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

Treatment Protocols for Eating Disorders: Clinicians’ Attitudes, Concerns, Adherence and... Curr Psychiatry Rep (2016) 18: 36 DOI 10.1007/s11920-016-0679-0 EATING DISORDERS (C GRILO, SECTION EDITOR) Treatment Protocols for Eating Disorders: Clinicians’ Attitudes, Concerns, Adherence and Difficulties Delivering Evidence-Based Psychological Interventions Glenn Waller Published online: 18 February 2016 The Author(s) 2016. This article is published with open access at Springerlink.com Abstract There are several protocols in existence that guide in a way that is reflective of their individual case, but guided clinicians in the implementation of effective, evidence-based by a set of principles. The clinical skill and artistry in the psychological interventions for eating disorders. These have delivery of evidence-based therapy lie in how the clinician been made accessible in the form of treatment manuals. implements the protocol for the individual patient (1). However, relatively few clinicians use those protocols, prefer- However, despite this clear recognition that protocols and ring to offer more eclectic or integrative approaches. manuals need to be used flexibly, they are perceived negative- Following a summary of the research that shows that these ly by many clinicians (2), who regard them as constraining evidence-based approaches can be used successfully in rou- their practice and artistry by limiting the individualisation of tine clinical settings, this review considers why there is such formulation and intervention approaches (1). Therapists rou- poor uptake of these therapies in such settings. This review tinely deviate from those evidence-based approaches—aphe- focuses on the role of service culture and on clinicians’ own nomenon termed ‘therapist drift’ (3, 4). attitudes, beliefs and emotions. Possible means of enhancing Many clinicians argue that evidence-based practice is a uptake are considered, but these cannot be considered to be more useful approach than the use of empirically supported ideal solutions at present. interventions. Evidence-based practice combines those empirically-supported approaches (usually based on the use . . of a protocol/manual) with clinicians’ own judgement and Keywords Eating disorders Evidence-based practice . . Protocols Manuals Adherence therapist drift patients’ values. However, there are two issues to consider here. First, the evidence to date does not really support the superiority of this wider ‘evidence-based practice’ approach. In most cases, clinician judgement results in poorer outcomes Introduction than protocol-based approaches (5, 6), and there is little evi- dence that the individualised formulations that clinicians de- Protocols, usually codified in the form of treatment manuals, are key methods for the dissemination and reliable implemen- velop are clinically reliable or useful to the patient (7). Second, in eating disorders in particular, patient values are often in tation of evidence-based psychological treatments. It is impor- tant to recognise a protocol for what it is intended to be—a direct conflict with the necessary elements of evidence- based treatments—for example, the anorexia nervosa sufferer broad set of methods, designed to be applicable to the patient who wants to achieve recovery (e.g. regaining their health, completing their education, being able to have children, being This article is part of the Topical Collection on Eating Disorders accepted by those around them) whilst remaining at a weight that makes this impossible, or the bulimia nervosa sufferer * Glenn Waller who wants treatment that alleviates their bulimic symptoms g.waller@sheffield.ac.uk whilst losing weight at the same time. Therefore, one needs to be wary of the assumption that evidence-based practice (with its tripartite nature) will be superior to the single element of a Clinical Psychology Unit, Department of Psychology, University of Sheffield, Western Bank, Sheffield S10 1NT, UK protocolised evidence-based treatment. 36 Page 2 of 8 Curr Psychiatry Rep (2016) 18: 36 Clinicians working with eating disorders are potentially & Treatments for adults with anorexia nervosa had weak fortunate, in that there exists a range of evidence-based proto- evidence, with weak outcomes (even when they include cols that we can use to guide our clinical practice (8–14, 15� , treatments delivered in more intensive settings), and little 16, 17). Whilst none of these achieves 100 % success (see difference between therapies. below), they have demonstrable levels of benefit and can be & There was virtually no evidence base relating to the treat- implemented in routine clinical practice. This review will ment of atypical eating disorders (other than binge eating briefly consider the evidence that we can treat the eating dis- disorder), despite this category representing the largest orders in research and routine clinical settings, using single category of eating disorders (19). protocolised approaches. It will then explore whether we use those approaches in routine practice and the reasons that we Since those reviews were published, a number of important do or do not do so. Finally, ways in which clinicians might be treatment trials have been published in the field. The key encouraged to use evidence-based protocols and methods and changes in our evidence base as a result can be summarised as: whether such encouragement is likely to be effective will be considered. & CBT has been shown to be effective in the treatment of atypical cases of eating disorder where the patient is not The Evidence Base for Psychological Treatments underweight (25), though there is no evidence that there for Eating Disorders has been any improvement in outcomes for bulimia nervosa or binge eating disorder with developments in Once a protocol has been developed and piloted, evidence- CBT. based treatment requires two major forms of study before it & Outcomes for patients with anorexia nervosa are some- can be considered to be viable. First, there need to be well- what improved, particularly for CBT (26 , 27), though controlled trials of