It seems to be a truth almost universally acknowledged that the combination of a pandemic and a lockdown may have negative consequences for mental health (Holmes 2020, BBC News website). Eating disorders tend not to be the first mental illness people remember (despite their mortality rate of up to 6%) (Arcelus, 2011), but the eating disorder charity BEAT reports call rates up 35% since lockdown began (BEAT website) and the experts are concerned (Touyz, 2020).
One of the mainstays of NICE-recommended, evidence-based treatments for eating disorders in adults is CBT-E (Enhanced Cognitive Behavioural Therapy) (CBTE). Some of its originators and trainers have written a guide for clinicians on its use in the current COVID-19 situation.
This is a descriptive update on delivering CBT-E online during COVID-19.
The authors acknowledge a lack of evidence for using CBT-E remotely, but hope it will be possible to develop a therapeutic relationship as you would “in real life”, and suggest it is better than phone only. They skirt the vexing question of which software to use, though they highlight the need to consider safety and confidentiality; different healthcare providers will likely have guidance for their own clinicians to follow.
Adapting CBT-E for online delivery and during COVID
The authors talk therapists step-by-step through the CBT-E manual. They acknowledge the challenges of COVID, including that with one’s world suddenly smaller, and possibly feeling more out of control, it may be harder to shift focus away from concerns about weight and shape. But, like the rainbows springing up in windows across the country, the authors are keen to positively re-frame. Possible barriers of lacking time to eat, or focus fully on treatment, may have gone. Lack of access to “safe” foods could be a chance to try out new foods. Videoconferencing may be an opportunity to build up tolerance to seeing your own face (though they also note that you can turn off this feature in some software).
They advise beginning with a medical assessment of risk, to make sure that remote CBT-E is safe and appropriate given the patient’s physical and mental state, but suggest that this needs to be balanced against the currently heightened risks of inpatient admission. Practical challenges around sharing formulations and enabling self-monitoring are considered pragmatically. There is detailed advice about in-therapy weighing: ideally the patient can bring their device to the scales so they can be supported immediately post-weighing; the therapist will continue to plot the readings; the sudden move from using the therapist’s scales to the patient’s scales provides an opportunity to practice thinking more flexibly about the margin of error.
There are suggestions about supporting patients to manage meal planning when at home all the time and buying in bulk rather than day by day: for example, cooking and portioning up meals at a time of day when binges are less likely; freezing food, or putting food in less accessible places, to make binges less easy; planning a day structure with things to do between meals. Sharing meal-times virtually may offer useful support for those living alone.
The authors conclude that offering CBT-E online may be a useful intervention in the current COVID lockdown situation.
For more information about delivering online psychotherapy during the pandemic, please read Liesbeth Tip’s Mental Elf blog from earlier this week: Guidance for online therapy during COVID-19.
Strengths and limitations
This is a very useful document on how to adapt CBT-E for the current global situation. The authors acknowledge that there is no evidence for delivering CBT-E online, but they have written a pragmatic, positive and responsive guideline.
Of course, as many of us are currently discovering, videoconference is not the same as real life. In many ways it feels more tiring; maybe because connections drop, audio and visual quality varies enormously, we miss cues from body language and it can be hard to know when it’s your turn to speak. Not everyone has access to fast Wifi and excellent internet-enabled devices. I hope the guidelines’ authors, and others, are researching whether delivering CBT-E online does work, for whom and when, so that when we hopefully return to having options about how it is delivered, we can choose wisely.
Implications for practice
Whilst we work to maximise social distancing, and whilst people with eating disorders may be struggling even more than usual, it seems likely that CBT-E via videoconference is better than nothing, and whether you’re delivering or receiving it, these guidelines might be useful.
Statement of interests
Murphy, R., Calugi, S., Cooper, Z., & Dalle Grave, R. (2020). Challenges and Opportunities for CBT-E in light of COVID-19.
Holmes, E. A. et al. (2020) ‘Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science’, The Lancet Psychiatry. doi: 10.1016/S2215-0366(20)30168-1
https://www.bbc.co.uk/news/health-52295894 BBC News, last accessed 27 April 2020
https://www.beateatingdisorders.org.uk/sanctuary BEAT website, last accessed 27 April 2020
Touyz, S., Lacey, H. & Hay, P. Eating disorders in the time of COVID-19. J Eat Disord 8, 19 (2020).
Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality Rates in Patients With Anorexia Nervosa and Other Eating Disorders: A Meta-analysis of 36 Studies. Arch Gen Psychiatry.2011;68(7):724–731. doi:10.1001/archgenpsychiatry.2011.74
https://www.cbte.co; last accessed 27 April 2020