Putting the ‘B’ back into CBT
for eating disorders
Glenn Waller
Vincent Square Eating Disorders Service, London and
Institute of Psychiatry, King’s College, London
Central and North West London
NHS FoundationTrust
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Unhappy families
• CBT is not a monolith
• A family of therapies (Fairburn, 2011)
• Varying degrees of relatedness
– and sometimes getting on like families do around midafternoon on Christmas day
• In the eating disorders, only a few members of
that family have evidence in support of their
effectiveness
– Bulik (1995); Fairburn (2008); Fairburn et al. (1993); Ghaderi
(2006); Gowers & Green (2009); Waller et al. (2007)
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Unhappy families
• Other CBT and non-CBT approaches are
commonly chosen by services, therapists and
patients
– for reasons other than being evidence-based
– lots of clinical expertise, but coming to different
conclusions
– remember: no reliability = no validity
– and the Dodo Bird Hypothesis looks pretty weak
• The core distinguishing element in evidencebased CBT for the eating disorders is…
• Behavioural change
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Recommended manuals
• Manual use is associated with better
adherence to CBT procedures, by the way…
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The central role of behavioural change
• Evidence-based practice in CBT for the eating
disorders is centred on the behavioural element
– always necessary: sometimes sufficient
• Little or no evidence that purely cognitive
approaches are effective
• Behaviour change predicts outcome and relapse
– lets us tell patients when they are at risk of failing to
benefit from CBT
• Where did the ‘B’ go, and why?
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A common assumption in ‘CBT’
• Start with the
cognitions and
the emotions
Cognitions
(e.g., "I am going to
keep gaining weight"; “I
have broken my rules”)
Behaviour
Emotions
(e.g., avoid food;
overeat)
(e.g., anxiety)
• Behavioural
change and
physiological
recovery will
follow
Physiology
(e.g., starvation; serotonin
disturbance; autonomic
function)
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What is needed for evidence-based CBT?
• Start with the
behavioural
and biological
Cognitions
(e.g., "I am going to
keep gaining weight"; “I
have broken my rules”)
Behaviour
Emotions
(e.g., avoid food;
overeat)
(e.g., anxiety)
• Making mood
more stable
and cognitions
more flexible
Physiology
(e.g., starvation; serotonin
disturbance; autonomic
function)
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What am I ranting about?
• Cognitive behavioural therapies that are
delivered without a core behavioural element
– cognitive therapies
– many ‘third wave’ therapies
– not even going to consider non-CBT approaches here
• But far, far more egregious
– badly delivered ‘evidence-based’ CBT
• All demanding that the patient tries to change
with their physiology in knots
– starvation effects on cognitions
– serotonin deprivation effects on emotions
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A preview of some nasty, nasty numbers
• Survey of eating disorder CBT practitioners
– including BABCP members (thank you)
– courtesy of Hannah Stringer and Caroline Meyer
• What core CBT behaviour-based procedures are
used by what proportion of clinicians?
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What core, evidence-based
CBT procedures are used?
• In short
• No procedure is used routinely by even half of
clinicians using CBT with eating disorders
• Behavioural interventions are treated as optional
– and clinicians are opting out…
• And a substantial minority of clinicians doing
‘CBT’ for the eating disorders appear to use no
CBT procedures at all
– including cognitive restructuring
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Roadblocks to behavioural procedures?
• Our patients have their own safety behaviours,
which maintain the eating disorder
Patient anxiety
(f ears loss of
control over
w eight, etc.)
Long-term
enhancement
Short-term
reduction
Patient saf ety
behaviours
(avoid threatened
changes in diet,
etc.)
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Roadblocks to behavioural procedures?
• As clinicians, we have our own safety
behaviours, which stop us pushing for change
Patient anxiety
(f ears loss of
control over
w eight, etc.)
Long-term
enhancement
Clinician anxiety
(f ear of distressing
suf f erer, etc.)
Short-term
reduction
Short-term
reduction
Patient saf ety
behaviours
(avoid threatened
changes in diet,
etc.)
Long-term
enhancement
Clinician saf ety
behaviours
(avoid pushing for
behavioural
change)
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Roadblocks to behavioural procedures?
• Finally, our own safety behaviours interact with
those of our patients (accommodation)
Patient anxiety
(f ears loss of
control over
w eight, etc.)
Long-term
enhancement
Clinician anxiety
(f ear of distressing
suf f erer, etc.)
Short-term
reduction
Short-term
reduction
Patient saf ety
behaviours
(avoid threatened
changes in diet,
etc.)