the protocol in research settings (‘efficacy not in modified versions of CBT where weight gain is studies’). Then, the treatment needs to be tested in routine de-emphasised (28). CBT is now demonstrably more ef- clinical settings (‘effectiveness studies’). Both have been car- fective than other therapies for this group, at least by the ried out in the field of treating eating disorders. end of therapy (29, 30). Its effects remain weak compared to the outcomes for patients who are not underweight, Efficacy Studies with recovery in only approximately 30 % of anorexia nervosa patients entering CBT, but this is better than the There is clear evidence from large research trials that some outcomes demonstrated by other therapies (15� , 30, 31). therapies are efficacious in working with eating disorders. That evidence had been well summarised up until a few years Other findings in recent years (32) simply reinforce the ago, in the form of a number of reviews with very consistent conclusions from the earlier literature, as outlined above. It conclusions (18–24). A reasonable summary of those reviews is particularly noteworthy that there has been little improve- might have led to the following summary, a decade ago: ment in the outcomes of pharmacotherapy in that time (33). In particular, it cannot be assumed that combining medication & A number of therapies had been identified that reduced the with psychotherapies is a useful strategy, as the combination severity and presence of bulimia nervosa and binge-eating does not reliably add to the benefits of the psychotherapies in disorder, including cognitive-behavioural therapies isolation (34). (CBT), interpersonal psychotherapy (IPT), and dialectical Finally, it is worth noting that the change in diagnostic behaviour therapy (DBT). Of those therapies, CBT had criteria with DSM-5 does not appear to have altered outcome the strongest evidence of the greatest and most rapid rates appreciably. However, it does mean that there is some effects. doubt about the comparability of studies. & Those therapies were usually more effective if delivered in an individual, face-to-face setting. Effectiveness & Medications had a limited role in the treatment of eating disorders, with some evidence for symptom alleviation in Obviously, it is important to consider whether these evidence- bulimia nervosa and binge-eating disorder, but no support based treatments can be delivered outside of highly resourced for treating anorexia nervosa and no clear evidence for research settings. A common belief amongst clinicians is that medication/psychotherapy combinations being superior. the results from such research trials cannot be replicated in The studies were often hard to rely on as indicators of routine clinical settings, due to the patients in research settings remission or recovery, as they had very short follow-ups. being more carefully selected (e.g. to exclude comorbidity), & Younger adolescents with less long-lasting cases benefit- an unachievable level of supervision and training for thera- ted more from family-based therapies (FBT). pists, and greater resources being spent on the treatment than �� Curr Psychiatry Rep (2016) 18: 36 Page 3 of 8 36 in routine practice. However, this is an empirical question— single version that combines the focused form with the affect can the results from clinical research (efficacy) be replicated in regulation module of the broad form (50). Finally, studies vary everyday practice (effectiveness)? in how they treat outcomes, with some studies of anorexia Fortunately, the past decade has seen the publication of nervosa treating hospitalisation as a routine event and others several effectiveness studies that give a clear answer to this as a reason for defining therapy as having failed (26�� , 29). question, using large routine clinical populations of patients Whilst developments and differences in delivery are clinically with different diagnoses (35–40), and the answer is clear. The understandable, the key differences need to be highlighted, to clinical outcomes are very close to those found in research ensure that differences in outcomes can be understood. trials, though the attrition rate is somewhat higher. To summarise, the number of patients who receive Unfortunately, the literature is almost entirely based on CBT. evidence-based therapies is probably very low, outside of re- Therefore, there is a need for more effectiveness studies to search settings. This pattern of therapist drift and the conse- determine whether other evidence-based therapies maintain quent evidence-practice gap are not confined to eating disor- that evidence in everyday practice. However, given the lack ders (3, 4). However, as in other disorders, the gap is a concern of support for common clinician beliefs (e.g. ‘The research because we have no idea whether it is justified in terms of just does not apply here’) relating to the most strongly evi- patient benefits. Few clinicians document or report on the denced psychological therapy, one might argue that clinicians outcome of their eclectic or integrationist (or random) ap- who want to discount other therapies should be required to proaches to treatment. The use of individualised approaches make the case that the evidence base cannot be applied in their to treatment of eating does not preclude measurement of ef- place of work. fectiveness, but the lack of such measurement does not reas- sure others that this individual-centred approach is more ef- How Widely Used Are the Evidence-Based Interventions? fective than a protocol-based approach. Indeed, it is important to remember that an individual-centred approach based on Despite the evidence outlined above, the simple answer to this clinician judgement has been shown to be substantially less question is: ‘Not very widely’. The number of eating-disorder effective than the use of a protocol-based approach (6). specialist clinicians who report adhering to evidence-based Therefore, once again, the obligation to demonstrate effective- protocols and manuals is between 6 and 35 % (41, 42). Far ness could be argued to lie with the clinician who adopts the more