Patient's Perceptions of Post-Treatment Factors that Influenced Skill Use After Cognitive-Behavioral Therapy for Bulimia Nervosa Spectrum Disorders

Liu, J., Wang, H., Wetherall, L., Giannone, A., & Juarascio, A. (2024). Patients' perceptions of post‐treatment factors that influenced skill use after cognitive‐behavioral therapy for bulimia nervosa spectrum disorders. International Journal of Eating Disorders, 57(7), 1589–1598. https://doi.org/10.1002/eat.24123

Summary by: Lina Kovač

Introduction

The main evidence-based treatment for patients with bulimia nervosa spectrum eating disorders (BN-EDs) is enhanced Cognitive-behavioral therapy, focused version (CBT-E) (Fairburn et al. 2009). While 30% of patients achieve remission at the end of this treatment (Linardon & Wade, 2018), 30% of them relapse (return to meet diagnostic criteria after remission) within one year after completing CBT-E (Södersten et al., 2017). Knowing predictors of deterioration (worsening of symptoms after a period of symptom improvement) could help us design effective deterioration prevention strategies (Liu et al., 2024). Previous studies have detected some prevailing predictors for deterioration among patients with BN-EDs (see Liu et al., 2024), but mainly focused on patients in higher levels of care, overlooking those receiving CBT-E in outpatient settings. Only two studies explored post-treatment predictors (Cockell et al., 2004; Keel et al., 2005) with one of them identifying (Cockell et al., 2004) a lack of structures and support, low self-efficacy, unrealistic expectations and lack of coping strategies for real-life challenges. One of the post-treatment factors crucial for preventing symptom deterioration in BN-EDs is the continued use of therapeutic skills after treatment, which can be difficult due to the loss of guidance and support from therapy (Cockell et al., 2004). While studies focusing on skill practice as relapse prevention after CBT for depression and substance use disorders have shown effectiveness (Eilert et al., 2023; Powers et al., 2008; Rose et al., 2012; Simons et al., 2005), no studies were done about obstacles and motivators in the context of skill use after CBT for BN-EDs. Due to the lack of research exploring post-treatment factors of deterioration, it is necessary to develop targeted deterioration prevention. This study aimed to qualitatively research post-treatment factors that contributed to deterioration and what are the motivators and barriers to post-treatment skill use (Liu et al. 2024).

Methods

The study included 12 participants (M(age) = 40.08, SD = 13.52) with BN-EDs who received 16 sessions of CBT-E and experienced symptom improvement that met the inclusion criteria at the end of treatment (EOT) compared to baseline (for more details see Liu et al., 2024). The majority of participants self-identified as female (75%), white (59.33%), and non-Hispanic (91.67%). The average follow-up time was 39.85 months (SD = 3.95). Eleven participants experienced deterioration at some point since EOT. The participants completed the study in two Zoom sessions – during the first one they provided consent and demographic data, completed the Eating Disorder Examination (EDE; Fairburn & Cooper, 1993) and a self-report survey on post-treatment experience and skill use; during the second session, they completed a qualitative interview about post-treatment factors within different domains. Inductive, data-driven thematic analysis was used to analyse the core themes that emerged during the qualitative interviews.

Results and Discussion

Researchers identified four themes that summarize post-treatment contributors to deterioration and barriers to/motivators of post-treatment skill use of outpatients with BN-EDs. Firstly, participants reported a sudden loss of accountability following treatment, which resulted in a drop in practising essential skills, especially those related to managing mood and urges. Without therapists' guidance, many struggled to self-motivate. The patients abandoned these skills because of the lack of external monitoring, structured check-ins and therapist's encouragement, particularly during times of negative emotions or stress when they would be more needed.

Secondly, continued body dissatisfaction and fear of gaining weight were perceived as a major driver of decreased eating-related skills and deterioration. Even though participants received a weight-neutral ED treatment (Salvia et al., 2023), many returned to restrictive eating behaviors after treatment because they were worried about gaining weight and their body shape. The continuous use of eating-related skills reduced weight concerns during treatment, but the abandonment of these practices after treatment increased the patients' dissatisfaction and disordered eating.

Thirdly, the discontinued practice of binge analysis resulted in decreased awareness of how poor skill application contributed to ED behaviors. Many believed they were already aware of their triggers and therefore ceased this practice. However, they overlooked how lapses in their skill practices—like inconsistent eating habits—could lead to binge episodes. This highlighted the necessity for ongoing binge analysis after treatment.

Finally, financial and time limitations restricted access to post-treatment therapy, making it difficult for participants to seek help when needed. Without the presence of professional support, participants struggled to stay accountable and continue using their skills, which contributed to symptom relapse.

These findings indicate that deterioration prevention in outpatient CBT-E relapse prevention should focus on enhancing self-accountability, intrinsic motivation, reinforcement of continuous use of skills (like binge analysis) post-treatment, and addressing body image issues (Liu et al., 2024).