Villa Garda CBT-E Clinical Service for Eating Disorders

Riccardo Dalle Grave, MD

Agenda• Hystory of Villa Garda clinical service• Problems we had in 2002• Why we chose to introduce CBT-E?• How this was done step-by-step?• Adaptations you have had to make to CBT-E?• Difficulties we addressed• Future plans

Villa Garda Eating Disorder Clinical Service

Hystory1984 – 1994• Psychodynamic Psychotherapy with medical/psychiatric management1995– 2002• Generic and broad CBT with medical/psychiatric management2003 – 2008• Transition to CBT-EFrom 2008• CBT-E with patients of all ED diagnosis and age (from 13 years), and in three levels of

care– Outpatient treatment– Intensive outpatient treatment– Inpatient + Day-hospital treatment

Problems we had in 2002

Eclectic and not theory driven treatmentPsychologists• delivered a generic and eclectic form of CBT (4 psychologist – 4 different

treatments!!)Other team members (dietitians, nurses, physicians, and psychiatrists)• maintained a predominantly medical-directive-based approach Patients• were not focused on addressing the core maintaining mechanism of their eating

problem • received contrasting information and different treatment strategies and

procedures• had a different nature of treatment when changed the intensity of care (e.g.,

from outpatient to inpatient and vice versa)

Why we chose to introduce CBT-E

2002 – 2008Transition to CBT-E

Christopher Fairburn presented in Verona the new transdiagnostic cognitive behavior theory and outpatient treatment for all eating disorders

Why we chose to introduce CBT-E

Main reasons1. The transdiagnostic nature of CBT-E is particularly suitable for the inpatient

treatment where patients with different DSM diagnoses are usually admitted2. CBT-E is a flexible and high individualized treatment (liked both by patients and

therapists) addressing the psychopathology (not the DSM diagnosis) of the patients

3. CBT-E involve actively the patients in the treatment and does not use a directive approach that may increase their resistance to change

4. The personal formulation of CBT-E is a potent instrument to integrate the work of a multidisciplinary team

5. The precise method of addressing the eating disorder psychopathology helps to focus the treatment on the core maintaining mechanisms of severe ED patients

6. The ineffectiveness of outpatient CBT-E in some patients may depend on insufficiently intensive care rather than the nature of the treatment itself

How this was done step-by-step

Main Steps1. We discussed the idea of adapting the new CBT-E for inpatient treatment with

Christopher Fairburn2. We designed a completely new inpatient treatment based on the CBT-E theory

and treatment3. We implemented the new treatment in the unit

– Periodic supervisions with Christopher Fairburn– Round table with therapists and patient– Peer supervision

4. We designed and implemented a 3-year randomized control trial– Promising result for a large number of inpatients

Mean BMI and eating disorder psychopathology (global EDE-Q) over 20 weeks of Villa Garda inpatient treatment and 12-month of follow-up

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Completers: CBT-Ef, n=37, 88.1%; CBT-Eb, n=35, 92.1% (p = .550)

Dalle Grave R, Calugi S, Conti M, Doll HA, Fairburn CG. Inpatient cognitive behaviour therapy for anorexia nervosa: A randomized controlled trial. Psychotherapy and Psychosomatics 2013; 82: 390-398.

Villa Garda inpatient cognitive behavior therapy for adolescents with anorexia nervosa: immediate and longer-term effects

Dalle Grave R, Calugi S, El Ghoch M, Conti M, Fairburn CG. Inpatient cognitive behavior therapy for adolescents with anorexia nervosa: immediate and longer-term effects. Frontiers in Psychiatry. 2014;5:14.

83% of patients still had normal weight 1 year after treatment

How this was done step-by-step

Further developments1. We developed intensive outpatient CBT-E

– To offer to patients who were unresponsive to conventional outpatient CBT-E a less expensive treatment than day-hospital or inpatient treatments

2. We developed and adaptation of CBT-E for adolescents

CBT-E for adolescents with anorexia nervosa (N=46)

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Dalle Grave R et al Behaviour Research and Therapy 2013, 51: R9-R12.

Age, years 15.5 (1.3)

Duration of eating disorder, years, 0.86 (0-5)

Body mass index centile 2.86 (3.3)

BMI centile of <1.0. 23 (50%)

Completers: n=29, 63%;

CBT-E for adolescents and adults with anorexia nervosa

Significantly more adolescents reached the goal BMI than adults (65.3% vs. 36.5%; P=0.003).

The time required by the adolescents to restore body weight was about 15 weeks less than that for the adults (mean 14.8 weeks vs. 28.3 weeks, log-rank=21.5, P<0.001).

Calugi S, Dalle Grave R, Sartirana M, Fairburn CG, Journal of Eating Disorders, 2015

Three-quarters of 68 patients completed the full 20 sessions. There was a marked treatment response with two-thirds (67.6%, intent-to-treat) having minimal residual eating disorder psychopathology by the end of treatment.

Difficulties we addressed

Organization• We actively involved the organisation in this change

– Describing the problem of the eclectic treatment– Describing the advantages (clinical and economics)

Collegues attitudes• We actively involved the colleagues in this change

– Group discussion– Extensive training– External supervision with CGF– Peer supervision– Workshops– Inpatient RCT… Two psychologists decided to leave the unit

Difficulties we addressed

Treatment• We gradually eliminated any residual procedures that were inconsistent with

the new CBT-E-based approach –Medical-directive-based approach – Broad and eclectic psychological procedures–Medical unit atmosphere

• We developed new procedures specifically designed for the inpatient CBT-E – Assisted eating– CBT-E groups

• We developed new procedures specifically designed for the adolescent CBT-E – Patients’ engagement– Parents involvement

The Villa Garda Clinical Service

Goals• Providing all patients with an evidence-based treatment (CBT-E), whatever their

ED diagnosis or age, and whether they are outpatients, day patients or inpatients.

• The default is to deliver CBT-E on an outpatient basis (a transdiagnostic evidence-based treatment), but some patients require more intensive treatment (i.e. intensive outpatient or hospitalisation) and these patients embark upon CBT-E while in hospital.

• Whenever possible, they continue with the CBT-E on discharge without any interruption

Villa Garda CBT-E Clinical Service

Advantages1. Patients are treated with a single, well-delivered, evidence-based treatment,

rather than the evidence-free “eclectic” approach common elsewhere2. It minimizes the problems associated with transitions from outpatient to

intensive treatment, as it avoids subjecting patients to the confusing and counterproductive changes in therapeutic approach that commonly accompany such transitions.

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Villa Garda CBT-E Clinical Service

Future1. Collect good outcome data2. Disseminate CBT-E clinical services 3. Developing more potent procedures to address some features of eating

disorder psychopathology

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Why a clinical service based on CBT-E?

Rational• It is a treatment to treat most patients with

– Patients with any ED diagnosis (“transdiagnostic”) – Adults and adolescents – Complex patients– Outpatients, day patients and inpatients

• Liked by patients• Detailed treatment guide• Good evidence base

The treatment guides

Fairburn CG: Cognitive Behaviour Therapy and Eating Disorders.Guilford Press, New York, 2008

Dalle Grave, R. (2012). Intensive Cognitive Behavior Therapy for Eating Disorder. Hauppauge NY, Nova Publisher

Dalle Grave, R. (2013). Multistep Cognitive Behavioral Therapy for Eating Disorders: Theory, Practice, and Clinical Case. Lanham: Jason Aroson

Buona CBT-E da Villa Garda