clinicians report that they use (un-tested or un-support- non-standard approach. ed) mixtures of some techniques that are derived from empir- ically supported treatments and some techniques that are not Why Are Evidence-Based Therapies So Rarely supported even at that level (41, 43). Used for the Eating Disorders? Even when clinicians say that they are using an evidence- based therapy, that claim should be treated with caution. For Difficulties with delivering evidence-based therapies can be example, many clinicians who state that they are delivering identified at different levels. First, there are service-centred CBT or FBT report that they omit many of the key techniques reasons. Eating disorder services vary in their culture, and that make up those treatments (44, 45, 46� , 47). This omission consequently, their willingness to change towards evidence- is reflected in the accounts of eating-disordered patients based methods. Possibly the best example of service-level reporting on the treatment that they have received (48� , 49), reluctance is that provided by Lowe and colleagues (51), as their accounts suggest widely divergent patterns of tech- who attempted to introduce a ‘normalisation of eating’ module niques delivered under the title of CBT. into the care package delivered by an existing set of eating A further complication is that the same label is used for disorder services. They described extreme difficulties in intro- therapies with different content. CBT is a classic example of ducing this element of treatment, facing resistance based on this issue, with the content differing in important ways. For the staff teams’ and services’ philosophy and practice of care, example, one might not be surprised that a form of CBT for even though the administrators of the clinical services had anorexia nervosa that reduced or removed the emphasis on approved the proposed change. weight gain (the key outcome variable [21]) has relatively Second, patient-centred reasons exist for non-use of low rates of weight gain (28). Similarly, in recent years, there evidence-based methods. Patients’ values can conflict with has been widespread dissemination of an enhanced form of the delivery of evidence-based treatments. Many patients CBT (CBT-E [10]), though it has never been compared direct- who have previously had therapy express a preference for an ly with the previous form of CBT to determine whether it is approach that is less challenging, omitting key elements such more effective with bulimia nervosa or binge eating disorder. as weighing and record-keeping (52). Given the degree to Indeed, one has to be careful to understand which version of which therapists omit some of the key elements of therapy CBT-E is being used when considering outcomes, as the orig- (see above), it cannot be a surprise that many eating- inal two versions (broad and focused) have converged into a disordered patients have previously had several unsuccessful 36 Page 4 of 8 Curr Psychiatry Rep (2016) 18: 36 therapies and have become acculturated to the idea that ther- include patient chronicity, comorbidity and complexity, even apy is a relatively unchallenging experience. In short, inade- though the evidence would not support these as reasons for quate therapy experiences have the potential to teach patients such an exclusion or change in practice (65–67). that treatment should not be challenging in any way, when it is Clinicians’ emotions are also important in understanding clear that the evidence-based approaches are based on chang- the delivery of protocols and evidence-based treatment. As ing ingrained behavioural, social, cognitive and emotional with other disorders (68� ), clinicians who are more anxious patterns. Of course, this avoidance of challenging is not con- are less likely to deliver some of the key elements of treatment fined to the patient, as clinicians also seem to do the same for eating disorders (44, 47). This avoidance of more ‘de- thing in order to reduce their own anxiety (see below). This manding’ elements of therapy has been suggested to be an joint pattern is perhaps most clearly seen when the therapist example of clinicians engaging in their own safety behav- and patient fall into the pattern of discussing causes of the iours—avoidance of tasks (e.g. weighing patients; changing eating disorder without engaging in change of the maintaining their food intake). Such avoidance means that the clinician factors (e.g. not changing eating patterns). does not feel like a ‘bad therapist’ for distressing the patient, Finally, there are clinician-centred reasons for non- even though the longer-term result is that the patient does not delivery of evidence-based approaches. One key reason ap- improve and the clinician is less effective (4). Meehl (69)has plies to psychological therapies in general—many clinicians referred to this ‘protection’ of patients from the demands of (approximately one third) are untrained in the therapy that change as reflecting clinicians having a ‘spun glass theory of they are employed to deliver (53, 54). The second important the mind’ of their patients—the belief that our making de- reason is the fact that many clinicians’ actions typify the ‘af- mands of our patients will somehow damage them (like a filiation hypothesis’—because one believes in a therapy’sef- fragile spun-glass decoration), even though such protection fectiveness, it will be effective when one uses it. In the case of means that patients cannot learn to change for the better. the eating disorders, this is a hypothesis that has been com- prehensively disproved by the work of Poulsen and colleagues How Could Clinicians Be Encouraged (55�� ), who have shown that therapists being affiliated to a to Use Evidence-Based Methods? psychodynamic approach to treating bulimia nervosa does not mean that their recovery rate comes even close to the The mean length of time for research findings to enter into outcome from evidence-based CBT, even when the psycho- routine clinical practice is a (perhaps) startling 15–20 years dynamic therapy is several times longer. (70). In some cases, this delay is a matter of ignorance, and in