A Cognitive-Interpersonal Therapy Workbook for Treating Anorexia Nervosa

The Maudsley Model

Ulrike Schmidt, Helen Startup, Janet Treasure

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781317543053
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Based on the authors' pioneering work and up-to-date research at London's Maudsley hospital, A Cognitive Interpersonal Therapy Workbook for Treating Anorexia Nervosa provides adults with anorexia nervosa and the professionals working alongside them with a practical resource to work through together.

The approach described is recommended by the National Institute of Clinical and Care Excellence (NICE) as a first-line, evidence-based treatment for adults with anorexia nervosa. A Cognitive Interpersonal Therapy Workbook for Treating Anorexia Nervosa provides adults with anorexia nervosa and the professionals working alongside them with a practical resource to work through together.

The manual is divided into accessible modules, providing a co-ordinated, step-by-step guide to recovery. Modules include:

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• Nutrition

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• Developing treatment goals

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• Exploring thinking styles

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• Developing an identity beyond anorexia.

A Cognitive Interpersonal Therapy Workbook for Treating Anorexia Nervosa is a highly beneficial aid to recovery for those with the condition, their families and mental health professionals.

Chapter 1

The background to MANTRA

The promises and problems of anorexia

Anorexia nervosa is a puzzling illness. At the heart of it are symptoms which to the casual observer are hard to understand. Persistent food restriction, driven by intense fears of fatness, fullness and eating certain foods leads to significant weight loss. A range of other behaviours designed to aid weight loss may also be used. As the illness gathers momentum, it increasingly takes a toll on the person’s brain, body and mind. Thinking becomes preoccupied with food and how to avoid it, decision making and concentration become impaired, the ability to read one’s own and others’ emotions becomes limited, anxiety and depression increase, and myriad physical problems arise affecting all major organs from the heart to the bones. In parallel, the illness becomes ever more visible to others, who in turn become increasingly concerned and may be alarmed by the person’s obliviousness to growing concerns and danger.

One rarely speaks of a ‘mild’ case of anorexia. The problem with anorexia is that for a sensitive individual facing a period of life stress, it does a lot of things very well: it promptly and efficiently numbs the person’s emotions; it consumes their thoughts by setting itself as the priority; it narrows the person’s interpersonal world; and it acts as a buffer to the demands of loved ones. In the short term, anorexia offers something of a cocoon from the demands of life and the social world, but in a relatively short space of time it takes hold as symptoms become rewarding, compulsive or habitual. It represents a quandary: it is a serious psychiatric condition with a high mortality rate, yet from the perspective of the person with anorexia it is often considered a ‘valued’ part of their identity.

Most clinicians dedicated to work in eating disorders are united in the acknowledgement that this is a tricky and at times anxiety-provoking area of clinical work. Whether you are a person with anorexia, a loved one wanting to be of help or a therapist supporting your patient toward recovery, the journey to overcoming anorexia requires a great deal of patience and endurance along with a genuine curiosity to get to know the specifics and subtleties of the illness. We have developed a treatment approach that has been directly informed by the views of people with anorexia and their families, by our clinical work and our research in this field. The modules stem from growing research data, highlighting that individuals with anorexia have particular struggles managing their social and emotional world and a particular thinking style and that the effects of starvation have a big role to play in the ‘stuckness’ endured by individuals with anorexia. The aim of the treatment is to encourage the individual with anorexia to get to know their anorexia as fully as possible, to be conscious and curious about its role in all spheres of life so that they can make decisions about whether to remain with anorexia or whether to take steps to live in a different way.

In this chapter we will begin with an overview of available psychological treatments for anorexia; we will present our MANTRA model and then some evidence for its effectiveness. Finally, we will present some evidence outlining what patients and therapists think of MANTRA.

Available treatments: is the glass half empty or half full?