Long-term
enhancement
Clinician saf ety
behaviours
(avoid pushing for
behavioural
change)
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Formulation
• Case formulations that ignore the behavioural
element of maintenance
– and their impact on physiology
• Too much exclusive focus on emotion, cognition,
metacognition, schema modes, etc.
• For example, do your formulations include:
– ‘compensation’ → behaviour
• starve → binge, rather than vice versa
– safety behaviours and their full outcomes
• e.g., body checking; vomiting
– likely impact of starvation on cognitions and emotions
• and hence on further behaviours
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Measurement of outcomes
• Outcomes are not routinely measured
– or do I just know a disproportionate number of
disappointing clinicians?
– on the plus side, it is not hard to change that practice
• Clinicians respond to (or generate) therapyinterfering behaviours by accommodating them
– remember how few weigh their patients…
– many seem unconcerned about diaries, weighing, etc.
• And if measured, outcomes are routinely
ignored…
– “I don’t know why my patient is still bingeing…”
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Comorbidity and risk
• Commonly see CBT clinicians ignoring key risky
behaviours and comorbidity
• Without bringing such things into treatment, do
not expect to address the eating disorder
– the patient is likely to be unable to do so
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Treatment
• So what behavioural elements do we need to
bring (back) into treatment?
–
–
–
–
eating
exposure with response prevention
behavioural experiments
behavioural approaches to motivation
• Each has a vital role in the core eating pathology
– but is also valuable in addressing concurrent
problems
• e.g., eating to reduce mood problems
• e.g., exposure to address anxiety features
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Treatment
• Other behavioural methods can be of use, but
have less of a central impact in the eating
disorders
– e.g., behavioural activation, habit reversal, skills
training
• No evidence that the role of behavioural
interventions differs across different eating
disorders
• But first, a quick aside
– the therapeutic relationship
– because if I don’t mention it, you will be thinking it…
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Micro-class: But won’t all this behavioural
stuff screw up the alliance with my patient?
• Empirical evidence base
• The therapeutic relationship has only a weak
impact on the outcome of therapies
• Even less impact on structured therapies, such as
CBT
• The therapeutic relationship can be driven by
behavioural change, rather than vice versa
• Patients doing evidence-based CBT for eating
disorders report a strong working alliance
– similar to the findings in DBT
• [See summaries in: Crits-Cristoph et al.,1991; Evans et al.,
in press; Waller et al., in press]
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Skill 1: Eating
• This element seems to be surprisingly neglected
– while it is included in exposure and in behavioural
experimentation, remember that it is a skill
• Need to teach the patient basic rules and how to
operationalize them in their lives
• Tools needed:
– a healthy eating plan
– a Department of Health plate
– knowledge of the number of calories needed to gain
weight…
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Eating
• What sort of food to eat?
– food groups rather than specifics
– never be fazed by specific food preferences (but
challenge the general ones…)
• How much to eat?
– rigidity of rules tends to cause fights, but common
purposes tend to get alliance
• And always be ready to answer the ‘Why’
question
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Eating: What goes wrong in the clinic?
• Someone else’s job
– this is not difficult in most cases
– it does not require a dietitian to do hand-holding
– dietitians are better dedicated to specialist cases
• “We will do that after the cognitive work”
– see earlier point about handicapping the patient
• Finding the balance between rigidity and lack of
rules
– it is called ‘individualisation…’
– it is not a bad thing
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Skill 2: Exposure
• Exposure with response prevention (ERP)
• Two elements, each of which is essential
– elevation of anxiety
• cannot learn if there is no anxiety
– avoidance of safety behaviours
• to reduce escape/avoidance conditioning
• Can be augmented by cognitive techniques
– e.g., cognitive challenges; mindfulness; distraction
• But cannot be replaced by those techniques
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Examples of exposure
• Change in pattern and content of eating
• Needs to start early in treatment
– evidence that this is of benefit in bulimia (Wilson et al., 1999)
– early weight change in underweight patients
• Start with structure and content
– roll out content across the day
– challenges the patient’s beliefs about the perils of
eating early
• Individuals differ in response to food
– so work with the individual and changes in symptoms
(e.g., binges, weight)
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Examples of exposure
• Reduction in body-related behaviours
• Checking, avoidance, comparison and display
– all function as safety behaviours
– reduction in anxiety, followed by feeling worse
• ERP - not using the behaviour, tolerating the
anxiety, and learning that mood improves in time
– e.g., exposure to mirror image
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Other times when we use exposure
• Body image work
– mirror work
• Fill in the diary when you get the urge to binge
– make bingeing an active choice
• Reducing compensatory behaviours
– waiting for 30-40 minutes after eating to allow the
anxiety to subside
• Eating ‘forbidden’ foods
• etc., etc.
