The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 4
4 - Usable
The intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components
Usability
Core Components
MANTRA is a manualized, individualised treatment specifically designed for the treatment of anorexia nervosa (AN) in adults. Its components address the cognitive, emotional, relational and biological factors that are associated with the maintenance of anorexia, by supporting individuals to identify alternative, adaptive coping mechanisms. MANTRA adopts a specialist integrated approach, drawing from and combining several treatment modules that include: developing intrinsic motivation for recovery, improving nutrition and food intake, developing alternative thinking styles, increasing emotional regulation and expression, addressing interpersonal challenges, and developing an identity that is outside of AN. The modules delivered, as well as the exact factors addressed, are tailored to the needs and preferences of the person receiving treatment.
As part of the treatment process, patients receive a patient’s handbook from which the patient and therapist co-select themes and exercises that address the patient’s needs and symptomatology. This handbook is easily accessible, available from many online bookshops. MANTRA is particularly suited to individuals who present with limited flexibility in their thinking, challenges with emotional processing, positive beliefs about anorexia, and little or no support network, or a support network that feel unable to help. As such, the authors of MANTRA propose that the therapy is suitable for those with traits of obsessive-compulsive personality disorder, a common comorbid condition with anorexia nervosa.
MANTRA can be delivered weekly, over 20-40 sessions, but can be delivered in fewer or more sessions to meet the needs of the person receiving treatment. MANTRA has a homework component which provides opportunities for patients to challenge themselves between sessions. The homework component can be excluded for patients unwilling to complete the work outside of the sessions. MANTRA may also be said to be suited to individuals who are pre-contemplative in terms of readiness to make change to their AN, as it includes a dedicated chapter based around Motivational Interviewing (MI) techniques. This may distinguish MANTRA from some other approaches for AN in terms of being applicable to those individuals who may not be ready to make active change at the outset of therapy.
Fidelity
Practitioner training will enhance treatment fidelity. Adherence to the MANTRA intervention can be assessed by reviewing practitioners’ workbook which should include a record of the main topics discussed / modules addressed in each session and reviewing recorded therapy sessions. NICE recommends weekly treatment in the first 10 weeks of therapy, with subsequent sessions delivered on a flexible schedule to suit the needs and preferences of the patient.
Modifiable Components
There is flexibility in the delivery of MANTRA, including number of sessions, factors addressed, and core modules delivered. MANTRA in integrated group format, i.e. a combination of both group and individual sessions, has been shown to be an effective, alternative delivery format (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207787/pdf/40337_2021_Article_424.pdf). The Maudsley model of anorexia nervosa treatment for adolescents and young adults (MANTRa) is currently being evaluated (https://jeatdisord.biomedcentral.com/track/pdf/10.1186/s40337-021-00387-8.pdf).
Supports - Rating: 4
4 - Supported
Some resources are available to support implementation, including at least limited resources to support staff competency and organisational changes as a standard part of the intervention
Supports
Support for Organisation / Practice
Implementation Support
Practitioner training is delivered by trainers from Maudsley Learning at the South London and Maudsley NHS Foundation Trust (SLaM), and the Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King’s College London. This training is available to practitioners in NHS eating disorder services.
Guidance on implementing MANTRA is provided via initial training and through associated resources provided as part of training, in the MANTRA guidebook, and through www.mantraweb.co.uk .Formal supports for implementing MANTRA within services are not currently organised by the training provider (SLaM), although resources and guidance on fidelity and assessment of competence are included in the post-training materials.
Resources from the training and some supplemental resources (such as for formulating in the MANTRA model) are provided to those who undertake the training. These, along with the published manual, can be used to deliver the model to patients.
The training provider (SLaM) does not currently provide guidance on administration or on data systems/data collection for the implementation of MANTRA. MANTRA has stakeholder and community engagement strategies built into the training. They advise that any local strategies would need to be considered at a service level.
Start-up Costs
The MANTRA manual is widely available for purchase. The most significant upfront cost is the staff training delivered online via SLaM. Training costs for practitioners in eating disorder services in Scotland can be confirmed by contacting maudsleylearning.com. Since using model-specific MANTRA supervision is a stipulation from SLaM for using MANTRA within services, there may also be ongoing supervision costs to consider.
Building Staff Competency
Qualifications Required
Practitioners who deliver MANTRA are typically core mental health professionals who work in specialist adult or all-age eating disorder services. They include psychologists, psychotherapists, psychiatrists, mental health nurses, allied health professionals and social workers.
Training Requirements
Practitioners complete training prior to delivering MANTRA. Practitioners attend 7-hours of training daily, over a period of 5-days. Training is delivered online.
