Interprofessional Enhanced Cognitive Behaviour Therapy (CBT-IE): A pilot trial exploring the feasibility and efficacy of an interprofessional outpatient treatment in anorexia nervosa

Interprofessional Enhanced Cognitive Behavioural Therapy (CBT-IE) is an interprofessional adaptation to Enhanced Cognitive Behavioural Therapy (CBT-E) which is a leading outpatient psychotherapeutic model for eating disorders. CBT-IE retains the structure and content of CBT-E, although it is distinct in its delegation of content regarding malnutrition, nutritional rehabilitation, and dietary restraint to the dietitian. Detailed information regarding session content can be found in Cristopher Fairburn’s (2008) book 'Cognitive behaviour therapy and eating disorders' (henceforth referred to as 'The CBT-E manual'). CBT-E is traditionally delivered in 'focused' (20 sessions) or 'broad' (40 sessions) form based on the participant's need for weight restoration to a minimum body mass index (BMI) of 20. - Where a participant has a BMI of less than 20 at the start of treatment they will receive treatment up to 40 sessions to achieve a BMI of greater than or equal to 20. Where a participant achieves a BMI of 20 and has completed all session content detailed in the CBT-E manual prior to 40 sessions this will mark the end of treatment. - Where a participant has a BMI of equal to or greater than 20 at the start of treatment sessions will continue until they have addressed undereating and have completed all session content detailed in the CBT-E manual to a maximum of 40 sessions. - Sessions will be one hour in duration - Session attendance checklists will be documented throughout the pilot trial - The number of sessions required to achieve a minimum BMI of 20 and address undereating will determine the duration of the intervention; intervention duration may therefore vary among participants Assessment (Sessions A1 and A2) - The assessment stage of Interprofessional Enhanced Cognitive Behaviour Therapy (CBT-IE) involves one assessment session with the mental health professional and dietitian, respectively - The mental health professional’s CBT-IE assessment session is conducted as per ‘The Initial Evaluation Interview’ as per the CBT-E manual - The dietitian’s CBT-IE assessment session is conducted as per ‘The Initial Session’ of the CBT-E manual, including a standard dietetic assessment - An interprofessional case consultation is held after A1 and A2 are completed - Assessment sessions will be held at approximately weekly intervals Stage One (Sessions 1 to 7) - Stage one is focused on gaining a shared understanding of the person’s eating problem, providing education about the impact of the eating disorder, and helping the individual improve nutritional intake - The dietitian delivers stage one of CBT-IE, adapted as per the ‘Underweight and Undereating’ chapter of the CBT-E manual - Sessions with the mental health professional are conducted in stage one if acute and severe psychological concerns are identified - Stage one sessions will be held at approximately weekly intervals Stage Two (Session 8 to maximum 9) - Stage two is a brief transitional stage involving one interprofessional case consultation followed by one or two joint sessions with the dietitian, mental health professional and the patient where progress is reviewed, and plans are made for stage three - Although joint sessions are preferred, where this is not practical, the mental health professional should independently conduct stage two sessions without the dietitian - Stage two sessions will be held at approximately weekly intervals Stage Three (Sessions 9 or 10 to maximum 36) - Stage three is focused on the processes that maintain the person’s eating problem - Sessions are delivered by the dietitian and mental health professional in a modular or alternating format at varied frequency based on patient need - The dietitian delivers modules ‘Underweight and Undereating’ (where still relevant after stages one and two) and ‘Dietary Restraint, ‘Dietary Rules and Controlling Eating’ as per the CBT-E manual - The mental health professional delivers modules ‘Shape Concern, Shape Checking, Feeling Fat and Mindsets’ and ‘Events, Mood and Eating’ as per the CBT-E manual - The dietitian delivers optional modules to address comorbid nutrition diagnoses, nutrition for physical activity, and nutrition for weight maintenance if relevant to the patient - The mental health professional delivers optional modules to address ‘Clinical Perfectionism’, ‘Core Low Self-Esteem’, and ‘Interpersonal Relationships’ as per the CBT-E manual if relevant to the patient - An interprofessional case consultation between the dietitian and mental health professional is held after sessions 20 and 30 - Stage three sessions are held at approximately weekly intervals if ongoing weight restoration is required, or at approximately fortnightly intervals where ongoing weight restoration is not required Stage Four (The final 4 to 6 of maximum 40 sessions) - Stage four is concerned with ending treatment well - The mental health professional addresses concerns about ending treatment, discusses strategies to ensure psychological progress is maintained, and makes plans to minimise risk of lapse/relapse relating to these issues - The dietitian discusses strategies to ensure progress is maintained with regards to dietary change, and makes plans to minimise risk of lapse/relapse relating to these issues - The final session is a joint session between the dietitian, mental health professional and the patient - An interprofessional case consultation between the dietitian and mental health professional is held after the final session - Stage four sessions are held at approximately fortnightly intervals if ongoing weight restoration is required, or at approximately monthly intervals where ongoing weight restoration is not required Interprofessional case consultations between the mental health professional and dietitian will be held after sessions 7, 20 and 30. These will be 30-60 minutes in duration. Interprofessional case consultations are included to facilitate delivery of Interprofessional Collaborative Practice which has been shown to improve health outcomes as well as the patient and clinician experience of treatment. Discussion points at interprofessional case consultations will include: - Clinical impression - Progress to date: - Weight - EDE-Q - Barriers to change - Formulation and proposed changes - Any changes to the treatment plan