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Exposure: What goes wrong in clinic?
• Needs to be a skill that generalises
– needs to be carried outside into the real world
– patient’s responsibility
• Clinicians trying to defend the patient from the
anxiety involved
– clinician safety behaviour
– need to find that anxiety-based ‘bite’ point
• Too much, too soon
– make it progressive
– systematic desensitization works better than flooding…
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Skill 3: Behavioural experiments
• Aim to test out beliefs in a systematic way, rather
than simply change behaviour
• Use of planned behavioural change to:
– test existing beliefs about the self, others and the world
– develop and test more adaptive beliefs
• Commonly used to address eating, weight and
shape cognitions
– also valuable in working with cognitions regarding
interpersonal issues and failure
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Going through the steps
1
2
Establish the
current belief
Rate the
strength of
this belief
5
Establish the
alternative
belief
3
Behavioural
manipulation
to test the
two beliefs
Rate the
strength of
this belief
4
6
7
8
Agree a
timeframe to
be sure that
either belief
has support
Assess the
outcome –
which belief
was right?
Revisit and
re-rate the
beliefs
• If you have not taken all these
steps, it is not likely to work…
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Behavioural experiments:
What goes wrong in the clinic?
• Failure to keep other variables static
– e.g., agree to stick to eating plan rather than
compensating
• Not planning a ‘safe’ time to start the experiment
• Not agreeing a time frame
• Not planning where to go afterwards
• Not allowing for the full range of outcomes
– be Socratic
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Skill 4: Motivation
• Motivation is all about discussion, isn’t it?
– a verbal run around the stages of change model before
CBT begins
– very commonly used (over 50%)
• Unfortunately, that verbally-based approach does
not really work in the eating disorders
– a very, very consistent evidence base (Waller, in press)
• Motivation as a manifesto
– a statement to get something: not a statement of intent
• Worth trying a more behaviourally-based
approach
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Actions speak louder than words
• To start with, build patient and clinician optimism
– through early, controllable symptom change
– and working with therapy-interfering behaviours
• And then, start responding to the patient’s real
motivation
– motivation as a manifesto
• Disengagement
• Disability training
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Motivation: What goes wrong in the clinic?
• Believing in the manifesto, rather than attending
to what is actually happening
• Clinician reducing demands of therapy
– encouraging the patient to engage in change or not?
– avoiding emotional arousal in the room
• Clinician ‘masterly inactivity’
– “something is bound to happen if I just wait…”
• Clinician ‘masterly hyperactivity’
– “if I do everything all at once, something will work”
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I’ve started…so should I just carry on?
• OK, so I have been doing it all wrong so far
• So should I just give up with the patients I am
already seeing, and change for all new patients?
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Sometimes, we work with systems…
• Helping colleagues
• Supervision as a skill to enhance behavioural
interventions
– focus clinicians on good symptom outcomes and the
skills needed to achieve them
– responsibility for doing as well as anyone else can
• Dealing with supervision-interfering behaviours
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Sometimes, we work with systems…
• Helping teams
• Focus the team on the possibility of change
– give reasonable targets
• Stress the recording of objective outcomes
• behaviours, weight, eating attitudes
• Get the team to talk about cases openly
– including successes
• Encourage appropriate turnover of patients
– including disengagement where appropriate
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Sometimes, we work with systems…
• And if the team members want to try something
else, then discuss it as a team
• Ask three key questions
– Have you tried the evidence-based route properly?
– Can you explain the theory behind this?
– How are you going to structure this experiment?
• anticipated outcome
• time frame
• report back to the team
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Sometimes, we work with systems…
• Helping carers
• Focus on reducing carer stress and stuckness
• Work with carers on self-blame
• Change behaviours to reduce levels of
accommodation
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To conclude
• There are evidence-based CBT approaches…
• …and there are other CBT approaches
• Evidence-based CBT is behavioural at its core…
• …but it is uncommon in everyday practice
• Evidence-based CBT works just as well in nonresearch settings…
• …and other CBT approaches work just as badly
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To summarise…
• Getting patients to do evidence-based CBT is
much easier than clinicians seem to assume
– just be an optimistic realist
– and use the skills that I have been idly chatting about
– no magic skills
• The final behavioural task of the session
– you know the skills needed to help patients…
– you know that this approach works
– you know why we use ineffective approaches at times
• Choose
– for every new patient and for every existing patient
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References
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collaborative approach to eating disorders. London: Routledge.
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