Clinician beliefs and attitudes have a strong influence on others, it is a product of resistance at a variety of levels. Whilst clinical practice. Outside the field of eating disorders, it has ignorance of the existence of methods to treat different disor- been shown that clinicians’ ratings of their skills and clinical ders can be overcome relatively easily through didactic outcomes indicate that we believe we are far more effective methods, that is not the same as teaching or persuading clini- that we actually are (56–58). There is no reason to assume that cians to use them and to do so appropriately. eating disorder clinicians differ from this general pattern of Training clinicians is a challenging area (71). Commonly, a beliefs. Another clinician-based factor is our knowledge of single teaching session of a few hours to two days is treated as and attitudes to protocols and manuals. These vary consider- ‘training’, even though there is little evidence that this works. ably from clinician to clinician (2, 59), within and outside the For example, whilst it is known that such sessions can influ- eating disorders. Some clinicians are unaware of the existence ence knowledge of and attitudes to exposure therapy, both for of manuals and protocols and others hold very negative eating disorders and anxiety disorders (72, 73), it is not yet attitudes towards them. It is also clear that we hold attitudes known whether such changes translate into better use of the to some elements of therapy for eating disorders that are not in necessary skills in everyday practice. In short, does education keeping with the evidence about them. For example, some translate into competence, and does competence translate into elements of therapy for eating disorders appear to be adherence to protocols and hence to more effective treatment? overvalued, such as pre-therapy motivational work (60, 61) For example, many people have learned to drive safely whilst and the presumed universal importance of prioritising the de- being closely monitored (competence), but after a short period velopment of a strong working alliance in order to facilitate of driving without that monitoring their driving deteriorates change (62, 63). In contrast, clinicians undervalue some key (non-adherence). elements of therapy for eating disorders, such as the need to It is commonly assumed that clinical supervision is a means weigh patients regardless of the specific evidence-based mod- of ensuring that clinicians should adhere to best quality prac- el (64). Finally, clinicians often hold beliefs about what Meehl tice. However, there are some worrying caveats to that as- (5)terms ‘broken leg exceptions’—leading us to exclude pa- sumption. First, does the supervisor have an adequate grasp tients from evidence-based treatments on the grounds of ap- of the necessary evidence and skills base to be able to teach the parently spurious ‘justifications’. Those ‘justifications’ can supervisee to be adherent? Given the time it takes for evidence Curr Psychiatry Rep (2016) 18: 36 Page 5 of 8 36 to reach practice (70) and the number of clinicians who lack manuals and protocols rarely (41–45, 46� , 47, 48� )—afailure training in the therapy that they deliver (53, 54, 55�� ), ade- that can be attributed to our lack of knowledge, negative atti- quate supervision is an optimistic assumption in many cases. tudes and emotional characteristics (47, 82). At present, a Second, do supervisors appraise their supervisees’ skills accu- reliance on training and supervision to ensure competence rately? Whilst this question has not been investigated in the and adherence is probably best described as an act of faith, field of eating disorders, it has been considered elsewhere, and requiring more clarity about what the training and supervision the worrying conclusion is that supervisors substantially over- should contain. Our patients would benefit if clinicians and rate their supervisees’ clinical skills (74), with the likely result supervisors were to focus on clinical outcomes and the better that the therapist continues to drift off-protocol. Clearly, fur- implementation of protocols, to improve the level of patient ther research is needed to help us to understand whether or not improvement and recovery. we can trust in the value of supervision to ensure the delivery of protocolized, evidence-based therapies for eating disorders, Compliance with Ethical Standards but the evidence to date is not promising. Conflict of Interest The author declares that he has no conflict of Of course, a strong means of persuading clinicians to interest. change their practice should be to require them to attend to patient outcomes. The existing effectiveness studies (35–40) Human and Animal Rights and Informed Consent This article does show that such outcomes are easily collected, and yet few not contain any studies with human or animal subjects performed by any of the authors. services collect or respond to such information. In part, that poor response might be the product of a lack of research/audit skills or dedicated time, either of which could be rectified. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http:// However, evidence from outside the field of eating disorders creativecommons.org/licenses/by/4.0/), which permits unrestricted use, (75) points to a more worrying fact—that clinicians vary distribution, and reproduction in any medium, provided you give appro- substantially in their interest or willingness to attend to outcome priate credit to the original author(s) and the source, provide a link to the data. If data are regarded as being irrelevant, inconvenient or Creative Commons license, and indicate if changes were made. challenging, then the danger is that clinicians will ignore rather than respondtothem(76). References Where clinicians do attend to data, it is important that they should be encouraged to attend to the most clinically mean- Papers of particular interest, published recently, have been ingful data. 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Treatment Protocols for Eating Disorders: Clinicians’ Attitudes, Concerns, Adherence and Difficulties Delivering Evidence-Based Psychological Interventions

