BABCP guidance for the remote delivery of evidence-based CBT for eating disorders

These guidelines have been developed in response to the impact of the Coronavirus pandemic. While CBT has been delivered via telehealth for many years, its results have not been impressive in working with eating disorders (e.g., Loucas et al., 2014), possibly because there are many elements in evidence-based CBT for eating disorders (CBT-ED) that have been developed around face-to-face delivery. That is no longer possible, in days where social isolation is vital. The guidelines reflect the fact that many of us are now working at home, and having to either transfer patients to online treatment or run the whole therapy by telephone or online. It is important not to start with negative expectations of this approach (e.g., “It cannot work” or “The alliance is going to fall to pieces”), as such expectations can very easily lead us to drift, creating a self-fulfilling prophecy. This document reflects recent changes in practice that we have been finding useful. Those changes have ensured that we can deliver CBT-ED remotely without losing sight of the evidence-based principles and practice. We have considered ways of using technology and used our experience to shape them to allow us to achieve key treatment outcomes. Of course, we start by recommending that CBT-ED clinicians should employ evidence-based CBT-ED protocols, as always (see below). We have already been seeing some very positive outcomes by staying on protocol despite the move to telehealth, and there is no reason that this should not work for all of us.

Basics of treatment

There are a number of general competences and metacompetences that we should always attend to, and these are just as important as ever when working via telehealth:

• Advise the patient to remain safe and socially isolated, as directed.
• Monitor and respond to physical and suicide risk, directing patients to appropriate medical resources if necessary. It is important to make sure that you ask these questions each time, either directly or as part of a routine assessment tool.
• Work with the patient to address any therapy-interfering behaviours or situations (e.g., using online shopping to ensure food is available; keep to regular time slots).
• Maintain professional and ethical boundaries.
• Work within your professional and employment requirements.
• Address patient and therapist concerns about telehealth from early on, discussing this as ‘business as usual under unusual circumstances’. To date, we have found that it tends to be the therapists who can have more concern about this working.
• If the patient is worried about the shift to a different format, then suggest that it is worth trying it as an experiment, rather than waiting for the resumption of ‘normal service’.
• Monitor progress as well as outcomes, and do not let the remote method of working stop you from pressing the patient to make early behavioural change (as this is the best predictor of outcome, regardless of the setting).

Practical issues in telehealth

Telehealth can seem daunting or it might seem like an extension of how you interact with many other people already. Either way, make sure that you consider the following technical issues:

• Pick an appropriate, secure platform, with video linkage if possible. Follow local guidance on appropriate technology to use, but be aware that some platforms are currently more secure (e.g., Google Meet; VSee) than others (e.g., Skype; Zoom). Use recording facilities where they exist. Remember that these platforms drain batteries, so avoid the stress of worrying about whether your battery will last by plugging in.
• Turn off any assistant devices (e.g., Alexa; Google Assistant; Siri), as these can be recording your conversations for external scrutiny.
• If having to use a phone, use a work phone or block your outgoing number when calling a patient.
• Turn off your phone ringer, alerts, etc., as these can be distracting.
• Treat this as a work situation – dress as you would for a face-to-face session; be on time; work to an agenda.
• Clarify and agree session conditions with the patient – encouraging minimal opportunity for interruption, turning off other forms of communication, being on time etc,
• Make sure that interruptions are minimised, or that you warn the patient if it is likely to happen. We have found that patients are very understanding, and will often need to break off to deal with issues at home themselves.
• Communicating key material that is normally presented on paper can usually be done electronically, especially if the patient keeps their food diary on their phone, uses an online food diary system, emails in photos of a paper record, uses scanning apps for diagrams, etc. Some platforms allow you to share screens and to demonstrate material via ‘whiteboards’.
• Routine pdfs and fillable versions of eating and other questionnaire measures are available in a number of places (particularly from the Centre for Clinical Interventions, and can be sent by email to the clinician.
• More tips on remote therapy provision are available

Staying on target

A key element of evidence-based practice is that it requires us to work to the protocols, to avoid drifting off course and thus running the risk that we make treatment more protracted and less effective. However, as with all protocols, remember to apply them flexibly, according to the needs of the individual (Wilson, 1996). Therefore, we recommend the following:

