Treatment Options
When considering treatment approaches for an eating disorder, it is important to understand that different people respond to different treatment approaches. Treatment type and the setting in which the treatment is provided should be matched according to the type of eating disorder, the severity of the problem and the person’s goals, values and readiness for change.
Treatment Settings and Levels of Intensity
Treatment for an eating disorder can take place within a variety of settings across outpatient, inpatient, residential or day programs, and involves a multidisciplinary team of providers. The treatment team at a minimum would comprise a mental health professional and a medical practitioner, and dietitians, other health professionals, and recovery support professionals may also be involved.
Treatment options for people experiencing an eating disorder within Australia include both private and public options.
Outpatient Treatment
Eating disorder treatment can usually be provided on an outpatient basis. Outpatient treatment is treatment that takes place within a setting that does not involve an overnight stay. Typically, outpatient care involves visiting the hospital, treatment centre, or treatment provider’s clinic for appointments at a frequency required for the person.
The evidence-based outpatient treatments listed below have been found to be effective for eating disorders. There is also evidence for the effectiveness of some of these treatments in higher levels of care, such as in residential, day program and inpatient care.
Outpatient Psychological Treatments
Psychological therapies are shown to have the greatest impact on eating disorder symptom reduction and other outcomes. Several outpatient psychological therapies have been identified as effective first-line treatments for eating disorders. Psychological therapy is provided as part of a multidisciplinary care approach in combination with medical and nutritional management and recovery-based supports, and as much as possible, involves the person’s family, carers, and supports.
The treatments outlined below sit within a broader evidence-based approach to safe and effective care for eating disorders. For an overview, please see the ANZAED eating disorder treatment principles and general clinical practice and training standards and the ANZAED practice and training standards for mental health professionals providing eating disorder treatment.
Enhanced Cognitive Behavioural Therapy (CBT-E)
What is CBT-E?
Enhanced Cognitive Behavioural Therapy – Enhanced (CBT-E) (1) is a manualised psychological treatment that is “transdiagnostic”. This means that it is designed to address the key features of anorexia nervosa, bulimia nervosa, binge eating disorders and other specified feeding and eating disorders. CBT-E focuses on addressing the characteristic disruptions in eating habits and attitudes to shape and weight that keep an eating disorder in place.
CBT-E has four stages, beginning with developing a mutual understanding of the person’s eating problem and helping them modify and stabilise their pattern of eating. CBT-E is individualised in that the therapist creates a specific version of CBT-E to match the exact eating problem the person receiving treatment is experiencing. Targets of the treatment include personalised education, addressing concerns about body shape, weight and eating; enhancing the ability to deal with day-to-day events and moods; and addressing dietary restraint. CBT-E ends with a focus on dealing with setbacks and maintaining the changes that have been obtained.
A detailed treatment guide is available (1).
What are the intended outcomes of CBT-E?
CBT-E supports individuals to decide and take action to reduce eating disorder behaviours and unhelpful beliefs related to control of body weight, shape and eating. psychopathology. Where indicated, weight gain is an important outcome. CBT-E also aims to equip people with the skills to self-manage and maintain recovery, including identifying and responding to lapses.
How long could CBT-E treatment take?
With people who are not significantly underweight, CBT-E generally involves an initial assessment appointment followed by 20 50-minute treatment sessions over 20 weeks. With people who are underweight treatment needs to be longer, often involving about 40 sessions over 40 weeks.
Who it is for?
CBT-E is a leading evidence-based psychological treatment for adults (18+) with moderate to severe:
- Anorexia Nervosa (AN)
- Bulimia Nervosa (BN)
- Binge Eating Disorder (BED)
- Other Specified Feeding and Eating Disorders (OSFED) (2)
While there have been limited studies on CBT-E efficacy in young people, there is some evidence for the efficacy of CBT-E with family support for older adolescents. (3)
Who can deliver CBT-E?
Evidence-based outpatient therapies delivered by an eating disorders-informed clinician are considered most efficacious (4). Thus, CBT-E should be delivered by a mental health clinician who has completed introductory eating disorders training and approved training in CBT-E with ongoing supervision in CBT-E.
Note: Other evidence-based CBT treatments for eating disorders exist in addition to CBT-E. For a review, see here (5).
Cognitive Behavioural Therapy-Guided Self Help (CBT-GSH)
What is CBT-GSH?