Current Psychiatry Reports , Volume 18 – Feb 18, 2016

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Abstract

Curr Psychiatry Rep (2016) 18: 36 DOI 10.1007/s11920-016-0679-0 EATING DISORDERS (C GRILO, SECTION EDITOR) Treatment Protocols for Eating Disorders: Clinicians’ Attitudes, Concerns, Adherence and Difficulties Delivering Evidence-Based Psychological Interventions Glenn Waller Published online: 18 February 2016 The Author(s) 2016. This article is published with open access at Springerlink.com Abstract There are several protocols in existence that guide in a way that is reflective of their individual case, but guided clinicians in the implementation of effective, evidence-based by a set of principles. The clinical skill and artistry in the psychological interventions for eating disorders. These have delivery of evidence-based therapy lie in how the clinician been made accessible in the form of treatment manuals. implements the protocol for the individual patient (1). However, relatively few clinicians use those protocols, prefer- However, despite this clear recognition that protocols and ring to offer more eclectic or integrative approaches. manuals need to be used flexibly, they are perceived negative- Following a summary of the research that shows that these ly by many clinicians (2), who regard them as constraining evidence-based approaches can be used successfully in rou- their practice and artistry by limiting the individualisation of tine clinical settings, this review considers why there is such formulation and intervention approaches (1). Therapists rou- poor uptake of these therapies in such settings. This review tinely deviate from those evidence-based approaches—aphe- focuses on the role of service culture and on clinicians’ own nomenon termed ‘therapist drift’ (3, 4). attitudes, beliefs and emotions. Possible means of enhancing Many clinicians argue that evidence-based practice is a uptake are considered, but these cannot be considered to be more useful approach than the use of empirically supported ideal solutions at present. interventions. Evidence-based practice combines those empirically-supported approaches (usually based on the use . . of a protocol/manual) with clinicians’ own judgement and Keywords Eating disorders Evidence-based practice . . Protocols Manuals Adherence therapist drift patients’ values. However, there are two issues to consider here. First, the evidence to date does not really support the superiority of this wider ‘evidence-based practice’ approach. In most cases, clinician judgement results in poorer outcomes Introduction than protocol-based approaches (5, 6), and there is little evi- dence that the individualised formulations that clinicians de- Protocols, usually codified in the form of treatment manuals, are key methods for the dissemination and reliable implemen- velop are clinically reliable or useful to the patient (7). Second, in eating disorders in particular, patient values are often in tation of evidence-based psychological treatments. It is impor- tant to recognise a protocol for what it is intended to be—a direct conflict with the necessary elements of evidence- based treatments—for example, the anorexia nervosa sufferer broad set of methods, designed to be applicable to the patient who wants to achieve recovery (e.g. regaining their health, completing their education, being able to have children, being This article is part of the Topical Collection on Eating Disorders accepted by those around them) whilst remaining at a weight that makes this impossible, or the bulimia nervosa sufferer * Glenn Waller who wants treatment that alleviates their bulimic symptoms g.waller@sheffield.ac.uk whilst losing weight at the same time. Therefore, one needs to be wary of the assumption that evidence-based practice (with its tripartite nature) will be superior to the single element of a Clinical Psychology Unit, Department of Psychology, University of Sheffield, Western Bank, Sheffield S10 1NT, UK protocolised evidence-based treatment. 36 Page 2 of 8 Curr Psychiatry Rep (2016) 18: 36 Clinicians working with eating disorders are potentially & Treatments for adults with anorexia nervosa had weak fortunate, in that there exists a range of evidence-based proto- evidence, with weak outcomes (even when they include cols that we can use to guide our clinical practice (8–14, 15� , treatments delivered in more intensive settings), and little 16, 17). Whilst none of these achieves 100 % success (see difference between therapies. below), they have demonstrable levels of benefit and can be & There was virtually no evidence base relating to the treat- implemented in routine clinical practice. This review will ment of atypical eating disorders (other than binge eating briefly consider the evidence that we can treat the eating dis- disorder), despite this category representing the largest orders in research and routine clinical settings, using single category of eating disorders (19). protocolised approaches. It will then explore whether we use those approaches in routine practice and the reasons that we Since those reviews were published, a number of important do or do not do so. Finally, ways in which clinicians might be treatment trials have been published in the field. The key encouraged to use evidence-based protocols and methods and changes in our evidence base as a result can be summarised as: whether such encouragement is likely to be effective will be considered. & CBT has been shown to be effective in the treatment of atypical cases of eating disorder where the patient is not The Evidence Base for Psychological Treatments underweight (25), though there is no evidence that there for Eating Disorders has been any improvement in outcomes for bulimia nervosa or binge eating disorder with developments in Once a protocol has been developed and piloted, evidence- CBT. based treatment requires two major forms of study before it & Outcomes for patients with anorexia nervosa are some- can be considered to be viable. First, there need to be well- what improved, particularly for CBT (26 , 27), though