• Ensure that you use evidence-based protocols (e.g., Fairburn, 2008; Fairburn et al., 1993; Gowers & Green, 2007; Thomas & Eddy, 2019; Waller et al., 2007, 2019), rather than letting yourself ‘drift’. Remember that these protocols require us to be flexible for the individual patient – just flex without losing track.
• Beware of the temptation to ‘add on’ a few more sessions due to COVID-19, as this is likely to mean that you give yourself an excuse to drift from effective treatment.
• Always start with an agenda. Where the patient wants to talk about COVID-19 and nothing else, build time for this topic into the agenda so you can acknowledge the difficulties at this time, but limit the time so that the CBT-ED itself can be addressed. You may find it useful to refer the patient to resources such as the BABCP podcast on anxiety around coronavirus, or other resources on the covid-19 resources page: https://www.babcp.com/Therapists/Covid-19-Resources.aspx
• When delivering treatment by telephone, acknowledge that sometimes you might interrupt each other or talk over one another, as you can’t see each other’s non-verbal cues. Acknowledge that it is okay, and does not mean you cannot do meaningful work together. Similarly, therapists might have to give permission for there to be periods of silence on the telephone (e.g., “I’ll just give you a minute to think about that”), so that patients feel okay with the process of reflection during telephone/online sessions
• Use supervision to keep you on track (see the associated BABCP guidance for supervision under COVID-19 conditions)
• Maintain focus on patient progress and outcomes during that supervision
• Maintain the frequency of supervision, to ensure that you keep on track (and to allow the supervisor to check on your own experience of isolation and remote working)
• Group supervision can still be employed with video platforms, but avoid using the phone for this, as conference phone calls can be slow and confusing.
• A brief email from the clinician at the end of the session can help the patient to understand and deliver on the treatment plans. It is also useful in some cases to get the patient to take responsibility for this summary, and how and when they will send it before the next session.
• Use the following resources to consider ways of implementing CBT-ED effectively under COVID-19 conditions:
  CBT-ED and CBT-T tips when working online
  Challenges and opportunities for CBT-E in light of COVID-19

Specific CBT-ED competences

Clinicians have expressed concerns about how they and their patients will be able to implement specific CBT-ED skills under these conditions of social isolation. However, each of these is manageable when using appropriate levels of flexibility in delivering the techniques. In some cases, patients might say that they cannot implement the techniques due to the situation at home. In that case, you can stress the ‘If not now, then when…?’ approach, stressing that trying it now means the possibility of recovery sooner, while waiting until normal is reinstated is unlikely to enhance outcomes, but will definitely mean longer with the eating disorder and associated comorbid mood, risk, etc.

Another issue to consider is whether the patient would benefit from involving family members in the delivery of CBT-ED. If the patient is living in social isolation with their family, we recommend asking the patient to consider involving them in the treatment, including being on the calls for part or all of the session if appropriate. This might be particularly helpful for underweight patients working on weight regain (e.g., monitoring weight each week).

Nutrition is a key element of CBT-ED, as well as being inherent to exposure therapy for the eating disorders (see below). Therefore, food requires some additional consideration:

• Ensuring an adequate supply of the necessary foodstuffs. It is as important as ever to guide the patient as to what constitutes a healthy balance of eating, and to ensure that they change their habits in order to meet guidelines such as the ‘Eatwell plate’. Our experience so far is that patients have not had difficulty in managing to find the foods that they need, using that template. Indeed, many have learned that an unplanned change of brand, shop or foodstuff has been far less frightening than expected.
• Fear of exposure and susceptibility to the COVID-19 virus. Obviously, the patient should be encouraged to follow guidance on reducing the risk of exposure to the virus (particularly social distancing and online shopping). Fears about susceptibility to the virus are a good opportunity to discuss healthy, balanced eating rather than the disturbed pattern that the patient is used to (e.g., excluding carbohydrates). Reliable sources of information about such eating patterns can be found at the Academy of Nutrition and Dietetics and the Association of UK Dieticians. 

A number of other CBT-ED techniques also need to be adapted for the current situation. These can include:

Exposure therapy. Given the core nature of eating pathology in the cognitive-behavioural model (fear of uncontrollable weight gain; body image disturbance), exposure to food is a critical element of CBT-ED. Therefore, we have to consider how we can enhance exposure opportunities and maximise the patient’s anxiety (in order to maximise expectancy violation within the inhibitory learning model).

• First, do not use the current experience of telehealth as a reason to reduce focus on enhancing structure and content of eating, as per existing protocols. Pushing the patient’s eating pattern so that they are anxious enough is just as critical as ever, to enable them to experience a difference between anticipated anxiety and reality.
• So keep asking the patient to increase what they eat so that they gain/stabilise weight (according to need), and ensuring regular intake of (especially) carbohydrates to reduce bulimic behaviours, stabilise mood, and enhance cognitive and social functioning.
• Where in vivo exposure is not possible, then use imaginal exposure (e.g., social eating).
• Conduct eating exercises online (e.g., during the therapy session; by booking social eating with friends over teleconference).
• Use take-out and delivery meals, to enhance anxiety for the patient (e.g., not knowing the content and calorie count of foods).
• Body image exposure can be conducted by video call (or even by phone). Using a mirror requires careful positioning of the patient’s webcam. However, doing the work directly facing the screen, so that the patient and therapist can both see the patient’s image, is also possible (though it might be better if the patient has a large screen, such as hooking up to their television).

Linking weight to eating. Open weighing is a key element of evidence-based CBT-ED, so that the patient can learn that their beliefs about the effect of food on their weight are inflated. In face-to-face CBT-ED, we usually encourage patients to limit their weighing to once a week, in session, to ensure that the patient’s anxiety is maximised at the point of weighing (so that their expectancy is maximised, and they can learn very quickly that they are wrong). Indeed, we routinely ask patients to get rid of their bathroom scales to make sure that this pattern is observed. However, when working via telehealth in this way, we ask our patients to borrow or even buy scales (digital ones, if possible), so that they can weigh themselves during the session (following their description of what they have eaten). We ask them to put the scales away between sessions (e.g., ask a family member to keep them in their room), to reduce the risk of falling into excessive weight checking.