CBT-Guided Self Help (GSH) is a lower-intensity, manualised treatment by which a person experiencing a mild to moderate presentations of Bulimia Nervosa (BN), Binge Eating Disorder (BED), and disordered eating is guided by a health professional through self-help program materials. It is a highly structured, client-centred intervention based on the principles of Cognitive Behavioural Therapy (CBT). CBT-GSH supports the person to change unhelpful thinking patterns and behaviours that are maintaining the disordered eating or eating disorder, to maintain these changes and better manage challenges now and in the future.
What are the intended outcomes of CBT-GSH?
CBT-GSH intends to support people to move to a regular, healthy eating pattern, and to reduce or cease eating problems including restriction, binge eating and/or compensatory behaviours.
Who is CBT-GSH for?
In eating disorders, CBT-GSH is recommended as a first line, evidenced-based psychological intervention with a goal to restore normal eating habits for adults (18+) experiencing mild to moderate presentations of:
- Bulimia Nervosa
- Binge Eating Disorder
- Disordered Eating (with binge-type features)
While there have been limited studies on CBT-GSH efficacy in young people (6), for older adolescents experiencing mild to moderate BED, BN or disordered eating it is a worthwhile first-line treatment option to consider offering alongside family involvement and support.
Who can deliver CBT-GSH?
Health professionals who are familiar with the treatment program and have ideally completed training can deliver CBT-GSH.
How long could CBT-GSH take?
The program takes approximately 10 to 20 sessions to complete. Sessions can be delivered face-to-face or online; weekly or fortnightly; and completed in 25-50 minutes per session. Sessions should be adjusted to suit the individual’s treatment plan and progress, and are likely to be more intensive at the beginning
For a further overview of CBT-GSH, including treatment manuals see this NEDC Fact Sheet here.
Family Based Treatment (FBT)
What is FBT?
Family Based Treatment (FBT) (7) for eating disorders is commonly known as The Maudsley Model and is used to treat adolescents with Anorexia. Family treatment has also been adapted for young people with bulimia nervosa and is the first line treatment for this group (FT-BN). FBT is a manualised treatment that aims to empower the family, namely the parents, to bring about recovery in their child with an eating disorder within their home environment.
FBT for Anorexia is highly structured and consists of three phases:
Phase one focuses on nutritional and weight restoration. Parents are charged with the responsibility of refeeding their child and containing eating disorder behaviours. The clinician coaches parents to manage problematic eating disorder behaviours and brainstorm barriers to refeeding.
Phase two Focuses on returning control of eating to the adolescent. Parents gradually hand back control of eating to the young person whilst managing any lapses. Family issues and relationships are simultaneously addressed as the focus slowly moves away from weight and food.
Phase three addresses adolescent issues and treatment completion. The final stage assumes that the young person is weight restored and in control of their eating behaviours. The focus is on addressing normal adolescent issues and strengthening a sense of identity without the eating disorder. (8)
What are the intended outcomes of FBT?
FBT intends to equip parents to restore their child’s weight to normal levels expected based on developmental predictions of the young person’s age and height; hand the control over eating back to the young person, and; encourage normal development for their age.
Who it is for?
FBT is suitable for young people under the age of 19 who have been experiencing an eating disorder for three years or less. FBT has demonstrated efficacy for children and young people with:
– Anorexia Nervosa (AN)
– Bulimia-nervosa-focused family therapy (FT-BN) is recommended as the first line treatment for bulimia nervosa in children and young people
Who can deliver FBT?
Evidence-based outpatient therapies delivered by an eating disorders-informed clinician are considered most efficacious (4). Thus, FBT should be delivered by a mental health clinician who has completed introductory eating disorders training and approved training in FBT with ongoing supervision in FBT.
How long could FBT treatment take?
FBT treatment typically occurs over a 12-month period, although treatment time varies and is dependent upon progression through each of the three stages.
Specialist Supportive Clinical Management (SSCM)
What is SSCM?
Specialist Supportive Clinical Management (SSCM) has demonstrated effectiveness as an outpatient psychological treatment for adults with anorexia nervosa (9). SSCM combines two therapeutic components; clinical management which prioritises the establishment of normal eating and weight restoration, and provides targeted psycho-education and advice about eating disorders, eating and weight/shape concerns; and supportive psychotherapy which allows the person and their therapist to respond to other life issues that are important to the person, including those that may impact upon the eating disorder.
SSCM moves through three overlapping phases; firstly focusing on identifying symptoms, agreeing on goal weight and providing a personalised formulation supported by psychoeducation, then on nutritional education with a focus on the person’s physical state alongside supportive therapy, and finally on finishing up treatment, setting goals for the future and planning to maintain gains.
What are the intended outcomes of SSCM?