controlled trials of the protocol in research settings (‘efficacy not in modified versions of CBT where weight gain is studies’). Then, the treatment needs to be tested in routine de-emphasised (28). CBT is now demonstrably more ef- clinical settings (‘effectiveness studies’). Both have been car- fective than other therapies for this group, at least by the ried out in the field of treating eating disorders. end of therapy (29, 30). Its effects remain weak compared to the outcomes for patients who are not underweight, Efficacy Studies with recovery in only approximately 30 % of anorexia nervosa patients entering CBT, but this is better than the There is clear evidence from large research trials that some outcomes demonstrated by other therapies (15� , 30, 31). therapies are efficacious in working with eating disorders. That evidence had been well summarised up until a few years Other findings in recent years (32) simply reinforce the ago, in the form of a number of reviews with very consistent conclusions from the earlier literature, as outlined above. It conclusions (18–24). A reasonable summary of those reviews is particularly noteworthy that there has been little improve- might have led to the following summary, a decade ago: ment in the outcomes of pharmacotherapy in that time (33). In particular, it cannot be assumed that combining medication & A number of therapies had been identified that reduced the with psychotherapies is a useful strategy, as the combination severity and presence of bulimia nervosa and binge-eating does not reliably add to the benefits of the psychotherapies in disorder, including cognitive-behavioural therapies isolation (34). (CBT), interpersonal psychotherapy (IPT), and dialectical Finally, it is worth noting that the change in diagnostic behaviour therapy (DBT). Of those therapies, CBT had criteria with DSM-5 does not appear to have altered outcome the strongest evidence of the greatest and most rapid rates appreciably. However, it does mean that there is some effects. doubt about the comparability of studies. & Those therapies were usually more effective if delivered in an individual, face-to-face setting. Effectiveness & Medications had a limited role in the treatment of eating disorders, with some evidence for symptom alleviation in Obviously, it is important to consider whether these evidence- bulimia nervosa and binge-eating disorder, but no support based treatments can be delivered outside of highly resourced for treating anorexia nervosa and no clear evidence for research settings. A common belief amongst clinicians is that medication/psychotherapy combinations being superior. the results from such research trials cannot be replicated in The studies were often hard to rely on as indicators of routine clinical settings, due to the patients in research settings remission or recovery, as they had very short follow-ups. being more carefully selected (e.g. to exclude comorbidity), & Younger adolescents with less long-lasting cases benefit- an unachievable level of supervision and training for thera- ted more from family-based therapies (FBT). pists, and greater resources being spent on the treatment than �� Curr Psychiatry Rep (2016) 18: 36 Page 3 of 8 36 in routine practice. However, this is an empirical question— single version that combines the focused form with the affect can the results from clinical research (efficacy) be replicated in regulation module of the broad form (50). Finally, studies vary everyday practice (effectiveness)? in how they treat outcomes, with some studies of anorexia Fortunately, the past decade has seen the publication of nervosa treating hospitalisation as a routine event and others several effectiveness studies that give a clear answer to this as a reason for defining therapy as having failed (26�� , 29). question, using large routine clinical populations of patients Whilst developments and differences in delivery are clinically with different diagnoses (35–40), and the answer is clear. The understandable, the key differences need to be highlighted, to clinical outcomes are very close to those found in research ensure that differences in outcomes can be understood. trials, though the attrition rate is somewhat higher. To summarise, the number of patients who receive Unfortunately, the literature is almost entirely based on CBT. evidence-based therapies is probably very low, outside of re- Therefore, there is a need for more effectiveness studies to search settings. This pattern of therapist drift and the conse- determine whether other evidence-based therapies maintain quent evidence-practice gap are not confined to eating disor- that evidence in everyday practice. However, given the lack ders (3, 4). However, as in other disorders, the gap is a concern of support for common clinician beliefs (e.g. ‘The research because we have no idea whether it is justified in terms of just does not apply here’) relating to the most strongly evi- patient benefits. Few clinicians document or report on the denced psychological therapy, one might argue that clinicians outcome of their eclectic or integrationist (or random) ap- who want to discount other therapies should be required to proaches to treatment. The use of individualised approaches make the case that the evidence base cannot be applied in their to treatment of eating does not preclude measurement of ef- place of work. fectiveness, but the lack of such measurement does not reas- sure others that this individual-centred approach is more ef- How Widely Used Are the Evidence-Based Interventions? fective than a protocol-based approach. Indeed, it is important to remember that an individual-centred approach based on Despite the evidence outlined above, the simple answer to this clinician judgement has been shown to be substantially less question is: ‘Not very widely’. The number of eating-disorder effective than the use of a protocol-based approach (6). specialist clinicians who report adhering to evidence-based Therefore, once again, the obligation to demonstrate effective- protocols and manuals is between 6 and 35 % (41, 42). Far ness could be argued to lie with the clinician