Supervision Requirements
The Maudsley learning team (SLaM) stipulate that clinicians delivering MANTRA have regular access to model specific supervision on at least a monthly basis. MANTRA supervisors should have been trained in the model and have seen at least 10 MANTRA patients to completion, have received close supervision themselves, are currently supervised and delivering the intervention, and are experienced in supervising psychological therapies more generally. There is opportunity to undertake specific MANTRA supervisor accreditation training (contact SLaM Trust for more details on supervision).
Evidence - Rating: 4
4 - Evidence
The intervention has demonstrated effectiveness with one rigorous, external research study with the focus population and a control group.
Evidence
Theory of Change
MANTRA is founded on the cognitive-interpersonal maintenance model of AN, which proposes that cognitive, socio-emotional, and interpersonal elements predispose to AN, and are exaggerated in the ill state. It also proposes that personality traits like obsessive-compulsiveness and anxious-avoidance increase vulnerability to the development of AN and the maintenance of the disease. MANTRA therefore targets the biological and psychological predisposing and maintaining factors for anorexia, by supporting individuals to identify alternative, adaptive coping mechanisms, with the aim of facilitating wider changes in eating disorder symptomatology and weight.
Adult Evidence for MANTRA
Some of the best available evidence for MANTRA in the treatment of AN includes three RCTs.
The first RCT evaluated the effectiveness of psychological therapies in AN (1). It included 120 adults, aged 17 years or over, meeting diagnostic criteria for AN, and with BMI between 14.0 to18.5kg/m2. Participants were offered 25–40 fifty-minute sessions of MANTRA over a 10-month period. The study was conducted in Australia.
The second RCT was a comparison study of psychological treatments for AN (2,3). The study included 142 adult outpatients, aged 18-65 years, with broadly defined AN (body mass index (BMI) < 18.5 kg/m2). MANTRA was delivered in 20 to 30 weekly sessions (depending on clinical severity) with add-ons (4 follow-up sessions, optional sessions with dietician and with carers). The study was conducted in the UK.
The third RCT also evaluated the effectiveness of psychological therapies in adults (4). It included 72 out-patients with anorexia nervosa or eating disorder not otherwise specified, and with BMI less than 18.5 kg/m2. MANTRA was delivered in 20 once-weekly individual sessions and 4 monthly follow-up sessions. Optional sessions and assessments were offered as needed. The study was conducted in UK.
Adult Outcomes Achieved
The following outcomes were reported in within-group analysis;
- Significantly increased BMI at up to 12-months follow-up (1,3,4) sustained at 24-months follow-up (2).
- Significantly reduced eating disorders symptomatology, distress levels, and clinical/ psychosocial impairment at up to 12-months follow-up (1,3,4) sustained at 24-months follow-up (2).
Children and Young People (CYP) Evidence
No evidence was found for MANTRA in CYP.
Need
Comparable Population
MANTRA is typically delivered to adults with AN. Research studies have included adults with anorexia nervosa or eating disorder not otherwise specified, and with BMI less than 18.5 kg/m2.
Desired Outcome
MANTRA delivery in adults is associated with significant improvements across several outcomes including BMI, eating disorders symptomatology, distress levels, and clinical/ psychosocial impairment.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Values
MANTRA is a manualized, individualised treatment specifically designed for the treatment of anorexia in adults. MANTRA is founded on the cognitive-interpersonal maintenance model of AN. It therefore addresses the cognitive, socio-emotional, and interpersonal elements that predispose to AN, and are exaggerated in the ill state.
Priorities
MANTRA targets the biological and psychological predisposing and maintaining factors for AN, by supporting individuals to identify alternative, adaptive coping mechanisms, with the aim of facilitating wider changes in eating disorder symptomatology and weight.
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
MANTRA is typically delivered by core mental health professionals who work in specialist adult or all-age eating disorder services. These include psychologists, psychotherapists, psychiatrists, mental health nurses, allied health professionals and social workers. Practitioners can attend MANTRA training provided by SLaM, which can be delivered online. MANTRA is typically delivered in 20-40 weekly sessions to people using services.
Technology Support
MANTRA can be delivered without access to technology, but access to methods of recording sessions for fidelity monitoring will be useful.
Administrative Support
MANTRA is typically delivered in individual formats, within settings that offer eating disorder services. Integrated-group delivery format has also been shown to be effective. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.
Financial Support
Training costs for practitioners in eating disorder services in Scotland can be confirmed by contacting the training programme at maudsleylearning.com.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
