Cognitive Behavioural Therapy (CBT) for eating disorders is the way to go. So, why is it underused?
The worldwide consensus among scientists is that Cognitive Behavioural Therapy (CBT) is the best choice for treating eating disorders. Many tried and tested CBT protocols are available, but according to several publications (for example Waller et al., 2012) these protocols are often ignored. Frequently CBT-trained practitioners use interventions that have not been proven to be effective. Why does this “therapist drift” occur and what can we do about it?
Prof. dr. Sandra Mulkens (FHML/ FPN), professor in Feeding and Eating Disorders, recently published Behaviour Research and Therapy which explores “therapist drift” in the treatment of people with eating disorders. Mulkens’ goal was to replicate and expand Waller’s study.
For this study, 139 Dutch therapists were asked to participate and subsequently analysed. All participants are active in the field of eating disorders and trained in CBT. By means of a survey, Mulkens asked them about the use of specific techniques in their treatment of eating disorders, their convictions (i.e., about the importance of the therapeutic alliance and pre-treatment motivational techniques), insecurity, and personality. Mulkens’ results confirmed those of Waller: therapists more often used methods proven less effective than CBT in their daily work. Even though 83% of respondents said they used CBT-protocols, not all of these effective techniques are used systematically. Core CBT-techniques such as food diaries, exposure and cognitive restructuring (see sidebox) were only used by 40% of the participants. Less than 30% of the respondents weighed their clients each session, and 73% used motivational interviewing before starting the treatment, which is proven to have no effect.
What to do about “therapist drift”?
How can this “therapist drift” be explained? Mulkens and her team found some interesting correlations. Therapists with a strong faith in the therapeutic relationship with a client, are less likely to employ effective CBT-techniques. The fear-level of therapists also plays a part. Practitioners who scored high on the IUS (Intolerance of Uncertainty Scale) will not easily use behavioural techniques with uncertain outcomes, such as exposure and behavioural experiments.
How will this affect the education and supervision of practitioners? The results suggest that increasing therapist competence is not only a matter of training. There needs to be attention for the factors that cause therapists to not use CBT, such as the beforementioned fear and convictions. Therapists need to be reminded that behaviour change in eating disorders does not come from good client-therapist relationships, but the other way around. In order to create a good relationship with your client, you’ll need to offer them effective treatment that will increase their trust in you.
Cognitive Behavioural Therapy: is a set of intervention techniques that focus on changing thoughts, accompanying feelings and subsequent behaviours in (mental) health problems. These techniques include cognitive restructuring and exposure. CBT was originally created to treat depression, but is now used for other mental conditions such as anxiety disorders and eating disorders.
Exposure therapy involves exposing the patient to the anxiety source or its context and aims to let the patient discover that the feared outcome will not happen (in other words: that his catastrophic cognition is not true)
Cognitive restructuring is the process of investigating irrational beliefs/ identifying cognitive distortions and replace them by more functional and rational alternatives.
Sandra Mulkens was recently interviewed by Volkskrant for her views on orthorexia. Read that article here.
The article Behaviour Research and Therapy is published here (requires account).