Victoria Mountford

The Role of Emotional Abuse in the Eating Disorders: Implications for Treatment

This paper addresses the clinical links between emotional abuse and the eating disorders. It is argued that the core feature of a range of abusive experiences is emotional invalidation. Emotional abuse is associated with problems in the development of emotional skills, manifesting as alexithymia, poor distress tolerance, and emotional inhibition. Cognitive-behavioral approaches are outlined for work with eating-disordered patients with a history of emotional abuse. As well as addressing the central concerns about eating, weight, and shape (using existing evidence-based methods), the focus of treatment is on addressing the conditional assumptions about the acceptability of emotions and the core beliefs that underpin the emotional difficulties.

One size fits all: or horses for courses? Recovery-based care in specialist mental health services

IntroductionThe ‘recovery approach’ to the management of severe mental health problems has become a guiding vision of service provision amongst many practitioners, researchers, and policy makers as well as service users.MethodThis qualitative pilot study explored the meaning of ‘recovery’ with users of three specialist mental health services (eating disorders, dual diagnosis, and forensic) in 18 semi-structured interviews.ResultsThe relevance of themes identified in mainstream recovery literature was confirmed; however, the interpretation and relative weight of these themes appeared to be affected by factors that were specific to the diagnosis and treatment context. ‘Clinical’ recovery themes were also seen as important, as were aspects of care that reflect core human values, such as kindness.

Predicting premature termination of hospitalised treatment for anorexia nervosa: The roles of therapeutic alliance, motivation, and behaviour change

OBJECTIVESnThis study aims to investigate treatment drop-out, and the associated roles of motivation, alliance, and behaviour change exhibited over the first four weeks of hospitalised treatment for anorexia.nnnMETHODSn90 participants meeting DSM-IV criteria for anorexia nervosa completed questionnaires at admission, and four weeks into treatment. Weight data was collected over this same time period. At the end of treatment, participants were categorised into completer or premature termination groups.nnnRESULTSnThe overall rate of premature termination was 57.8%. Those who prematurely terminated treatment demonstrated lower discharge BMI (p<.0005), and weight gain (p<.0005) than those who completed. Therapeutic alliance proved significantly different between outcome groups at admission (p=.004).nnnDISCUSSIONnEnd-of-treatment outcomes for those who do not complete treatment are invariably poor. Therapeutic alliance appears to be a particularly important factor in this area.

Invalidating childhood environments in anorexia and bulimia nervosa

OBJECTIVEnThis study examined the relationship between an invalidating childhood environment and eating pathology, including diagnoses, eating attitudes and eating behaviours.nnnMETHODnFifty-eight eating-disordered patients completed a measure of invalidating childhood environments, and a standardised measure of eating pathology.nnnRESULTSnPatients with bulimia nervosa scored higher on levels of paternal invalidation than those with anorexia nervosa. There were no associations at the attitudinal level, but some behaviours were related to perceived parental style. Self-induced vomiting was associated with paternal invalidation, while those who experienced an invalidating mother were less likely to report binge-eating. Those who exercised excessively were more likely to have experienced a family style in which the focus is on remaining in control of ones emotions, success and achievement.nnnDISCUSSIONnInvalidating childhood environment was related to eating psychopathology in a clinical population - particularly the presence or absence of some behaviours. Implications for treatment are considered.

BODY CHECKING IN THE EATING DISORDERS: ASSOCIATION WITH NARCISSISTIC CHARACTERISTICS

There is substantial evidence that body image is a clinically important element of eating pathology, and that patients body checking cognitions and behaviours are key elements in the maintenance of that body image. However, there is little understanding of individual differences in body checking. This study considered the potential role of narcissism and narcissistic defences in driving body checking cognitions and behaviours. 68 eating-disordered and 70 non-clinical women completed well-validated measures of body checking and narcissism. There were specific patterns of association between different elements of narcissism and different aspects of body checking. These patterns are compatible with a model where body checking serves the defensive function of maintaining self-esteem, rather than promoting positive levels of narcissistic self-esteem.

