The current status of cognitive behavioral therapy for eating disorders: Marking the 51st Annual Convention of the Association of Behavioral and Cognitive Therapies

This Virtual Issue of the International Journal of Eating Disorders (IJED) marks the 51st Annual Convention of the Association for Behavioral and Cognitive Therapies (ABCT), held in San Diego in November 2017. It consists of a set of recent papers published in IJED, providing key evidence about the current status of cognitive behavior therapy for eating disorders (CBT-ED) We hope that such access will support ABCT members in putting the San Diego meeting material into context. We also hope that being brought up to date via both the conference and the Virtual Issue will encourage you to develop your own thoughts and experiences into research of your own, and that you will submit your research to IJED to add to that evidence base. Nobody can pretend that CBT-ED is perfect, despite its strong standing in the field. We need a multitude of perspectives, new ideas, and a willingness to grow the field, and we know that ABCT is a perfect organization for advancing our evidence base for CBT-ED. Why is it important that we should be thinking CBT-ED now? In 2017, the United Kingdom's National Institute for Health and Care Excellence (NICE) published a new set of guidelines, replacing the previous 2004 guidance. This effort reflected the substantial new evidence that had come forward over the previous decade, and the need to consider whether existing guidelines were adequate. It focused on outcomes from controlled trials, but also reflected the experience of users, carers, researchers, and clinicians. The full methodology is provided in the NICE (2017) guideline. For the purposes of this Virtual Issue and ABCT members, two outcomes from the NICE guidelines are critical. The first is a new term to encompass the different evidence-based forms of CBT for eating disorders—CBT-ED. This portmanteau term was developed to encompass all evidence-based forms (which does not include all CBT), because there was no clear evidence that any of the specific “brands” of evidence-based CBT was better than others. The second outcome that is relevant to ABCT members is the degree to which CBT-ED's position was supported as being the only recommended approach for the majority of adult cases (i.e., the non-underweight group), as well as being proven to be a viable option for the treatment of underweight adults and a second-choice treatment for many younger patients. In short, CBT-ED has moved ahead of many other therapies, to become a clear treatment of choice. Now, it is time to implement that knowledge. The papers in this Virtual Issue cover a range of topics, and are divided into categories to assist the reader in understanding the literature. Starting with the evidence that CBT is an effective treatment, Hay's (2013) systematic review provides a clear basis for concluding that CBT-ED is an effective approach to treating eating disorders in adulthood, as NICE concluded even more firmly. However, she also points to directions for future research, and for better understanding of how to address weight management where obesity is an issue. An issue that NICE takes into consideration is cost-effectiveness—the perfect therapy is not going to be much help if it is so expensive if it cannot be made accessible to patients. Fortunately, the recent paper by Le, Hay, Wade, Touyz, and Mihalopoulos (in press) addresses just this point, showing CBT-ED to be a cost-effective treatment for many of our patients. It is also possible to get good results with CBT-ED delivered in a group format (Jones & Clausen, 2013; Wade, Byrne, & Allen, 2017). Finally, and again with low-cost interventions in mind, Chithambo and Huey (2017) show the potential of CBT-ED as a prevention tool, giving results that are comparable with those of dissonance-based interventions. Of course, a critical question is: “Does it work here?” While Hay's (2013) systematic review considered the evidence based on a range of randomized controlled trials (RCTs), the question arises of how easily such findings can be transferred to the “real world” settings where most of us see our patients. Fortunately, there is now substantial evidence that we can take CBT-ED into our everyday practice with very similar results to those from the RCTs, as long as we deliver the same therapy. That includes work in specialist eating disorder services (Calugi et al., 2016; Waller et al., 2014) as well as non-specialist services (Rose & Waller, in press). A further consideration is whether CBT-ED is just too narrow, failing to address the wider range of problems that our patients experience. Some of the papers cited in this Virtual Issue show that CBT-ED has much broader effects, reducing anxiety, depression, and more. However, we should draw particular attention to the way that CBT-ED has positive impacts on quality of life—indeed, a greater impact than many other therapies (Linardon & Brennan, 2017). When implementing any therapy for eating disorders, we have to be aware of what does and what does not work. Several papers in this Virtual Issue address just this point. For example, we are very clear that exposure with response prevention is a key tool, as detailed by Steinglass et al. (2014) when treating anorexia nervosa and Trottier, Carter, MacDonald, McFarlane, & Olmsted (2015) when addressing body image. However, we should not be complacent about the use of exposure, as it is a treatment technique that is on the move more broadly. Reilly, Anderson, Gorrell, Schaumberg, and Anderson (2017) point to ways in which we can use a more contemporary model of exposure therapy to increase its impact. As well as techniques, we should think about the timing of change. It is always tempting to take it easy at first, to acculturate the patient to therapy. A key paper in this field is that of Raykos, Watson, Fursland, Byrne, and Nathan (2013), who have shown that early change in CBT-ED has substantial clinical impact—a finding that has been replicated extensively in other centers and across therapies (e.g., Linardon, Brennan & de la Piedad Garcia, 2016; Vall & Wade, 2015). This work demonstrates that we should be using CBT-ED intensively from the beginning, as change by 4–5 weeks is a key predictor of outcome. That early symptom change has another impact, but one that is different in CBT-ED to other therapies. Graves et al. (2017) have shown that the usual assumption of the early alliance driving therapeutic change in the eating disorders might be true of other therapies, but is not true of CBT-ED. Again, the most effective early element of CBT-ED appears to be early symptom change, which results in the development of a better alliance. The papers included in this Virtual Issue have been chosen to reflect the state of our clinical science—what is best in CBT-ED? While we hope that you find them useful, we would like to draw your attention to one point that emerged when selecting these papers—their global origins. The teams undertaking this research come from Australia, Canada, Denmark, Italy, the United Kingdom, and the United States of America. While this was not a strategic choice, we hope that you share our view that this Virtual Issue reflects the truly international nature of the IJED. There were many more papers from IJED that we could have included in this Virtual Issue, but we obviously could not include them all. We have selected papers that reflect the range of recent research that IJED has published, but go online and search through the journal and you will see far more research that relates to CBT-ED and many other topics related to eating disorders. Please enjoy the papers here, and use them to support your learning at the ABCT meeting. We hope to see more papers from ABCT members and attendees over future editions. Finally, we would like to give our particular thanks to Dr. Taryn Myers, President of the Obesity and Eating Disorders Special Interest Group (OED SIG) at ABCT, for her assistance in making this Virtual Issue a reality.

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