Saturday, August 17, 2019

Ten-Session CBT Proposed

Vol. 30 / No. 4  
A shorter period of CBT might reduce costs and make treatment available to more patients.
During a plenary session at the 2019 ICED meeting in New York in March, Glenn Waller, DPhil, of the Department of Psychology at the University of Sheffield, Sheffield, UK, described a 10-session cognitive behavioral therapy (CBT-T) program that he and his  colleagues have recently developed.
Dr. Waller pointed to the ICED conference theme, “Start Spreading the News,” and asked where the news is coming from and where is it going. “We should be listening,” he said.  “We have effective but not perfect therapies; these could be better,” he added. Dr. Waller and colleagues have developed a shortened form of CBT that is showing early promise. He added some key (and perhaps provocative) points contrasting traditional psychotherapy and CBT-T:
  1. More therapy does not make for a better outcome, according to Dr. Waller. He said, “Typically, if we do wait for patients to spring into action in bulimia nervosa, the number of sessions is usually a mean of 45. This is twice the recommended number of sessions.”
  2. Manuals improve outcomes but many clinicians don’t even pick them up; “we still rely on osmosis,” he said.
  3. Therapists don’t need specific training for a specific disorder.
  4. Most therapists are over-trained for what they do.
  5. If he had his choice, Dr. Waller said, he would develop treatment models that don’t rely on over-trained, overly expensive therapists. More therapy doesn’t make for better outcomes, he added.
Dr. Waller said that CBT-T began as a result of many frustrations, especially from poor attention to patient outcomes.  One of the questions his group and others have had to face was how to get patients into therapy quickly and effectively. A faster turnover was needed to deal with resource limitations, where lengthy waiting lists keep people from receiving needed treatment.
To test the efficacy of CBT-T, Dr. Waller and colleagues recently treated 93 non-underweight adult eating disorder patients. These patients received a protocolized 10-session program of CBT, which was delivered by clinical assistants, under supervision (Int J Eat Disord. 2018; 51:262).  By the end of their therapy 31% of the patients had dropped out. Statistically significant changes in EDE-Q Global and subscale scores as well as ED behaviors were seen at the end of treatment and at a three-month follow-up.  The authors note the magnitude of change was in the range seen in studies of more traditional CBT approaches. (More recently, Pellizer, Waller, and Wade [Eur ED Rev,2019, epub ahead of publication] reported a second trial of 52 individuals treated by 6 different trainees, with similarly encouraging results.)
Dr. Waller and his colleagues were pleased to find that the shorter-term CBT showed similar efficacy as that reported in larger, separate studies of longer-term therapy, and it could mean reduced patient costs and improved access to care. He added, “We initially thought that shorter treatment would not be as effective, but patient experiences were generally very good. Briefer therapy can work just as well as longer therapy. Now we have to transmit the news: we as clinicians can be more treatment-resistant than patients are, and we need to spread the news to patients and others that briefer treatment is better.”
These results should prompt discussion and perhaps reconsideration of treatment models for eating disorders. Can some therapies be shorter? Which individuals might benefit, and which need longer treatment?  And, finally, while short-term outcomes are encouraging, is long-term outcome similarly positive?

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