In this episode of Let’s Talk about CBT- Research Matters, Steph speaks with Dr Daniel Wilson, a clinical psychologist and researcher based in Brisbane, Australia. Dan is the lead author of the paper “CBT-E following discontinued FBT for adolescents with eating disorders: time for a more individual approach?” published in The Cognitive Behaviour Therapist.

Steph and Dan explore key findings from the study, which compared the effectiveness of CBT-E (enhanced cognitive behavioural therapy) for young people who had previously discontinued FBT (family-based treatment) versus those who had not tried FBT at all. The research offers important insights into treatment options for adolescents with eating disorders and highlights the value of providing alternative pathways to recovery.

Links & Resources:

Read the paper: “CBT-E following discontinued FBT for adolescents with eating disorders: time for a more individual approach?” - https://bit.ly/3Eysxd0

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Transcript:

Steph: Hello and welcome to Let’s Talk about CBT- Research Matters, the podcast that explores some of the latest research published in the BABCP journals with me Steph Curnow. Each episode, I'll be talking to a recently published author about their research, what was the motivation behind it and how they hope it will impact the world of CBT.

In this episode, I’m talking to Dr Daniel Wilson. Dan is lead author on the paper CBT-E following discontinued FBT for adolescents with eating disorders: time for a more individual approach? Which was published in the Cognitive Behaviour Therapist.

Hi Dan. Welcome to the podcast.

Dan: Thank you very much. Thanks for having me.

Steph: It's really exciting to have you on. Actually, you are our first guest from Australia. So would you like to tell the listeners a little bit about yourself, maybe where you work and your research areas?

Dan: Yep. Sure. So I'm a clinical psychologist. I'm from Brisbane, Australia, and my work here in Brisbane, I do a little bit of a mix. So I am working at Children's Health Queensland at a specialist eating disorders clinic for our child and youth mental health service and I work clinically there as part of the CBT-E team. I'm on a research fellowship for the last two years and we're researching eating disorders generally and what factors contribute to treatment outcomes amongst adolescent eating disorders. And also do a little bit of work in private practice as well.

Steph: Okay, brilliant, thank you. So I was really keen to get you on the podcast. It was Eating Disorders Awareness Week here in the UK a couple of weeks ago. And, as we just talked about off air, we also recorded a Practice Matters podcast with Rebecca Murphy, which you said you listened to as well for Eating Disorders Week, talking all about it. So I thought this would intersect really nicely with that. We don't actually get many eating disorders papers into the journal as well, so I thought it'd be really nice to showcase this one and talk about what you do. So could you tell us a little bit about how this paper came about? Was there any particular motivation for the research?

Dan: Yeah, so I guess in part, it was on behalf of our young people, on behalf of the treatments that we offer as well. I think unfortunately still with all the evidence we've got with treatment with eating disorders, sometimes they can get a bit of a bad rap. Not so much within our service, but they can be perceived as people that are hard to treat, or the treatments don't work, or people don't recover, despite there being like really good evidence for outcomes. And so what in particular we noticed as well was with family-based treatment, it's a treatment that a lot of people have heard of. It's probably the most well studied treatment for adolescent eating disorders and when it's not going well or it hasn't completely worked, then that kind of perception that, oh, they're not going to recover, can be even worse. And sometimes when family-based treatment doesn't go well, it can not look too good. There can be a lot of distress, there can be a lot of like argumentativeness so that the perception- this is very much anecdotally- is well, if they haven't been able to recover with full family support, what hope is there? And that they're not suitable for an individual treatment. But within our service, what we noticed was that when we'd had sort of some young people that hadn't done quite so well with FBT and we gave them a chance for CBT-E, a good proportion of them did really well and engaged really well on the treatment. So we thought that was really important to be able to demonstrate to give the families and to also clinicians hope that, even if their family-based treatment hasn't worked, then the young people can still achieve full recovery through a treatment like CBT-E.

Steph: That's probably a really good point then to just talk about the two treatments a little bit. Would you be able to just sort of talk a little bit about the differences between the two for those who might not be so familiar, and actually maybe why family-based treatment might not work as well? I'm quite intrigued to some of the reasons why.

Dan: Yeah, sure. I think that's, that's a really important distinction between the two treatments to make. And I think that's also a really great, to have two treatments that contrast quite differently. I think a lot of times in psychology there's a large overlap between the treatments and it's like one hasn't worked then the other one maybe is also quite similar. But with FBT and CBT-E, there's some really striking differences there, which I think might give some rationale for why if one doesn't work, the other one might work.