SSCM intends to support people across two broad aims; to help them establish a link between their symptoms and their eating behaviour and weight, and to support them in a gradual return to normal eating and weight restoration.
Who can deliver SSCM?
Evidence-based outpatient therapies delivered by an eating disorders-informed clinician are considered most efficacious (4). Thus, SSCM should be delivered by a mental health clinician who has completed introductory eating disorders training and approved training in SSCM with ongoing supervision in SSCM.
SSCM builds on the existing core skills and strengths of mental health clinicians of clinical management and supportive psychotherapy to equip general mental health clinicians to apply their core skills to working with clients experiencing eating disorders.
How long could SSCM treatment take?
SSCM is typically delivered over 20-30 once-weekly individual therapy sessions depending on symptom severity, and four monthly follow-up sessions.
Who it is for?
SSCM is more suited to people who want a flexible approach, where they are free to create their own agenda and talk through issues that they are already aware of. It may be most useful for people who have engaged with a number of therapeutic approaches before with little success, who have co-occurring mental or psychosocial difficulties, or who are less motivated to engage in an active therapeutic process. SSCM has demonstrated efficacy for adults (>18) with:
– Anorexia Nervosa (AN)
A therapist manual (McIntosh et al., unpublished) is available with detailed psycho-educational handouts.
Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA)
What is MANTRA?
The Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) is an empirically based cognitive-interpersonal treatment which has demonstrated effectiveness as an outpatient psychological treatment for adults with anorexia nervosa.
MANTRA aims to address the cognitive, emotional, relational and biological factors which tend to maintain AN by working out what keeps people stuck in their anorexia, and gradually helping them to find alternative and more adaptive ways of coping. Which modules and factors are addressed in treatment depends on individual needs and preferences.
What are the intended outcomes of MANTRA?
MANTRA intends to support people to develop better ways of coping and overcoming difficulties with emotional processing, relationships, unhelpful thinking styles and identity.
Who can deliver MANTRA?
Evidence-based outpatient therapies delivered by an eating disorders-informed clinician are considered most efficacious (4). Thus, MANTRA should be delivered by a mental health clinician who has completed introductory eating disorders training and approved training in MANTRA with ongoing supervision in MANTRA.
How long could MANTRA treatment take?
MANTRA consists of seven core modules conducted over 20-40 sessions although a key component of MANTRA is that modules can be worked through at the person’s own pace. This means that clinicians tend not to be too specific about how long a person will be in therapy, and instead will be led by a client’s needs and preferences. (10)
Who it is for?
MANTRA is generally recommended for people who report an extremely rigid thinking style, positive beliefs about their anorexia, and either no support network or a support network that does not always feel helpful to the client. MANTRA is an evidence-based treatment that was specifically developed for adults with
– Anorexia Nervosa (AN)
Dialectical Behaviour Therapy for Eating Disorders (DBT-ED)
What is DBT-ED?
DBT for Binge Eating and Bulimia (DBT-ED) is a treatment based on an emotion dysregulation model of problem eating, meaning that binge eating occurs in part as a way to cope with difficult emotions. Comprehensive DBT-ED treatment comprises both weekly group therapy “skills training” in which the large package of DBT skills are systematically taught, and weekly individual therapy in which daily difficulties are examined and the transfer of newly acquired skills to daily life situations is facilitated.
Treatment includes addressing any behaviour that interferes with treatment, addressing ways to reduce and eventually cease binge eating, reducing challenges in “giving up” as a pathway to binge eating and, lastly, targeting behaviours that seem irrelevant but that actually contribute to ongoing binge eating. The treatment involves the development of skills in mindfulness (a non-judgmental, receptive mind state in which one observes thoughts and feelings as they are), emotion regulation (the ability to exert control over one’s own emotional state), and distress tolerance (the ability to manage distress skilfully).
What are the intended outcomes of DBT-ED?
DBT-ED intends to support the person to live a rich and meaningful life by assisting them to learn and practice methods of “adaptive” affect regulation that may replace their current “maladaptive” binge-eating strategy.
Who can deliver DBT-ED?
Evidence-based outpatient therapies delivered by an eating disorders-informed clinician are considered most efficacious (4). Thus, DBT-ED should be delivered by a mental health clinician who has completed introductory eating disorders training and approved training in DBT-ED with ongoing supervision in DBT-ED. Furthermore, comprehensive individual DBT treatment also comprises a skills-based group component, for which facilitators should also be suitably trained.
How long could DBT-ED treatment take?
