Insights: Enhancing Treatment Of Eating Disorders With Professor Tracey Wade

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People with eating disorders often face long waiting lists for therapy, and many will drop out before they ever get the help they need. This can be dangerous: eating disorders are associated with the highest mortality rates of all the psychiatric disorders, apart from substance abuse.

Now a study by Professor Tracey Wade and her team from Flinders University in Adelaide has found that giving eating disorder patients a brief intervention while on the waiting list for therapy may significantly increase the likelihood that they will complete treatment. We got in touch to discuss what she learned, and how she is building upon this information with her next study.

The study: connecting with wait-list clients

The researchers focused on if a short supportive email or a cognitive remediation therapy session while on the wait list increased the completion rate of CBT-ED (cognitive behavioral therapy for eating disorders).

The 85 participants (who were all over the age of 15 and had a DSM-5 diagnosis of an eating disorder) were randomly allocated to 1 of 3 groups while on a waiting list to receive 10 sessions of cognitive behavioral therapy. Participants were non-underweight, except for 4 people with anorexia who had a BMI of less than 18.5, but they were medically stable and motivated to gain weight. The exclusion criteria for the study included substance dependence, active psychosis, high suicidality, and difficulty understanding or speaking English.

The first group received one therapist-led session at the beginning of their waiting period, followed by homework tasks, with participants being emailed weekly reminders to complete them. This intervention was based on a cognitive remediation therapy (CRT) program developed for anorexia patients by a co-author of the study, Professor Kate Tchanturia, of King’s College London. CRT uses mental exercises, such as puzzles, to improve flexibility of thinking, which can be impaired in people with anorexia.

The second group received a short supportive email, referring to them by name, and a psychoeducation handout about nutrition and neuroplasticity halfway through their time on the waiting list. The handout explained the gene-environment interaction in EDs, how brain activity is affected by malnourishment – including decision-making, problem-solving, and emotion regulation – and outlined that recovery is possible with adequate renourishment.

The third group (the control) waited on the list as usual.

The results

The researchers found that groups one and two were three times more likely to complete their course of CBT-ED (cognitive behavioral therapy for eating disorders). Wade suggests that the improved completion rates may be due to how they make people feel: “[They feel] they are being valued in some way and form a loyalty to the service provider to see the treatment through. Or it could indicate the content of the interventions created hope for change, that keeps people in subsequent treatment.” Another benefit of the interventions used in the study was that they were not resource-intensive, and did not need to be given by expert clinicians. According to Wade: “They can be used by anyone to aid dissemination and are intended to help clients kick start [their] own ability to change.”

The study did not find that the interventions improved the patient symptoms during the waiting list period: none of the conditions were associated with a significant reduction in dietary restraint between assessment and the commencement of therapy.

Writing in the journal Cognitive Behaviour Therapy, the researchers described their findings as “clinically important given as many as one out of four clients can be expected to drop out of CBT-ED” (Wade notes that the non-completion rates are even higher, at 40%, for anorexia nervosa). Further investigation may serve to clarify these results. In addition to recommending replication of the study at a larger scale, the researchers conclude: “Further research should investigate whether simply keeping in touch with clients over the waitlist period rather than providing an intervention or psychoeducation also significantly retains people in treatment.”

Bringing in B.E.S.T. principles

In her follow-up study (which hasn’t yet been peer-reviewed), Wade has sought to improve the brief interventions offered to those waiting for treatment. The 47 participants in this second study were randomly allocated to receive a behavioral activation intervention, a growth mindset intervention, or an emotion regulation intervention.

This time, Wade and her team incorporated the B.E.S.T. principles, developed by psychologist Dr Jessica Schleider of Northwestern University, into their interventions:

• B is for ‘brain science information’ – focusing on the brain’s potential to grow and change.

• E is for ‘empower’ – elevating participants to a helper/expert role, to strengthen their feeling of agency.

• S is for ‘saying is believing activities’ – to solidify learning.

• T is for ‘testimonials’ – providing evidence from valued others, to engage people both cognitively and emotionally.

The researchers found there was an improvement in symptoms during the waiting list period across all three groups within the second study. This was measured by a significant decrease in dietary restriction between assessment and the commencement of therapy. One limitation of the study, however, was its small size.

Wade advises therapists treating patients with eating disorders to “expect that around half of patients can start to make immediate changes. Give them that opportunity rather than treating them like fragile glass”.

Key takeaways

• 1 in 4 eating disorder (ED) patients (and 40% of those with anorexia nervosa specifically) will drop out of treatment.

• A single cognitive remediation session or email / psychoeducation intervention can help people on ED waiting lists complete their treatment.

• Optimising the single-session intervention with B.E.S.T. principles may also improve symptoms while they wait for therapy to start.