A Transdiagnostic Approach to Treating Eating Disorders

By Rebecca Berman, LCSW-C, CEDS, MLSP

Eating disorders are complex mental illnesses that require specialized treatment provided by a skilled multidisciplinary team. As clinical trends indicate that our clients become more complex, our treatment must face the challenge of addressing the many facets of their clinical presentation. An additional challenge is that despite the demonstrated benefits, evidence-based treatments are rarely used in routine clinical practice (Gyani, Shafran, Myles, & Rose, 2014). This problem, called the research-practice gap, refers to the phenomenon in which psychotherapy treatments that show efficacy in the laboratory or academic setting fail to be adequately disseminated and implemented by clinicians in the real world.

The vast majority of eating disorder clinicians and treatment programs do not report using evidence-based practices in their work with clients (Attia, Marcus, Walsh, & Guarda, 2017; Cooper & Bailey-Straebler, 2015; Mulkens, de Vos, de Graaff, & Waller, 2018; von Ranson, Wallace, & Stevenson, 2013). As the number of individuals with eating disorders across a diverse range of demographics continues to increase, clinicians must increase their awareness of and competence in treatment approaches that demonstrate efficacy in promoting life-sustaining change for individuals with eating disorders (Goode, 2016; Kazdin, Fitzsimmons‐Craft, & Wilfley, 2017). Identifying an achievable solution to the research practice-gap has been an ongoing struggle throughout the fields of medical and behavioral health, and the field of eating disorders is no exception.

Unified Treatment Model
David Barlow, PhD, a longtime researcher and academic specializing in anxiety disorders, recognized this gap and developed The Unified Protocol (UP) for Transdiagnostic Treatment of Emotional Disorders. The UP (Barlow et al., 2011) is a modular, emotion-focused treatment designed to be applicable to mental health conditions that involve a prominent emotion component (e.g., mood, anxiety, personality, and eating disorders). Barlow observed that while there are many manuals for single disorders, most clients do not have just one problem. The UP distills and incorporates key principles of existing evidence-based treatments and emotion science. Through extensive meta-analysis and multifactorial analysis, Barlow’s team was able to identify the most potent and overlapping principles of evidence-based treatments, such as cognitive behavioral therapy, exposure therapy, dialectical behavioral therapy, acceptance and commitment therapy, and motivational interviewing. The UP is designed to address the core, underlying mechanisms of common emotional disorders, and is offered as an alternative to the myriad treatment approaches and manuals for specific disorders.

In 2012, The Renfrew Center, an eating disorder treatment center for women, approached Barlow regarding collaboration by which Renfrew’s existing relational cultural-feminist model would be adapted and integrated into Barlow’s UP. This adaptation came to be known as the Renfrew Unified Treatment (UT) Model for Eating Disorders and was fully implemented across the Renfrew network by the end of 2015. The UT is designed to treat the whole person, addressing both the eating disorder and comorbid symptoms by explicitly targeting core underlying maintaining mechanisms of emotional dysregulation, intolerance, and experiential avoidance. Similarly to the UP, the UT—which is applied more specifically to eating disorders—is a transdiagnostic model. A transdiagnostic approach is ideal in the treatment of eating disorders, as it recognizes the complexity of this population. A transdiagnostic approach cuts across DSM-5 disorders, and targets core mechanisms, not specific disorders, while providing a unifying case conceptualization to the treatment of complex clients. Additionally, working with one set of therapeutic principles is comprehensive and effective, is able to address comorbidity as well as subthreshold symptoms, is more efficient for training clinicians, and is easier for clients to understand.

One hallmark of the UT is that it conceptualizes eating disorders as emotional disorders. Individuals with emotional disorders experience negative affect more intensely and more frequently than the general population, view these emotional experiences as unwanted and intolerable, and use maladaptive emotion regulation strategies (attempts to avoid or dampen the intensity of uncomfortable emotion) to cope. The maladaptive strategies ultimately backfire and contribute to the maintenance of symptoms (e.g., eating disorder symptoms, substance use, and self-harm) and interpersonal disconnection. Those with emotional disorders become experientially avoidant, meaning their drive to avoid negative emotional experiences may be evident in avoidance of situations, physical sensations, memories, and emotions that make them feel badly. The experiential avoidance has been found to be a key maintaining factor for many psychiatric illnesses.

Cyclical Patterns, Transitory Relief
We have come to learn that diverse symptoms function similarly and continue in a cyclical pattern. The individual experiences an unpleasant internal experience, which leads to emotional avoidance and unwillingness to have the emotion, resulting in avoidant and/or symptomatic behavior, and ultimately—albeit quite temporarily—relief from the unpleasant internal experience. Unfortunately, long-term consequences ensue. Despite the severity of these long-term consequences to eating disorder symptoms, the temporary relief that is experienced is often enough to keep the individual stuck in the cycle. When individuals use symptomatic behaviors or, more precisely put, emotion-driven behaviors, the client is not building emotional tolerance. They are, in fact, further linking the connection in their brain and body to experience emotion and then aversively react by avoiding situations, places, things, and people to circumvent the emotion. This pattern of avoidance greatly restricts both their internal and external world. A patient who turns away from unpleasant internal states by using eating disorder behaviors will enjoy transitory relief, but will have reinforced the association between distress and this avoidant action in the future. Additionally, the more a person acts on impulses to avoid difficult thoughts and emotions, the stronger and more destructive these impulses become. For example, clients may be avoiding stress at school or work by focusing on exercising excessively and rigidly controlling their food intake, as body size may be viewed as controllable, whereas stress at school or work may not.