DBT-ED is undertaken via a 20-session format. Comprehensive DBT includes both weekly group therapy “skills training” in which DBT skills are systematically taught, and weekly individual therapy in which daily difficulties are examined and the transfer of newly acquired skills to daily life situations is facilitated.
Who it is for?
DBT-ED was developed for people experiencing binge-type eating disorders, and particularly those for whom emotion regulation was a key challenge. It has evidence as an effective treatment for adults (>18) with
- Bulimia Nervosa (BN)
- Binge Eating Disorder (BED)
- Other Specified Feeding and Eating Disorders with Binge features
Interpersonal Psychotherapy for Eating Disorders (IPT-ED)
What is IPT-ED?
Interpersonal Psychotherapy for Eating Disorders (IPT-ED) is an evidence-based manualised, structured and time-limited treatment for adults with Bulimia Nervosa. IPT-ED is underpinned by the theory that how you relate to others impacts your emotional and mental health, and thus eating disorder symptoms.
IPT-ED supports the person to develop a formulation which links interpersonal problems and eating disorder symptoms. The treatment then works to help the person to systematically identify and resolve key relationship-based maintaining factors with the aim of resolving eating disorder symptoms. Key interventions include learning to better handle conflict, loss, transition and relational difficulties. (11)
What are the intended outcomes of IPT-ED?
IPT-ED intends to assist the person to establish a sense of themselves as embedded within an accepting, supporting, and respecting social context that provides a viable alternative to the eating disorder in seeking positive esteem and emotional wellbeing.
Who can deliver IPT-ED?
Evidence-based outpatient therapies delivered by an eating disorders-informed clinician are considered most efficacious (4). Thus, IPT-ED should be delivered by a mental health clinician who has completed introductory eating disorders training and approved training in IPT-ED with ongoing supervision in IPT-ED.
How long could IPT-ED treatment take?
IPT-ED is typically implemented as a time-limited treatment, consisting of 12 to 20 sessions spanning four to six months. (11)
Who it is for?
IPT-ED has demonstrated efficacy as a viable alternative to cognitive-behavioral therapy for adults (>18) for the treatment of:
- Bulimia Nervosa (BN)
- Binge Eating Disorder (BED) (12)
Adolescent-Focused Therapy (AFT)
What is AFT?
Adolescent-focused therapy is an individual psychotherapy for teenagers suffering from anorexia, and is recommended as a second-line alternative to family-based treatment (FBT) (13). AFT consists of three phases of treatment spread across approximately one year and focuses on the young person’s ability to change their own behaviours with the support of the family and therapist.
The young person is supported to find more adaptive coping strategies, manage difficult emotions, and develop greater autonomy and a stronger sense of self, while reducing risky behaviours and restoring weight.
What are the intended outcomes of AFT?
AFT intends to support the young person to develop alternate coping skills and reduce eating disorder behaviours, and to engage and educate parents about anorexia in order to play a major supportive role.
Who can deliver AFT?
Evidence-based outpatient therapies delivered by an eating disorders-informed clinician are considered most efficacious (4). Thus, AFT should be delivered by a mental health clinician who has completed introductory eating disorders training and approved training in AFT with ongoing supervision in AFT.
How long could AFT treatment take?
AFT typically consist of 32 to 40 individual sessions over 12 to 18 months, with:
- more regular sessions early on, to help the person build a relationship with the practitioner and motivate them to change their behaviour
- 8 to 12 additional family sessions with the person and their parents or carers (as appropriate)
Who it is for?
AFT has demonstrated efficacy as a viable alternative to FBT for children or young people (<18) with:
- Anorexia nervosa (AN) (14)
The complete manual “Adolescent-Focused Therapy for Anorexia Nervosa: A Developmental Approach” can be found here (15).
Focal-Dynamic Psychotherapy
What is Focal-Dynamic Psychotherapy?
Focal-Dynamic Psychotherapy is a psychodynamic-oriented individual treatment with an evidence base for adults with Anorexia Nervosa. The program is divided into three phases (initial, middle, closure), with treatment centred around specific areas as determined from an initial interview. Intervention is based on addressing often largely unconscious symptomatic, maladaptive relationship patterns, central life-threatening conflict themes, and challenges related to the “structure” or aspects of personality.
Focal-dynamic psychotherapy involves a clear treatment agreement that includes weight parameters, meal structure, and accompanying medical examinations.
What are the intended outcomes of Focal-Dynamic Psychotherapy?
Focal-Dynamic Psychotherapy intends to support people to reduce eating disorder symptoms and re-establish autonomy and personal responsibility through addressing eating-disorder related beliefs, self-esteem issues and depression, as well as body image and working with the family.
