Usability - Rating: 5
5 - Highly Usable
The intervention has operationalised principles and values, core components that are measurable and observable, a fidelity assessment, identified modifiable components
Core components
Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT and are used in the treatment of mental health disorders. This therapy recognises the inter-relationship between thoughts, emotions and behaviours, and how alterations in one domain can impact other domains. CBT therefore identifies, challenges, and modifies unhelpful cognitive structures, facilitating emotional and behavioural changes. Various CBT interventions have been developed to target eating disorders. These include specific manualised CBT approaches for anorexia nervosa, bulimia nervosa, and for binge eating (1-3).
In the context of Anorexia Nervosa (AN), CBT aims to reduce the symptoms of AN, its risks to physical health, and help individuals achieve and maintain a healthy weight. Treatment includes psychoeducation to identify the risks of malnutrition and being underweight, cognitive restructuring to address the cognitive aspects of the disorder, and behavioural strategies that can help promote normal eating patterns. CBT simultaneously addresses emotional regulation, body image issues, self-efficacy and relapse prevention. As part of the treatment process, a tailored treatment plan is established to address the processes suspected to sustain the eating disorder. CBT in children and young people (CYP) should take into consideration specific developmental needs of CYP.
In the context of Bulimia Nervosa (BN), CBT addresses the core features of this disorder, which have been identified as binge eating, use of inappropriate compensatory behaviours, and excessive body image concerns. Treatment therefore includes psychoeducation as it relates to weight and the negative effects of binge eating, purging, and extreme dieting. It also includes establishing a healthy eating pattern, addressing the eating disorder psychopathology, maintaining positive body image, and preventing relapse.
In the context of Binge Eating Disorder (BED), CBT aims to reduce dietary restraints and its influence on binge eating pathology via the use of cognitive and behavioural strategies. The treatment therefore involves the formulation of the person's psychological issues to identify the dietary and emotional factors that contribute to the eating disorder. Subsequently, cognitive restructuring, behavioural experiments and exposure are used to address the underlying triggers identified in the psychological formulation. Treatment also includes psychoeducation, monitoring of binge eating behaviours, addressing body image concerns (if any), and relapse prevention.
One widely used CBT intervention for eating disorders is Enhanced CBT (CBT-E) (4), which is a manualised transdiagnostic intervention for the treatment of all forms of eating disorders, including anorexia nervosa, bulimia nervosa, binge eating disorder and eating disorders not otherwise specified. CBT-E aims to help patients understand and disrupt the processes that maintain their eating disorder psychopathology. This helps to highlight the focus of treatment and facilitates a tailored approach to treatment. Hence, its exact form as an intervention is dependent on the individualised formulation of the processes that have been identified as maintaining the disorder. Patients are subsequently introduced to cognitive and behavioural strategies to address their individual eating disorder psychopathology and its maintaining processes. Family involvement is an essential part of CBT-E when the intervention is delivered to young people including young adults.
CBT-E has four stages:
- Stage 1: Focuses on gaining understanding about the patient’s difficulties/ challenges with food and eating. The stage also aims to establish and stabilise regular, healthy eating patterns
- Stage 2: Focuses on reviewing progress made, and developing a therapy plan
- Stage 3: Focuses on addressing the processes that maintain the eating disorder, e.g. concerns about shape and weight, extreme dietary restraints, low self-esteem or interpersonal problems
- Stage 4: Focuses on the future, including dealing with setbacks, maintaining the changes that have been achieved, and minimising the likelihood of relapse.
The Scottish Intercollegiate Guidelines Network recommends CBT for eating disorder (CBT-ED) programmes for people with eating disorders.
Fidelity
CBT for eating disorders should be delivered by competent practitioner(s) with ongoing supervision from accredited psychological therapists. The intervention should be delivered as per the validated manual and should be formulation-driven, to select the most appropriate techniques for the eating disorder presentation. Practitioner competence and fidelity to treatment can be monitored and evaluated using appropriate measures, e.g., via recording of treatment sessions and use of fidelity checklists to determine practitioner adherence against a CBT competency assessment tool, such as the Cognitive Therapy Scale-Revised (5). There are also CBT-ED specific rating measures under development, such as the CBT-E Components Checklist (6) and the Cognitive Behavioural Therapy Scale for Eating Disorders (CBTS-ED) developed by Beard et al. (7).
Modifiable Components
CBT can be delivered in several formats for the different types of eating disorders.
In the treatment of Anorexia Nervosa (AN), CBT can be delivered in an individualised format, offered in up to 40 sessions over 40 weeks. Up to 3 sessions per week should be offered in the first 2-3 weeks of therapy, if using Fairburn’s CBT-E model.