So with FBT to start off with, the theory behind the two treatments are quite different. With FBT, they take the medical model, the disease model. So with that model, the eating disorder is conceptualised as an illness that the young person has, they don't have any control over, and the symptoms of the illness are the eating disorder behaviours, which might be the concerns overeating, the concerns over weight and shape and the desire to restrict. So according to that model, if you've got the disease, it's something that's external to you that you have no control over. It's a little bit like having covid or something, you don't choose to have a sniffly nose, you don't choose to have a cough, you don't choose to feel awful. It's an illness that you’ve contracted so you need some form of external medicine, external control to recover from the illness. So when you've got covid, you take whatever medicine's going to help you recover from that. According to the FBT model, it's the eating disorder that is causing these symptoms. It's not something that the young person's chosen to have, but they need some sort of external force to regain control. And according to FBT, the food is the medicine, and the family is that external support that's required to help the young person regain control from their illness and achieve recovery.

So there's a lot of advantages to that model, in that because it's conceptualised an illness like no one's to blame. It's no one's fault. It's something that's happened. So the young person isn't to blame the families aren't to blame. And according to that model, you can garner the resource of the whole family to, to help the young person recover. So it's a good model and the evidence is that it works but it's also quite different to the CBT-E model where we take that psychological approach. So rather than it being an illness that you've got no control over, we think according to the CBT-E model, that there's reasons why this young person might be really concerned about their weight, concerned about their shape and want to engage in eating disorder behaviours. And it's not because they've got an illness or got something that's external to them. It's according to the CBT-E model we usually conceptualise it as being a maladaptive schema of achieving self-worth. So it's a way that the young person has learned to feel good about themselves. And if they can control their eating, if they can control their shape and weight, then they feel really good about themselves and they feel in control and they feel great and that's why they want to engage in the behaviours, and that's why they're so concerned. But there's also mechanisms that maintain it and can make it a problem. So according to that model, it's the road to recovery isn't through an external force being required. It's the road to recovery is understanding what the mechanisms are that the maintaining the eating disorder as a problem. Making the decision, okay, I want to explore other ways of achieving my self-worth. Other ways of feeling better about myself that don't rely on just controlling eating, weight and shape and then applying the strategies to be able to change them.

Steph: Yeah. So it sounds like it gives them more autonomy.

Dan: Yeah. Yeah definitely. And, yeah, in that early on in the stages of FBT, it's very much kind of parents are in control and that they need to be, because according to that model, the young person doesn't have any control. Whereas with CBT-E, it's all about autonomy from the very first session, it's like you are in control here, you are making the decisions through treatment and it's your decision to, to literally sit down in session one and talk about what's going on. And then if you want to hear more and make the decision to engage and it's your decision to go on from that. So, yeah, a lot of difference in the role of autonomy there.

Steph: Yeah, and this might be a bit of a left field question then, but do you think maybe that's why FBT doesn't work sometimes because the control feels more with the parents and not actually with the young person themselves?

Dan: Yeah. I think there's, there could be lots of reasons why FBT doesn't work. I think it's age appropriate for young people to want to be in control, that's a developmental milestone to try to feel in control and gain autonomy through that period. So I think that can lead to some clashes and can be really difficult for the young person to relinquish that control more generally to parents. But that said, through successful FBT, that's a part of the process as well is returning control back to the young person.

Steph: So shall we get into the paper then? So this was a pilot study, so what were your initial hypotheses for the paper? What were you trying to set out to find?

Dan: It was an effectiveness design, so we were, we didn't have any specific hypothesis per se, but we were wanted to compare the relative effectiveness of young people who had come with no FBT previously compared to people who'd had FBT that had been discontinued for some reason without achieving full recovery. So we really wanted to compare ok are these two groups similar or different in terms of their effectiveness and answering the question really, should we still be offering CBT-E to, to those who've not achieved recovery through FBT or is it, or are they going to not do well in that treatment either?

Steph: So tell me a little bit about the participants then, who were recruited and was it easy to recruit participants for this?

Dan: Well, yeah, it was based on everyone that've done CBT-E in our service. So we're a public mental health service, and the young people as part of our protocol, we offer FBT as usually the frontline treatments. So in terms of recruitment, we're the largest public service in Queensland and so we recruit from all around Brisbane and the local surrounding areas. So we do get a lot of, a large population, come through. So in terms of recruitment, that, yeah, wasn't too much of a problem and in terms of the protocol, I guess. Yeah, we offer FBT as frontline and so most of our young people typically go into FBT unless it's contraindicated or declined by the family for a range of different reasons. So we had a, if they're, if the family or the young people choose to not engage in FBT, then CBT-E is usually offered as a second line treatment. So we had, of our group, we had 69 young people and 42 of them engaged in CBT-E as their first treatment at our service. And then another 27, had tried FBT and that had been discontinued for one reason or another. And then they were offered a CBT-E suitability assessment.