Who can deliver Focal-Dynamic Psychotherapy?
Evidence-based outpatient therapies delivered by an eating disorders-informed clinician are considered most efficacious (4). Thus, Focal-Dynamic Psychotherapy should be delivered by a mental health clinician who has completed introductory eating disorders training and approved training in Focal-Dynamic Psychotherapy with ongoing supervision in Focal-Dynamic Psychotherapy. Additionally, treatment focus in Focal-Dynamic Psychotherapy is determined by results from the Operationalized Psychodynamic Diagnosis system (which the therapist must be trained and certified to use).
How long could Focal-Dynamic Psychotherapy treatment take?
Focal-dynamic psychotherapy progresses as the identified areas of challenge (foci) change and resolve, over approximately 40 to 50 sessions.
Who it is for?
Focal dynamic psychotherapy has evidence demonstrating efficacy in adults (>18) with:
- Anorexia Nervosa (AN) (16)
A full treatment manual can be found here. (17)
Outpatient Nutritional Management
Outpatient nutritional management for eating disorders is a specific nutritional approach to the treatment of eating disorders which aims to assist individuals to achieve recovery from an eating disorder and ensures accurate nutrition advice is delivered. Nutritional management is not a standalone intervention, rather it is provided as part of a multidisciplinary care approach in combination with psychological treatment, medical management and recovery-based supports.
Eating Disorders Nutrition Care
What is nutrition care?
Nutrition care is a service that nutrition and dietetics practitioners deliver. Nutrition care for people experiencing eating disorders involves eating disorder-specific nutrition assessment, diagnosis, intervention, monitoring, and evaluation. Nutrition care can play a pivotal role in treatment and sits alongside mental health and medical treatment for eating disorders.
What are the intended outcomes of Eating Disorders Nutrition Care?
Nutrition care aims to help individuals with eating disorders and their families understand the interaction between food, nutrition, and wellbeing, as well as support eating behaviours that align with their treatment and recovery goals.
Who can deliver Eating Disorders Nutrition Care?
Nutrition care is provided by nutrition and dietetics professionals as part of multidisciplinary care for an eating disorder and should be underpinned by best dietetic practice in the treatment of individuals with an eating disorder (18). Nutrition care for people experiencing eating disorders should be delivered by a nutrition and dietetics professional who has completed introductory eating disorders training and approved training in dietetic practice for eating disorders, alongside ongoing professional supervision in the area.
How long could Eating Disorders Nutrition Care take?
Eating disorders nutrition care is guided by the individual’s eating and nutrition-related goals and needs. This means that clinicians tend not to be too specific about how long nutrition care will take, and instead will be led by the person’s needs and preferences. Individuals may access nutrition care for brief, focused treatment, or for more ongoing support.
Who it is for?
Nutrition care may be relevant for all people experiencing eating disorders as part of a multidisciplinary care team approach.
Outpatient Medical Management
In contrast to psychological care, there have been fewer advances in pharmacological treatments for eating disorders. There is no standalone medication for the treatment of eating disorders and any medication is provided as part of a multidisciplinary care approach in combination with psychological therapy, nutritional management and recovery-based supports.
Medication
Psychological therapies are shown to have the greatest impact on eating disorder symptom reduction and other outcomes. Current evidence suggests that psychiatric medications should not be offered as the sole treatment for any eating disorder.
Medication may be indicated as an adjunct to psychological therapy where there is a co-occurring mental health condition, such as depression, anxiety, insomnia or psychosis which impacts upon the person’s wellbeing and ability to engage in treatment for their eating disorder.
Anorexia Nervosa (AN):
- Evidence for the effectiveness of psychotropic medications for anorexia nervosa are mixed.
- There is currently no empirically supported medication for the sole treatment of AN.
Bulimia Nervosa (BN)
- There are several trials supporting agents for the treatment of BN including topiramate and lisdexamfetamine but not as standalone treatments, and must be prescribed and used under specialist psychiatrist management.
- There is currently no empirically supported medication for the sole treatment of AN.
Binge Eating Disorder (BED)
- There are several trials supporting agents for the treatment of BED including selective serotonin reuptake inhibitors and lisdexamfetamine but not as standalone treatments, and must be prescribed and used under specialist psychiatrist management.
Medication-based approaches are often vital when a person with an eating disorder also has another type of disorder or illness, such as depression, anxiety, insomnia or psychosis. This is known as a comorbid or co-occurring disorder.
Medications can be discussed and prescribed by psychiatrists, GPs or other medical doctors and should only be used in conjunction with another treatment approach.
References
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