The UT is a transdiagnostic model that treats eating disorders and co-occurring disorders; recovery requires experiential challenge (doing things that have been habitually avoided) and reducing avoidance strategies.

Goals of the UT
Goals of the UT include the following:

• to restore physical and emotional health and heal relational disconnection by understanding and dealing with the emotions that drive disorders and learning to experience emotions without symptoms;

• to develop greater awareness of emotions as they occur—particularly their function and the interactions between physical sensations, thoughts, and behaviors;

• to explore underlying core appraisals while increasing cognitive flexibility;

• to practice applying skills in response to emotional experiences as they occur; and

• to do difficult things without depending on typical avoidance strategies/eating disorder behaviors to cope, which leads to sustainable change.

Clients coming into treatment for an eating disorder require a full comprehensive evaluation to assess medical risk, motivation, the impact of the eating disorder on daily life and relationships, other co-occurring disorders, frequency of symptom use, and ultimately the appropriate level of care. Once in treatment, it is important that clients begin by learning the function of their emotions. Clients with eating disorders and other mood disorders have spent much of their energy trying to avoid or decrease the intensity of their emotions. Many clients do not see the point of emotions at all, as they feel out of control, unsafe, or destabilizing. Clients are taught that no actual emotion is unsafe. While memories of bad things that happened may “feel” unsafe, and what an individual does in reaction to the emotion may be unsafe, the emotion itself is not unsafe. All emotions are actually good and have an adaptive function—even the “bad” or uncomfortable emotions. Clients learn that it can be appropriate and safe to feel sad, anxious, scared, or angry, because those feelings can prompt necessary responses and actions.

Final Thoughts
The purpose of clients participating in client-driven emotional exposures is not merely to accomplish the identified challenge or “cross it off the list.” The purpose is to build emotional tolerance and confidence in themselves that they can do other things that are similarly as difficult, because they have mastered the ability to experience the emotion without avoiding it or decreasing it. Research has shown that Renfrew’s UT Model is preferable to treatment provided in the “treatment as usual” (TAU) condition prior to the implementation of the UT. Studies on the effect of implementation on experiential avoidance outcomes have shown that clients make greater improvements during treatment, as compared with TAU, and continue to improve after discharge. The data also indicate that patients continue to demonstrate an improvement or decrease in depressive symptoms following discharge. Finally, patients were found to maintain the gains they made in treatment on their eating disorder symptomatology after discharge during six-month follow-up (Thompson-Brenner, Boswell, Espel, Brooks, & Lowe, 2018). The treatment provided using the UT model creates an opportunity for clients to experience long-term sustainable change and leave treatment knowing they can do the hard things.

— Rebecca Berman, LCSW-C, CEDS, MLSP, is a clinical training specialist at The Renfrew Center. She specializes in treating eating disorders, self-injurious behavior, and trauma. Berman has presented nationally on the transdiagnostic treatment of eating disorders and the treatment of trauma and eating disorders.

References
Attia, E., Marcus, M. D., Walsh, B. T., & Guarda, A. S. (2017). The need for consistent outcome measures in eating disorder treatment programs: A proposal for the field. International Journal of Eating Disorders, 50(3), 231-234.

Barlow, D., Farchione, T., Fairholme, C., Ellard, K., Boisseau, C., Allen, L. & Ehrenreich-May, J. (2011). Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide. New York: Oxford University Press.

Cooper, Z., & Bailey-Straebler, S. (2015). Disseminating evidence-based psychological treatments for eating disorders. Current Psychiatry Reports, 17(3), 12.

Goode, E. (2016, March 15). Centers to treat eating disorders are growing, and raising concerns. The New York Times. Retrieved from http://www.nytimes.com/2016/03/15/health/eating-disorders-anorexia-bulimia-treatment-centers.html

Gyani, A., Shafran, R., Myles, P., & Rose, S. (2014). The gap between science and practice: How therapists make their clinical decisions. Behavior Therapy, 45(2), 199-211.

Kazdin, A. E., Fitzsimmons‐Craft, E. E., & Wilfley, D. E. (2017). Addressing critical gaps in the treatment of eating disorders. International Journal of Eating Disorders, 50(3), 170-189.

Mulkens, S., de Vos, C., de Graaff, A., & Waller, G. (2018). To deliver or not to deliver cognitive behavioral therapy for eating disorders: Replication and extension of our understanding of why therapists fail to do what they should do. Behaviour Research and Therapy, 10(6), 57-63.

Thompson-Brenner, H., Boswell, J. F., Espel, H. M., Brooks, G. E., Lowe, M. R. (2018). Implementation of a transdiagnostic treatment for emotional disorders in residential eating disorder programs: A preliminary evaluation. Psychotherapy Research. doi: 10.1080/10503307.2018.1446563.

von Ranson, K. M., Wallace, L. M., Stevenson, A. (2013). Psychotherapies provided for eating disorders by community clinicians: Infrequent use of evidence-based treatment. Psychotherapy Research, 23(3), 333-343.