

• Impact of KMS group on retention in treatment?

• Impact of KSM group on treatment outcome?

Previous researchConcerns delivering CBT Attitudes to manuals

Attitudes to manuals – key findings

• Low uptake and implementation of ED evidence-basedtreatment (e.g. Von Ranson, Wallace & Stevenson, 2013)

• Key issue in delivery is the use of manualised methods

• Use of CBT manuals enhances reported use of coretechniques (Waller et al, 2012)

• Little training in their use, limited use!

Attitudes to manuals• Variation in use - situational and demographicfactors

• Beliefs about their impact upon therapeutic processand outcomes

• Attitudes towards manuals can effect outcomes(CBT for CFS; Wiborg et al, 2012)

• In eating disorders?

Method

Participants• 125 qualified therapists in UK

Measures• Attitudes to Treatment Manuals Questionnaire• Brief Symptom Inventory

Findings

• Majority aware of manuals• Only half using them often or always• Those who did tended to be

- Older- Less negative about impact on process- Report positive outcomes / attitudes

• Negative attitudes associated with less familiarityand lower mood level- Beliefs about impact of manuals on process

Implications1. Address therapist concerns about impact upon

therapeutic process in manuals (e.g.emphasising need for good alliance)

2. Ensure clinicians are familiar with manuals

3. Changing attitudes via supervision – encouragingexperimentation to see whether their use resultsin positive attitudes to structured psychologicaltreatment

Clinicians’ concerns delivering CBT• Evidence-based interventions under-used in ED

? Unaware of evidence base? (Meehl, 1986)

? Beliefs and attitudes about evidence-basedtreatments? (Shafran et al., 2009)?

? Level of training, competence and supervision ?(Fairburn & Wilson, 2013)

Method

Participant• 113 clinicians

Measures• 14 elements of CBT• Intolerance of Uncertainty Scale

Findings

• 4 distinct concerns

1. Process2. Education3. Cognitive4. Exposure

• Most worrying:• Body image work• Ending treatment

• Least worrying:• psychoeduation

Findings cont....

Clinician traits:• Older , more experienced clinicians less worried

• No general link between trait anxiety and concerns abouttechniques but

• Prospective anxiety = more concern re cognitive /exposure elements of change

• P and Inhib anxiety = more concern process-related elements (motivation / endings)

Implications• Importance of clinician’s own cognitions andemotions and their impact upon treatment:

• Prospective anxiety – less likely to use the impactladen interventions?- Cognitive restructuring- Behavioural experiments- Weighing & dietary change

• Inhibitory anxiety – less likely to manage endingsappropriately and extend treatment unnecessarily?

And finally, ideas for the future.....?• Patients’ views of (CPA) motivational assessmentletters

• Development of an ED / Diabetes measure

• Supervisor competencies / development of adisorder specific CTRS?