Steph: Okay. So then what kind of did you do with these participants and what did you find?

Dan: So we implemented the manualised CBT-E according to Riccardo Dalle Grave and Simona Calugi’s manual from 2020. So we went standard CBT-E, by the book. Our team is lucky enough to have supervision with Riccardo who is on the paper, who wrote the manual. So we're lucky to have tips from him. And that kind of keeps us hopefully fairly adherent to the model throughout. So yeah, in terms of what we did, the treatment was the same for everyone in terms of manualised CBT-E, the real kind of variance was what had they done before? So, we implemented between 20 to 40 sessions of CBT-E according to whether the young person needed weight restoration or whether they needed to do the broad form or the focused form of CBT-E, which is dependent on if they've got external maintaining mechanisms that are being identified that maintain their eating disorder as well. It takes a little bit longer to target those mechanisms.

So that was the intervention. and yeah, like I said, so the two groups contrasted in terms of one group went straight through and CBT-E was their first treatment. The second, the second group were people who had engaged in FBT previously. So again, they engaged in FBT at our clinic and we've got a really good FBT team as well that's really well trained. But if the young person hadn't had showed they were unable to progress, or they've being a little bit stuck, or the family had been unable to maintain the treatment or had chosen to disengage from FBT then they were offered the CBT-E assessment and then if they were suitable and the young person chose to engage and they received the CBT-E intervention.

Steph: Okay. Brilliant. And were there any surprises that you found then? Was there anything unexpected that kind of came out of this?

Dan: I don't think so. It reflected our initial thoughts. So the results that we found was that there was no difference between the groups on their measures of eating disorder psychopathology. So the measures we took, I should have mentioned that, sorry, was

Steph: That's okay.

Dan:  The Eating Disorders Examination, which is a measure of restraint and eating, weight, shape concerns. So a fairly standard eating disorder outcome measure. We also measured them on the Clinical Impairment Assessment which is a measure of not so much core eating disorder symptoms, but how much is it getting in the way of your life? How much is it impacting you doing the things that you want to do? And we also measured BMI Centiles as well.

So the results, what we found was that, yeah, both groups did similar on measures of eating disorders psychopathology and clinical impairment, the intervention worked, the effect size was large. And there was no difference in the magnitude of effect between the groups on those measures. So it confirmed what we'd seen that we hadn't really noticed much of a difference on what the young person's background was, they were like more or less likely to do the same, than it wasn't a big factor. In terms of treatment completion there was no difference between the groups either. So they were, the young people were just as likely to get through to the end of treatment, regardless of whether they'd done FBT previously or not.

We found a slight difference in BMI changes across treatment. And the group that had done FBT previously, they didn't change according to their BMI Centile across treatment, but the group who had no FBT did. So what we made of that, there's a lot of uncertainty around that measure because we didn't have like individual weight histories, we didn't have a lot of information that would know okay, did this young person, were they below their healthy weight range or what had happened to their weight across FBT? But the most likely explanation that we sort of think is that maybe those young people that had done FBT previously had achieved some level of weight regain or were maybe closer to their healthy weight range, through FBT. So they've had some benefit there, maybe whereas the group that had no treatment prior to that, maybe they needed to gain some weight to achieve their healthy weight range. That's a suspicion. We don't have enough data to, to be confident about that. But that's the yeah guesses we made.

Steph: Yeah. So given these findings then, what do you think are the implications for clinical practice or any future research? I always like to ask people what impact do you think this paper will have on the world of CBT?

Dan: I think it's got some important implications. I think, again, like circling back to our young people and our families, I think the biggest implication is hope for them. I think in our Australian context, definitely FBT is probably the more well known treatment, and around the world it's got a more robust evidence base. It's been studied more comprehensively than CBT-E. So a lot of young people, a lot of families have heard of FBT, and they're quite hopeful about achieving recovery through that treatment, as they should be. The flip side of that is when it hasn't worked, it can be disappointing, and I think some families and young people can lose a bit of hope with that. But the implications for this, I think is that they're just as likely to succeed with this treatment, despite whatever's happened with FBT previously. So I think, yeah, first and foremost, it's a hopeful story in terms of that there's a really good chance of achieving full recovery, which with eating disorders, they're horrible things. So, if we can give that hope to our young people and our families, that's super important.

I think for clinicians it's also important to know that again, like even if FBT hasn't worked, and even if FBT is not looking good for want of a better word, and you're like the young person might not be engaged and might not look like they're ready to take charge of change themselves, CBT-E can still be a viable option. And again, anecdotally, and this is maybe leading to future research, but it's we don't appear to have like really good markers of okay, like who, who is going to do better or worse. So it's implications I think is, it's worthwhile, offering the young person CBT-E, to see if it's something that they want to or are ready to engage in cause yeah, in our experience, there's some people that were really struggling with FBT that did really well in CBT-E. So I think that, having that in the back of your mind to, to offer the treatment to the young person and the family is important as well.