In the treatment of bulimia nervosa (BN), it can be delivered as a bulimia-nervosa-focused guided self-help intervention based on cognitive behavioural approaches. Brief practitioner support should supplement the self-help programme, with four to nine 20-minute therapist sessions provided over 16 weeks. CBT for the treatment of BN can also be delivered as an individualised format, offered in 20 sessions over 20 weeks. For CBT-E, Fairburn (4) recommends that 2 sessions per week should be offered in the first phase of therapy.
In the treatment of Binge Eating Disorder (BED), CBT can be offered as binge-eating-disorder-focused guided self-help interventions that are based on cognitive behavioural approaches. Brief practitioner support should supplement the self-help programme, with four to nine 20-minute therapist sessions provided over 16 weeks. CBT for the treatment of BED is available in group format, delivered in 16 weekly 90-minute group sessions over 4 months, and in an individualised format, offered in 16-20 sessions.
In addition to the enhanced version of CBT (CBT-E) which provides a transdiagnostic approach to treatment, CBT manuals are available to address the specific eating disorder (AN, BN and BED). A brief 10-session manualised CBT intervention (CBT-T) (8) is also available for all forms of eating disorders in patients who are not underweight.
Supports - Rating: 5
5 - Well Supported
Comprehensive resources are available to support implementation, including resources for building the competency of staff and organisational practice as a standard part of the intervention
Support for Organisation / Practice
Implementation Support
Implementation support is mainly provided by trained accredited supervisors who support the application of CBT within each therapist’s practice. Support for implementing CBT is also available through the NES Adult Mental Health and CAMHS workstreams. Regular CPD events can be accessed through the Turas Learn site: https://learn.nes.nhs.scot/46686/cognitive-behavioural-therapy/cpd-for-cbt-therapists. Implementation support is also provided by the British Association of Behavioural and Cognitive Psychotherapies (BABCP), the UK based accredited body for therapists practicing Cognitive Behavioural Therapy. BABCP also accredits training programmes and provides CPD, and resources related to CBT practice.
Start-up Costs
There are no start-up costs associated with training provided within university training programmes (if training through an NHS place organised by NES). Costs apply when training is provided by private organisations.
Building Staff Competency
Qualifications Required
Staff will usually hold an undergraduate degree in a relevant area (e.g. nursing, psychology, medicine) and will have completed postgraduate training in CBT (PG Diploma, MSc or Doctoral level).
Training Requirements
Cognitive Behavioural Therapy (CBT) training is included in the adult and child focused MSc CBT/PTPC programmes and the Doctorate in Clinical psychology training programmes in Scotland. Additional training in adapting CBT for eating disorders is available through the NES psychology workstreams and also available through professional organisations such as the British Association of Behavioural and Cognitive Psychotherapies (BABCP).
Supervision Requirements
Regular (minimum 1 hour a month) supervision by a supervisor who is a CBT therapist and has completed the following pathway of supervision training:
- NES Generic supervision competences training (GSC) (or equivalent)
- NES Specialist Supervision Training: CBT (adult or child focus)
It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/).
Need
Comparable Population
Research studies have included adolescents and adults with anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified.
Desired Outcome
CBT is associated with significant improvements across several eating disorder outcomes, including eating disorder psychopathology, remission, binging and purging behaviours, weight/ BMI, and mental health.
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
Cognitive Behavioural Therapy (CBT) is a psychological intervention that can be used in for the treatment of eating disorders (including anorexia nervosa, bulimia nervosa, binge eating disorder) in children, young people, and adults. CBT can also be delivered as enhanced CBT (CBT-E), a transdiagnostic intervention that aims to help patients understand and disrupt the processes that maintain their eating disorder psychopathology. Family involvement is an essential component of CBT-E when it is delivered to young people.
Priorities
CBT for eating disorders, such as CBT-E, adopts a tailored approach to treatment as the exact form of the intervention is dependent on the individualised formulation of the processes that have been identified as maintaining the disorder. CBT-E aims to equip patients with cognitive and behavioural strategies to address their individual eating disorder psychopathology and its maintaining processes.
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
CBT can be delivered by healthcare professionals (e.g. psychologists, psychiatrists, or mental health nurses) who have undergone training to support its delivery. CBT can be delivered to patients weekly.
Technology Support
Cognitive Behavioural Therapy can be delivered without access to technology but access to video platforms for remote delivery can be useful as is access to methods of recording sessions for supervision.
Administrative Support
CBT for eating disorders can be delivered in self-help, group or individual formats. Group and individual delivery can be held in several settings including community mental health centres, outpatient clinic settings, and hospitals. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.
Financial Support
Scottish Government/NES Psychology routinely funds training programmes in CBT and supervisor training. Training is available from other organisations at a cost.
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
