The third presentation was by Dr MadeleineTatham (Consultant Clinical Psychologist, Norfolk CEDS) and Julie Dodd (Assistant Psychologist) which gave an overview about current research activities and projects including an exciting pilot project on Cognitive Behavioral Therapy (CBT-T) in eating disorders, group therapy (Keeping Myself Safe) and an interesting research on clinicians’ attitude towards using CBT manuals.

1. Norfolk Community
Eating Disorders
Service
Research Updates
Dr MadeleineTatham
Consultant Clinical
Psychologist
Julie Dodd
Assistant Psychologist

2. Overview
•CBT-T
•Keeping Myself Safe Group
•Attitudes and concerns regarding CBT
manuals

3. Background
• Vikki Mountford
• Hannah Turner
• Madeleine Tatham
• Glenn Waller

4. 1. CBT-T
• Need for cost effective, faster, evidence-based
treatments
• Delivered by wide range of (non-specialist) mental
health providers?

5. 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 Clinical
Psychologist

6. Broad
structure of
CBT-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 = behavioural
experiments; mind-reading = surveys)
Reducing bingeing and purging - exposure work
Reducing emotional triggers to
bulimic behaviours
Monitoring risks and safety
Measurement of outcome, discussion with patient, response to no change
Engage; assess
maintaining factors
Relapse prevention

7. Measures
•EDE-Q
•GAD7
•PHQ9
•WAI-SR
•PBQ
•and ED10

8. 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 early
response to therapy

9. And beyond......
• Is it effective and if so, who for?
• Mediators and moderators of change
• Therapeutic alliance
• Long-term follow up

10. 2. Keeping Myself Safe Group
•Move away from MET
•Psychoeducation and therapeutic
stance

11. Rationale and aims
• Manage RTT targets
• Fostering early engagement following assessment
• Reducing isolation and shame
• Provide psychoeduation about ED symptoms and
associated health risks
• Promoting responsibility and autonomy for self-care
• Developing an individualised self-care plan (including
engaging with physical monitoring)

12. Group Format
•4 Group Sessions and an
individual follow up
•Our stance
•Overview
•Keeping myself safer plan and GP
summary
•Overcoming obstacles
•What has gone well?/ difficulties?

13. Impact....?
• Self-reported increases in likelihood of attending
physical monitoring.
• Increased belief ratings re the importance of self-
care
• Increased confidence to engage in proactive self-
care activities
AND
• Anecdotal observations regarding improvement in
symptoms.........

14. I.e. symptom change
2012 - 2013 2013-2014
0
1
2
3
4
5
6
No.ofsymptomsperweek
Eating Disorder Symptomatology
Binges Vomitting Laxatives
0
1
2
3
4
5
6
No.ofsymptomsperweek
Eating Disorder Symptomatology
Binges Vomitting Laxatives

15. And BMI.....
2012-2013 2013-2014
16.6
16.21
15.8
17.8
17.95
Diagnostic
cut off
14.5
15
15.5
16
16.5
17
17.5
18
18.5
Assessment Start Session 6 End Follow up
BMI
BMI (AN only)
16.3
17.3
16.7
17.01
17.4
Diagnostic
cut off
14.5
15
15.5
16
16.5
17
17.5
18
18.5
Assessment Start Session 6 End FU 1
BMI
BMI (AN only)

16. Research in progress......
• Impact of psychoeduational group on symptoms
whilst awaiting treatment?
• Impact of KMS group on retention in treatment?
• Impact of KSM group on treatment outcome?

17. Previous research
Concerns delivering CBT Attitudes to manuals

18. Attitudes to manuals – key findings
• Low uptake and implementation of ED evidence-based
treatment (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 core
techniques (Waller et al, 2012)
• Little training in their use, limited use!

19. Attitudes to manuals
• Variation in use - situational and demographic
factors
• Beliefs about their impact upon therapeutic process
and outcomes
• Attitudes towards manuals can effect outcomes
(CBT for CFS; Wiborg et al, 2012)
• In eating disorders?

20. Method
Participants
• 125 qualified therapists in UK
Measures
• Attitudes to Treatment Manuals Questionnaire
• Brief Symptom Inventory

21. 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 familiarity
and lower mood level
- Beliefs about impact of manuals on process

22. Implications
1. 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 – encouraging
experimentation to see whether their use results
in positive attitudes to structured psychological
treatment

23. Clinicians’ concerns delivering CBT
• Evidence-based interventions under-used in ED
? Unaware of evidence base? (Meehl, 1986)
? Beliefs and attitudes about evidence-based
treatments? (Shafran et al., 2009)?
? Level of training, competence and supervision ?
(Fairburn & Wilson, 2013)

24. Method
Participant
• 113 clinicians
Measures
• 14 elements of CBT
• Intolerance of Uncertainty Scale

25. Findings
• 4 distinct concerns
1. Process
2. Education
3. Cognitive
4. Exposure
• Most worrying:
• Body image work
• Ending treatment
• Least worrying:
• psychoeduation

26. Findings cont....
Clinician traits:
• Older , more experienced clinicians less worried
• No general link between trait anxiety and concerns about
techniques but
• Prospective anxiety = more concern re cognitive /
exposure elements of change
• P and Inhib anxiety = more concern process-
related elements (motivation / endings)

27. Implications
• Importance of clinician’s own cognitions and
emotions and their impact upon treatment:
• Prospective anxiety – less likely to use the impact
laden interventions?
- Cognitive restructuring
- Behavioural experiments
- Weighing & dietary change
• Inhibitory anxiety – less likely to manage endings
appropriately and extend treatment unnecessarily?

28. And finally, ideas for the future.....?
• Patients’ views of (CPA) motivational assessment
letters
• Development of an ED / Diabetes measure
• Supervisor competencies / development of a
disorder specific CTRS?