who adopts the more clinicians report that they use (un-tested or un-support- non-standard approach. ed) mixtures of some techniques that are derived from empir- ically supported treatments and some techniques that are not Why Are Evidence-Based Therapies So Rarely supported even at that level (41, 43). Used for the Eating Disorders? Even when clinicians say that they are using an evidence- based therapy, that claim should be treated with caution. For Difficulties with delivering evidence-based therapies can be example, many clinicians who state that they are delivering identified at different levels. First, there are service-centred CBT or FBT report that they omit many of the key techniques reasons. Eating disorder services vary in their culture, and that make up those treatments (44, 45, 46� , 47). This omission consequently, their willingness to change towards evidence- is reflected in the accounts of eating-disordered patients based methods. Possibly the best example of service-level reporting on the treatment that they have received (48� , 49), reluctance is that provided by Lowe and colleagues (51), as their accounts suggest widely divergent patterns of tech- who attempted to introduce a ‘normalisation of eating’ module niques delivered under the title of CBT. into the care package delivered by an existing set of eating A further complication is that the same label is used for disorder services. They described extreme difficulties in intro- therapies with different content. CBT is a classic example of ducing this element of treatment, facing resistance based on this issue, with the content differing in important ways. For the staff teams’ and services’ philosophy and practice of care, example, one might not be surprised that a form of CBT for even though the administrators of the clinical services had anorexia nervosa that reduced or removed the emphasis on approved the proposed change. weight gain (the key outcome variable [21]) has relatively Second, patient-centred reasons exist for non-use of low rates of weight gain (28). Similarly, in recent years, there evidence-based methods. Patients’ values can conflict with has been widespread dissemination of an enhanced form of the delivery of evidence-based treatments. Many patients CBT (CBT-E [10]), though it has never been compared direct- who have previously had therapy express a preference for an ly with the previous form of CBT to determine whether it is approach that is less challenging, omitting key elements such more effective with bulimia nervosa or binge eating disorder. as weighing and record-keeping (52). Given the degree to Indeed, one has to be careful to understand which version of which therapists omit some of the key elements of therapy CBT-E is being used when considering outcomes, as the orig- (see above), it cannot be a surprise that many eating- inal two versions (broad and focused) have converged into a disordered patients have previously had several unsuccessful 36 Page 4 of 8 Curr Psychiatry Rep (2016) 18: 36 therapies and have become acculturated to the idea that ther- include patient chronicity, comorbidity and complexity, even apy is a relatively unchallenging experience. In short, inade- though the evidence would not support these as reasons for quate therapy experiences have the potential to teach patients such an exclusion or change in practice (65–67). that treatment should not be challenging in any way, when it is Clinicians’ emotions are also important in understanding clear that the evidence-based approaches are based on chang- the delivery of protocols and evidence-based treatment. As ing ingrained behavioural, social, cognitive and emotional with other disorders (68� ), clinicians who are more anxious patterns. Of course, this avoidance of challenging is not con- are less likely to deliver some of the key elements of treatment fined to the patient, as clinicians also seem to do the same for eating disorders (44, 47). This avoidance of more ‘de- thing in order to reduce their own anxiety (see below). This manding’ elements of therapy has been suggested to be an joint pattern is perhaps most clearly seen when the therapist example of clinicians engaging in their own safety behav- and patient fall into the pattern of discussing causes of the iours—avoidance of tasks (e.g. weighing patients; changing eating disorder without engaging in change of the maintaining their food intake). Such avoidance means that the clinician factors (e.g. not changing eating patterns). does not feel like a ‘bad therapist’ for distressing the patient, Finally, there are clinician-centred reasons for non- even though the longer-term result is that the patient does not delivery of evidence-based approaches. One key reason ap- improve and the clinician is less effective (4). Meehl (69)has plies to psychological therapies in general—many clinicians referred to this ‘protection’ of patients from the demands of (approximately one third) are untrained in the therapy that change as reflecting clinicians having a ‘spun glass theory of they are employed to deliver (53, 54). The second important the mind’ of their patients—the belief that our making de- reason is the fact that many clinicians’ actions typify the ‘af- mands of our patients will somehow damage them (like a filiation hypothesis’—because one believes in a therapy’sef- fragile spun-glass decoration), even though such protection fectiveness, it will be effective when one uses it. In the case of means that patients cannot learn to change for the better. the eating disorders, this is a hypothesis that has been com- prehensively disproved by the work of Poulsen and colleagues How Could Clinicians Be Encouraged (55�� ), who have shown that therapists being affiliated to a to Use Evidence-Based Methods? psychodynamic approach to treating bulimia nervosa does not mean that their recovery rate comes even close to the The mean length of time for research findings to enter into outcome from evidence-based CBT, even when the psycho- routine clinical practice is a (perhaps) startling 15–20 years dynamic therapy is several times longer. (70). In some cases, this delay is a matter