Steph: So it's that real thing about treating the individual, isn't it, and not expecting them to fit into the model.

Dan: Yeah, exactly. And, yeah, and then I think that kind of like highlights future research is what we’d love to know is to be able to know who does better in what treatment so that we can get them straight into that to start off with and we, we don't have to do that dance. So yeah, ideally, that's like a little bit of the work that we're trying to do. It's a big question and I know that we're not the only ones to have thought of about asking that question, but if in part we can help figure that out, what are the factors that make people more or less suitable for FBT or CBT-E, then, we've got a better chance of being able to allocate them into a more successful treatment first time round so they recover quicker which is obviously what we want.

Steph: Yeah. This probably just leads on to my next question nicely then is, is there anything you would've done differently if you were going to do the study all over again now? Anything you'd change?

Dan: Yeah, I think so, well, yes is the answer to that. Lots. I think a lot of our limitations come at the setting that we are, it's not a research clinic, it's a real world clinic so we did have a lot of missing data, so I'd like to be able to tidy that up a little bit. We didn't collect data on who was offered CBT-E but then chose not to engage. So that would've been good to be able to understand a little bit more about the acceptability of the treatment. I was talking about weight trajectories before, so we didn't collect data on that, and we didn't have any data from what the young people were like prior to starting FBT. So it's hard to know the degree to which they improved prior to starting CBT-E. So all of those questions would be nice to have a little bit more data around.

I think, other things that would've been nice to be able to collect data on is more qualitative. So like asking the young people about what their experiences were like, and particularly like what made them engage in CBT-E, why did they want to do it? Obviously we listen to the young people and they tell us, but it would be nice to document that and have that understanding about what are the reasons why people choose CBT-E, and why do they choose that, particularly if they maybe haven't had a great experience with FBT previously would be good for us in the field to know.

Steph: Yeah. And I always like to ask this question mostly because I'm curious. As a journal's managing editor, it's always good for me to know. How did you find the peer review process going through with this paper?

Dan: It was really good. It was prompt, and it was really clear that the reviewers had taken time to read the paper well and pick up nuances and just really well thought out revisions that they suggested that really improved the paper. And yeah, that they both read the paper really well, and then they really articulated their comments, well, which made it really easy to respond and overall the paper was improved. So yeah, it was a good experience.

Steph: Good. So you weren't subject to the stereotypical reviewer two who's critical and difficult.

Dan: No, no we avoided the Reviewer Two syndrome

Steph: And just before I let you go and get back to your evening, because I appreciate that time difference between UK and Australia, this is eating into your evening now. What's up next for you? Is there anything that you're working on? Anything that we should be looking out for from you?

Dan: Yeah so we've got a couple of things on the go. As a follow up to this paper, we've just written like a clinical companion piece about managing that transition for the CBT-E clinician, for people that are working with clients that have previously done FBT. So we think that's a really important transition to manage and there's some real unique difficulties or challenges amongst people with that FBT history, because of the differences that I described earlier between the models. So I think that's, yeah, that, that was written with the CBT-E team that I think we did a really good job in writing that. And, yeah, I'm hopeful that it is out there because I think that's, important for the CBT-E clinician to know and understand because there's some little traps there or some things that can be important for not just a clinician, but the families, the young person, everyone in the treating team to understand and make that transition a successful one. So I've got that. And, yeah, the research that we're doing at the clinic, like I mentioned, we're looking at trying to understand more about the young people that we see and the factors that contribute to treatment outcomes. And yeah, ideally would like to know what makes people do better in treatments, what makes people more suitable for one treatment compared to the other? So we know like how we can allocate people to have the greater chance of success and also for to know, okay, who might need extra support or who might need other services that we can offer them.

Steph: Okay. Well that all sounds brilliant. Dan, thank you so much. This was really great to have you on.

Dan: No worries. It's been nice to chat.

Steph:  Thanks so much for listening. You'll find a link to the paper we discussed along with any other useful resources in the show notes, so please do go and check those out.  If you enjoyed this episode please take a moment to rate, review and subscribe. It really helps others to find us. And if you have any feedback then I would love to hear from you. You can reach me at [email protected] or follow us on Instagram and BlueSky @babcppodcasts. Our journals are there too, sharing all the latest research as soon as it is published.  And don't forget to check out our sister podcasts, Let's Talk About CBT and Let's Talk About CBT Practice Matters. Whether you're new to CBT or just looking to enhance your practice, they're full of insightful discussions and some really helpful tips.

 Thanks for tuning again, and I'll see you next time on research matters. Bye