Associations between body checking and disordered eating behaviors in nonclinical women

OBJECTIVEnRecent research suggests that body checking cognitions and behaviors are differentially associated with pathological eating behaviors in clinical women. However, it is unknown whether similar associations exist in nonclinical populations. The aim of this study is to examine whether body checking (cognitions and behaviors) is associated with pathological eating behaviors in a nonclinical sample of women.nnnMETHODnValidated measures of pathological eating behaviors, body checking cognitions, and body checking behaviors were completed by 342 nonclinical university women.nnnRESULTSnWomen engaging in binging (objective and subjective), purging, restraint, and excessive exercise reported consistently higher scores across all body checking cognitions and behaviors. All body checking cognitions and behaviors independently contributed to distinguishing those who reported each behavior as opposed to those who did not. The predicted classification was most accurate for the cardinal diagnostic symptoms for bulimia-objective binging and purging.nnnDISCUSSIONnBody checking cognitions are implicated in the development of pathological eating behaviors in nonclinical populations, requiring consideration for planning prevention programs.

Cognitive behavioural therapy for individuals with longstanding anorexia nervosa: Adaptations, clinician survival and system issues

Despite recent advances in the treatment of anorexia nervosa, some individuals will progress to a severe and enduring illness, with associated physical, psychological and social consequences. Working with these patients, however, may leave clinicians feeling overwhelmed, risking difficulties in the therapeutic relationship including disengagement or despair. Cognitive behaviour therapy has shown some promise in the treatment of eating disorders, yet some features may not be appropriate for this group. In this paper, we outline the ways in which we have adapted cognitive behaviour therapy to best meet the complex and challenging needs of this group. We stress the importance of maintaining a reassuring, accepting and motivational approach in combination with clear goal setting and boundaries.

Cognitive-behavioral therapy for bulimia nervosa and atypical bulimic nervosa: effectiveness in clinical settings.

OBJECTIVEnThe efficacy of cognitive-behavioral therapy (CBT) for bulimic disorders has been established in research trials. This study examined whether that efficacy can be translated into effectiveness in routine clinical practice.nnnMETHODnSeventy-eight adult women with bulimic disorders (bulimia nervosa and atypical bulimia nervosa) undertook individual CBT, with few exclusion criteria and a treatment protocol based on evidence-based approaches, utilizing individualized formulations. Patients completed measures of eating behaviors, eating attitudes, and depression pre- and post-treatment. Eight patients dropped out. The mean number of sessions attended was 19.2.nnnRESULTSnNo pretreatment features predicted drop-out. Treatment outcome was similar whether using treatment completer or intent to treat analyses. Approximately 50% of patients were in remission by the end of treatment. There were significant improvements in mood, eating attitudes, and eating behaviors. Reductions in bingeing and vomiting were comparable to efficacy trials.nnnDISCUSSIONnThe improvements in this real-world trial of CBT for adults with bulimic disorders mirrored those from large, funded research trials, though the conclusions that can be reached are inevitably limited by the nature of the trial (e.g., lack of control group and therapy validation).

Is the therapeutic alliance overvalued in the treatment of eating disorders

In this article, we make the case for a systematic program of research into the causal relationship between the therapeutic alliance and outcomes of psychological treatments for the eating disorders. To make that case, we need to begin by considering the validity of existing assumptions about that alliance-outcome relationship. We will then suggest what research is needed to allow clinicians to structure their work to best effect (e.g., should therapists focus on establishing a strong alliance even if it means not applying more therapy-specific techniques, or should they stress the application of those techniques even when the working alliance might seem likely to be weakened as a result). Although the authors have a background in cognitive-behavioral therapy (CBT), our aim is to suggest a research base that applies to a variety of psychotherapies, allowing for common or different conclusions about the alliance-outcome relationship, depending on what the proposed research indicates.

Beliefs about excessive exercise in eating disorders: The role of obsessions and compulsions

OBJECTIVEnThis study aimed to develop an understanding of excessive exercise in eating disorders by exploring the role of exercise beliefs, obsessive beliefs and obsessive-compulsive behaviours.nnnMETHODnSixty-four women were recruited from eating disorder services and 75 non-clinical women were recruited from a university. Exercise beliefs and behaviours, obsessive beliefs and behaviours and eating disorder psychopathology were assessed using self-report questionnaires.nnnRESULTSnThere was an association between exercise beliefs, obsessive beliefs and obsessive-compulsive behaviours in the eating-disordered group, but not in the non-eating-disordered group. In the eating-disordered group obsessive beliefs and obsessive-compulsive behaviours were associated with a significant proportion of variance in exercise beliefs after controlling for eating disorder psychopathology and BMI. In the non-eating-disordered group obsessive beliefs and behaviours were associated with beliefs about exercise as a method of affect regulation after controlling for BMI.nnnCONCLUSIONnThe results are compatible with a model in which obsessive beliefs and exercise beliefs could maintain exercise in eating disorders. This has implications for the assessment and treatment of excessive exercise. Further research is necessary to determine the causality of these relationships.