of ignorance, and in Clinician beliefs and attitudes have a strong influence on others, it is a product of resistance at a variety of levels. Whilst clinical practice. Outside the field of eating disorders, it has ignorance of the existence of methods to treat different disor- been shown that clinicians’ ratings of their skills and clinical ders can be overcome relatively easily through didactic outcomes indicate that we believe we are far more effective methods, that is not the same as teaching or persuading clini- that we actually are (56–58). There is no reason to assume that cians to use them and to do so appropriately. eating disorder clinicians differ from this general pattern of Training clinicians is a challenging area (71). Commonly, a beliefs. Another clinician-based factor is our knowledge of single teaching session of a few hours to two days is treated as and attitudes to protocols and manuals. These vary consider- ‘training’, even though there is little evidence that this works. ably from clinician to clinician (2, 59), within and outside the For example, whilst it is known that such sessions can influ- eating disorders. Some clinicians are unaware of the existence ence knowledge of and attitudes to exposure therapy, both for of manuals and protocols and others hold very negative eating disorders and anxiety disorders (72, 73), it is not yet attitudes towards them. It is also clear that we hold attitudes known whether such changes translate into better use of the to some elements of therapy for eating disorders that are not in necessary skills in everyday practice. In short, does education keeping with the evidence about them. For example, some translate into competence, and does competence translate into elements of therapy for eating disorders appear to be adherence to protocols and hence to more effective treatment? overvalued, such as pre-therapy motivational work (60, 61) For example, many people have learned to drive safely whilst and the presumed universal importance of prioritising the de- being closely monitored (competence), but after a short period velopment of a strong working alliance in order to facilitate of driving without that monitoring their driving deteriorates change (62, 63). In contrast, clinicians undervalue some key (non-adherence). elements of therapy for eating disorders, such as the need to It is commonly assumed that clinical supervision is a means weigh patients regardless of the specific evidence-based mod- of ensuring that clinicians should adhere to best quality prac- el (64). Finally, clinicians often hold beliefs about what Meehl tice. However, there are some worrying caveats to that as- (5)terms ‘broken leg exceptions’—leading us to exclude pa- sumption. First, does the supervisor have an adequate grasp tients from evidence-based treatments on the grounds of ap- of the necessary evidence and skills base to be able to teach the parently spurious ‘justifications’. Those ‘justifications’ can supervisee to be adherent? Given the time it takes for evidence Curr Psychiatry Rep (2016) 18: 36 Page 5 of 8 36 to reach practice (70) and the number of clinicians who lack manuals and protocols rarely (41–45, 46� , 47, 48� )—afailure training in the therapy that they deliver (53, 54, 55�� ), ade- that can be attributed to our lack of knowledge, negative atti- quate supervision is an optimistic assumption in many cases. tudes and emotional characteristics (47, 82). At present, a Second, do supervisors appraise their supervisees’ skills accu- reliance on training and supervision to ensure competence rately? Whilst this question has not been investigated in the and adherence is probably best described as an act of faith, field of eating disorders, it has been considered elsewhere, and requiring more clarity about what the training and supervision the worrying conclusion is that supervisors substantially over- should contain. Our patients would benefit if clinicians and rate their supervisees’ clinical skills (74), with the likely result supervisors were to focus on clinical outcomes and the better that the therapist continues to drift off-protocol. Clearly, fur- implementation of protocols, to improve the level of patient ther research is needed to help us to understand whether or not improvement and recovery. we can trust in the value of supervision to ensure the delivery of protocolized, evidence-based therapies for eating disorders, Compliance with Ethical Standards but the evidence to date is not promising. Conflict of Interest The author declares that he has no conflict of Of course, a strong means of persuading clinicians to interest. change their practice should be to require them to attend to patient outcomes. The existing effectiveness studies (35–40) Human and Animal Rights and Informed Consent This article does show that such outcomes are easily collected, and yet few not contain any studies with human or animal subjects performed by any of the authors. services collect or respond to such information. In part, that poor response might be the product of a lack of research/audit skills or dedicated time, either of which could be rectified. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http:// However, evidence from outside the field of eating disorders creativecommons.org/licenses/by/4.0/), which permits unrestricted use, (75) points to a more worrying fact—that clinicians vary distribution, and reproduction in any medium, provided you give appro- substantially in their interest or willingness to attend to outcome priate credit to the original author(s) and the source, provide a link to the data. If data are regarded as being irrelevant, inconvenient or Creative Commons license, and indicate if changes were made. challenging, then the danger is that clinicians will ignore rather than respondtothem(76). References Where clinicians do attend to data, it is important that they should be encouraged to attend to the most clinically mean- Papers of particular interest, published recently, have been ingful data. 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Published: Feb 18, 2016

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