To date, there are no evidence-based psychotherapies for treating co-occurring anorexia nervosa and AOD use specifically. Australian and international clinical practice guidelines for single disorder ED recommend the inclusion of psychotherapy as an essential component of treatment for anorexia nervosa [870, 1434]; however, it is recommended that, where indicated, more intense psychological therapies be initiated only after medical stabilisation and the cognitive effects of starvation have improved [870].
The effectiveness of existing psychotherapies is moderate at best, which may be due, in part, to high rates of treatment dropout and poor treatment retention [1429, 1435]. Regardless of the approach used, strategies to engage the client and maintain the therapeutic relationship throughout treatment may be beneficial to address high rates of treatment dropout. The interventions with the most theoretical and empirical support include family-based therapy (i.e., Maudsley family therapy), particularly among young people; CBT and CBT-enhanced (CBT-E). Other treatments with some evidence of low to moderate effect include focal psychodynamic therapy; interpersonal psychotherapy (IPT); cognitive analytic therapy; specialist supportive clinical management (SSCM); the Maudsley model of anorexia nervosa treatment for adults (MANTRA), MI, and psychodynamic approaches [870, 1429, 1435]. Table 54 provides a brief description of these approaches.
Research comparing different approaches has been limited and findings mixed (e.g., [1436–1443]); as such, there is no clear guidance for clinicians to suggest that one therapeutic approach is better than the other [1435, 1436, 1444]. In general, for children and adolescents with single disorder EDs, the best evidence is for Maudsley FBT and, for adults, the best evidence is for CBT or psychotherapy of a longer duration. As such, Australian clinical guidelines suggest that specialist-led manualised-based approaches (e.g., CBT approaches) that have the strongest evidence-base should be first line options, but do not stipulate any specific therapies as a first line treatment option [870].
Table 54: Brief description of psychotherapy approaches to ED
| Cognitive behavioural therapy – enhanced (CBT-E) |
| CBT-E is an extension of CBT focused on educating clients about being underweight, starvation and the initiation and maintenance of regular eating patterns. Included in the therapy are components that focus on self-efficacy and self-monitoring, which are thought to be crucial to the treatment [1440]. CBT-E also addresses other features that often co-occur with eating disorders, including low self-esteem, clinical perfectionism, mood intolerances, and interpersonal difficulties [1423, 1445]. |
| Integrative cognitive-affective therapy (ICAT) |
| ICAT is focused on the relationship between emotions and bulimic symptoms as well as adaptive eating [1446]. The relationship between symptoms and factors that maintain bulimic behaviours are addressed in four phases of treatment: treatment ambivalence and emotions; adaptive coping strategies; problem areas believed to maintain bulimic symptoms; healthy lifestyle and relapse prevention. |
| Focal dynamic therapy |
| Focal dynamic therapy focuses on therapeutic alliance, pro-anorectic behaviour, self-esteem, behaviours viewed as acceptable, associations between interpersonal relationships and eating, and the transfer back to everyday life [1440]. |
| Cognitive interpersonal therapy (MANTRA) |
| MANTRA (Maudsley model of Anorexia Nervosa Treatment for Adults) is a social-cognitive interpersonal treatment that draws on MI, cognitive remediation, and the involvement of family and carers. It focuses on addressing intrapersonal and interpersonal processes that are thought to be fundamental to the maintenance of the disorder [1429]. |
| Family-based treatment (FBT/Maudsley therapy) |
| FBT, first developed at the Maudsley Hospital in London, is a treatment program for anorexia nervosa in young people. In Maudsley Therapy, the family is actively involved in treatment, which is primarily focused on weight gain, and families are encouraged to take control over refeeding. Later stages of treatment involve handing back control over eating to the young person, and addressing other issues [1429]. |
| Specialist supportive clinical management (SSCM) |
| SSCM combines features of clinical management and supportive psychotherapy including education, care, support, fostering of a therapeutic relationship, praise, reassurance, and advice. A central feature of SSCM is a focus on the abnormal nutritional status and dietary patterns typical of anorexia nervosa. Clients are provided with information on a range of strategies to promote normalisation of eating and restoration of weight [1429]. |
| Interpersonal psychotherapy (IPT) |
| IPT targets interpersonal issues which are believed to contribute to the development and maintenance of ED. Four interpersonal problem areas are addressed: grief, relationship difficulties and deficits, and role transitions [1429]. |
Adapted from Peckmezian et al. [1429]. Note this is not an exhaustive list of all psychotherapies available for the treatment of ED. For a more comprehensive overview of approaches, see the Peckmezian and colleagues [1429] Evidence Review.