Most experts, including those on the NICE guidelines (2017),¹ agree that psychological therapies, which include a focus on eating and weight and related thoughts and feelings, are the treatment of choice for people with anorexia. For most people with anorexia, this can be delivered in community settings. In the UK only a small proportion of people with a very severe form of the illness get treated in specialist inpatient units. So how well are we doing with those psychological therapies, and is the glass half empty or half full? Until recently, we would definitely have said that in relation to anorexia treatments the glass was half empty. Now we think that the glass is at least half full, if not more so. What is the reason for this change in opinion? First, until about five years ago only a trickle of mainly small clinical trials focused on treatments for anorexia nervosa. This is reflected in the fact that the first set of eating disorder guidelines by NICE published in 2004² did not give a single ‘grade A’ recommendation about the treatment of anorexia nervosa. (NICE only gives grade A recommendations for treatments that are supported by several high-quality large clinical trials.) Since then the evidence base has much improved, and over the last five years in particular large-scale trials of anorexia treatments have emerged which give us much clearer answers as to what works. We can now say with considerable confidence that for children and adolescents with anorexia, family-based treatments work better than individual treatment. Different forms of effective family-based treatments are available, ranging from anorexia-focused family therapy (where everyone is included and seen together) to multi-family group treatments (where several families with youngsters with anorexia are seen together and can learn from each other) and separate treatment of parents and the young person. For adults with anorexia, three different individual psychological therapies have an evidence base and are recommended by NICE (2017) as a first choice. These are cognitive behavioural therapy (CBT), MANTRA and specialist supportive clinical management. A fourth treatment, focal psychodynamic therapy, can be considered as an alternative. As yet there is no clear front runner and it is hard to know which of these treatments works best for whom.

So what are the strengths and characteristics of MANTRA? Importantly, in contrast to some of the other anorexia treatments which have been adapted from treatments for other disorders, MANTRA is unique in that it has been designed with the needs, characteristics and illness- maintaining factors of anorexia in mind.

In our development of MANTRA we started off trying to map out the key factors that may ‘drive’ a person into anorexia and those that keep them ‘stuck’ with anorexia. We did this based on a thorough review of the research literature.³ This model has since been revised based on further research evidence.⁴ Our treatment programme is based on this model and is organised into modules that seek to directly tackle each of the factors that we know keep anorexia going. As every person with anorexia will vary, there is flexibility in the treatment programme. There are certain ‘core’ modules (Chapters 2 to 6), which most people with anorexia tell us are useful and important, and we would recommend that these are worked through in order. Then there are various other modules, some of which will suit some people and not others. As we go along, we will try to guide you to devise a treatment plan that suits you or the person you are trying to support. We will begin by sharing our model of anorexia; see what you think.

The MANTRA model

MANTRA (the Maudsley Model of Anorexia Nervosa Treatment in Adults) is a cognitive-interpersonal⁵ treatment for adults with anorexia that considers both the biology and psychology of the disorder and how these factors interact to keep anorexia going.^{3, 4, 6} MANTRA is a stand-alone treatment for anorexia that when delivered weekly can take between 20 to 30 one-hour sessions, depending on illness severity and the degree of support you have along the way. So far, MANTRA has been applied mainly within clinic settings and guided by therapists. However, an adapted version of MANTRA was recently piloted by our team in an internet-delivered relapse prevention study for individuals with severe anorexia.⁷ In this study individuals with severe anorexia who had been treated as inpatients and were leaving hospital completed the modules at home with weekly email support from a therapist. The study showed that patients benefited from MANTRA, suggesting that this treatment package can be completed with good outcome and with minimal professional guidance. However, we did encourage all the patients in the study to have some monitoring of physical risk from their general practitioner (GP) or eating disorder team. So if you are not working through MANTRA with a therapist, we would recommend that as a minimum you let your GP know that you are engaged in self-help treatment so that they can help you monitor your progress. We also suggest that you aim to choose at least one person you trust (either family or friend or professional) to share in your journey. This is someone you can call on for support and share in the highs and lows of recovery. What we did learn from the internet relapse prevention study is that minimal support (such as weekly emails from a sensitive professional) is very much more helpful than just going it alone.