Other body image work. As well as mirror exposure (above), we find that other key CBT-ED body image methods can be implemented with some modifications. These include:

• Body comparison experiments. When in social isolation, real life body comparison becomes less accessible (e.g., only when out shopping). It is also more subject to bias, as those who are out might not be fully representative of potential comparison figures (e.g., a preponderance of people out exercising). Therefore, one can change the terms from a full behavioural experiment to a naturalistic behavioural experiment (e.g., “Now that you cannot compare yourself with others, are you feeling better or worse about your body?”). However, if the patient’s body comparison involves social media use, then a full experiment to test their beliefs can be conducted, as usual.
• Body checking. This is generally amenable to a regular behavioural experiment, except when it requires the patient to weigh themselves to test their beliefs. If that is the case, then the patient might need to source scales (see above).
• Surveys. These are relatively easy to set up by screen sharing the survey. We have also found that circulating them via online survey methods (SurveyMonkey, Qualtrics, Facebook, etc.) is effective in getting responses.

Exercise management. Your patient may be frustrated and fearful at the lack of opportunities for exercise. We find that treating this as a naturalistic behavioural experiment is helpful. As much as possible, you want to get the patient to make predictions regarding weight change that are as excessive as possible, so that the expectancy violation is very large when they fail to gain the predicted weight. In other words, the lockdown conditions might push up the patient’s fears of weight gain, but you can treat this as an opportunity for them to learn rather than a problem. Socratic questioning can be helpful in getting the patient to take a more rational perspective on the short-term nature of any impact on weight.

Relapse prevention. Some patients improve significantly during the lockdown, ahead of any intervention. This is often the case for those who had busy lives and were unable to plan or prepare food adequately, or those who prioritised other’s needs over their own. If the patient makes such advances, you can use therapy to help the patient to learn the value of these changes in lifestyle, and to consider how to implement similar positive strategies when lockdown ends.

Of course, the context that we are working in needs to be considered at all times. For example, under normal circumstances, we might recommend that the patient tries eating somewhere new or mixing with other people. Therefore, we need to consider using the resources that the patient has (e.g., making social links by phone or online).

In contrast, other CBT-ED techniques can be delivered pretty much as normal. We just have to remember to use them at the appropriate point, and in the appropriate way. These methods include:

• Most psychoeducation (apart from that relating directly to COVID-19). Psychoeducation materials are readily available, e.g.:
  Centre for Clinical Interventions 
  CBT-T website (includes The REAL Food Guide)
• Most cognitive restructuring techniques
• Working with emotional triggers to behaviours
• Core belief work , including imagery rescripting and chairwork (possibly building in some self-soothing work, as you will not be present when the patient is processing some of the experience)
• Group work (which patients seem to find very positive). We recommend asking the patients to self-weigh and report on their weight and their behaviours immediately before the group. This allows us to continue the helpful practice of talking with the group about overall group progress rather than discussing individual cases in front of the group.

Impact upon therapists

While CBT-ED by telehealth can be as effective as routine, face-to-face CBT, it is important to acknowledge this as a significant change in the way many clinicians are working. It should also be remembered that this change is coupled with the stressors that those clinicians (along with everyone else) are facing at the moment (e.g., home schooling, separation from loved ones, illness). Therefore, do not be surprised if delivering sessions remotely is more tiring, especially due to the increased concentration required to adapt, to read non-verbal communication, and to work with the limitations of the technology (e.g., audio visual delays). All these stressors may be occurring while access to our normal coping strategies is limited. Alongside routine advice about clinicians taking regular breaks, timing sessions appropriately, it is essential to reflect upon these challenges and use supervision, in order to ensure we remain healthy and able to deliver effective therapy.

Conclusion

It is beyond doubt that these are strange times, where routine, face-to-face delivery of CBT-ED is not possible in the great majority of cases. However, strange times can make us consider whether our normal pattern of delivery is the only one. In the past, telehealth methods have not been as effective as one might have hoped in the field of eating disorders, often because they involved a watered-down version of the therapy. However, the drive now is to get CBT-ED back on track when we cannot meet, rather than to deliver a less expensive version of the therapy.

We have found that it is perfectly possible to engage patients in evidence-based CBT-ED via telehealth, as long as we adhere to the core principles of that therapy and think flexibly about its delivery. The result is that we are all developing new skills. What is important now is to monitor how effective this new approach is, as early indications have been positive. Indeed, if one good thing comes out of the whole COVID-19 lockdown, it might be that we get more effective at delivering therapies via telehealth, and that it will become a much more viable option in the future.

Glenn Waller, Matthew Pugh, Madeleine Tatham, Jane Evans, Victoria A Mountford, and Hannah Turner, April 2020