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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:
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:
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:
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).
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:
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:
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.
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