The MANTRA model proposes that anorexia typically arises in people with a certain type of personality including anxious, sensitive and/or perfectionist, obsessional traits. Maybe you can recognise these traits? The model suggests that anorexia is maintained by four broad factors, all of which are intensified by the biological effects of starvation. Thus an unhelpful feedback loop is formed between the consequences of starvation and these maintenance factors. At the heart of the treatment manual is an individualised formulation depicted as a ‘vicious flower’ which maps out the ‘petals’ or factors that keep an individual’s illness going. These factors include, first, an inflexible, detail-focused and perfectionist way of approaching life tasks (such as needing to be absolutely certain a piece of work is ‘perfect’ before handing it in); second, difficulties in the domain of emotions and relationships (such as difficulties allowing, ‘being with’, managing and showing emotions, particularly in the context of relationships, feeling sensitive to rejection or the possibility of failure); third, in keeping with these characteristics, affected individuals typically develop beliefs about the positives of anorexia in their lives (such as anorexia keeps me safe, in control and admired by others); lastly, family members and partners may unwittingly maintain anorexia by bending their behaviours to the illness, enabling anorexia behaviours and/or getting very emotional about things. Low motivation or not being ready to change is common among those with anorexia. It is important to say that MANTRA assumes that this is the starting point for many people, and we will work with ambivalence associated with change. Early modules incorporate techniques to assess and work with issues of low or fluctuating motivation or limited confidence in one’s ability to change.

Anorexia is a notoriously relapsing condition, and therefore holding on to, maintaining and building on any gains that have been made in the face of life changes and stressors is considered crucial. The final module is focused on the ‘pulling together’ and consolidation of gains and also on relapse prevention. A ‘staying well plan’ is devised in the form of a ‘virtuous flower’ of health and wellbeing with petals that represent factors, for that individual, that promote positive mental health.

Does MANTRA work, and what do patients and therapists tell us about it?

The ‘gold standard’ method of evaluating whether a therapy works or not is to compare it directly with the next best treatment and to allocate patients randomly between these two treatments. So far, using this method, there have been three such clinical trials^8–12 comparing MANTRA against specialist supportive clinical management (SSCM)^8–11 and with CBT.¹² In all these trials, these psychological therapies were delivered as outpatient treatments. Whilst overall there was no clear front runner, and patients in all three treatments improved similarly, there were some differences between the treatment conditions. Findings suggest that compared to SSCM, which focuses mainly on improving poor nutrition and low weight, MANTRA had a number of advantages. First, MANTRA was thought by patients to be significantly more acceptable and credible than SSCM.¹³ Second, for those with a more severe form of the illness (i.e. greater weight loss at the start of treatment), MANTRA seemed to get better outcomes in terms of making greater strides towards recovery. Finally, while a small number of patients allocated to SSCM experienced adverse effects (such as increasing their weight through binge eating), no such negative effects were noted for MANTRA. Several of our patients who took part in our most recent large-scale trial testing MANTRA versus SSCM told us they wished they had had MANTRA early on in their illness, i.e. as their first treatment. Therefore, we separately looked at outcomes in those patients who had presented to us with their first episode of illness. Of those patients receiving MANTRA, 50% had made a complete recovery at two years after starting treatment compared to only 14% of patients receiving SSCM – a major and significant difference.

In our trials, both therapists and patients were very positive about the MANTRA programme.¹³–¹⁵ Interviews exploring therapists’ views of using the approach and manual described it as affording a good balance of structure and flexibility, along with offering a breadth of ‘tools’ to flexibly and successfully weave into a time-limited treatment. Patients’ reports of working collaboratively through the manual with their therapist also highlight the benefits of the structured approach, the value of gaining new perspectives on their difficulties, and of acquiring skills to manage their eating disorder as well as to enhance confidence and overall quality of life. Thus results from studies using this manual strongly support the case for the treatment approach being appealing and manageable for individuals with anorexia, and above all we hope will mean that individuals with anorexia feel ‘...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Acknowledgements
• Introduction
• Chapter 1 The background to MANTRA
• Chapter 2 Getting started
• Chapter 3 No (wo)man is an island – working with support
• Chapter 4 Improving your nutritional health
• Chapter 5 My anorexia nervosa: Why, what and how?
• Chapter 6 Developing treatment goals
• Chapter 7 The emotional and social mind
• Chapter 8 Exploring thinking styles
• Chapter 9 Identity
• Chapter 10 The virtuous flower of recovery from anorexia
• Appendix 1 Worksheets for supporters
• Appendix 2 Writing in therapy
• Appendix 3 EMOTIONS DIARY
• Appendix 4 Traffic light relapse prevention plan
• Index