nervosa. This was the first psychological treatment recommended by NICE. A hidden problem If you were to ask people in the street about eating disorders, the majority of people would probably be aware of anorexia nervosa and some would be aware of bulimia nervosa. However, Chris’s work and that of others has recently shown most people diagnosed with an eating disorder have neither. Although some 10 per cent have anorexia nervosa and 30 per cent bulimia nervosa, the majority fall into a residual category termed ‘eating disorder not otherwise specified’, a type of eating disorder that is just as severe but has barely been studied. “Although not much remarked upon,” Chris says, “there are notable similarities between the eating disorders. They have very similar clinical characteristics, and patients commonly move between the diagnoses.” This led to Chris having an ‘aha’ moment in the late 1990s. “I thought, given these similarities and links, there are likely to be common processes maintaining the eating disorders. Therefore, if we are capable of addressing these processes in one condition, bulimia nervosa, we ought be able to do the same in the other eating disorders.” This so-called transdiagnostic way of thinking was highly contentious, and many in the field were sceptical about its ‘one-size-fits-all’ nature. Still, in 2000, Chris was awarded funding from the Wellcome Trust for a trial that would test whether CBT works for any eating disorder. Results from the first part of this trial
are promising. Looking at the patients who were not significantly underweight (i.e. the 80 per cent of patients with bulimia nervosa or ‘eating disorder not otherwise specified’), the team found that the new version of CBT, designed for any eating disorder, worked for two-thirds of the patients, regardless of their original diagnosis4 – a finding that has subsequently been replicated. Most recently, Chris has reported the results from the remaining patients, those with anorexia nervosa, and they too respond to the new treatment. Researchers are applying the transdiagnostic way of thinking to other mental health disorders, and clinicians now have a single treatment that can be used across the eating disorders. Not surprisingly, the demand for training in the new treatment is immense, and this topic – how to train therapists on a large scale – is the focus of Chris’s latest line of work. “The way people learn psychological therapies today is ad hoc, and not dissimilar to the time of Freud,” Chris says. Typically, trainee therapists attend an initial one- or two-day training event held by an expert, followed by some form of case supervision for six to nine months. “This method is all very well but it results in very few people being trained. Moreover, there is a major shortcoming – most therapists never see the therapy being implemented. If you needed cardiac surgery, would you like a surgeon who’d never seen the procedure being done? This is stunning to me, but is totally accepted by our field.” To investigate new ways of training that are suitable for use on a large scale,
Chris has been awarded a Wellcome Trust Strategic Award. He plans to create web-based forms of training that will provide trainees with the opportunity to view entire (simulated) treatments online, made up from amalgams of real past treatments but with any personal identifiers removed. Chris plans to test these new web-based approaches against more conventional training methods. To do this, however, he and his international group of collaborators need to develop new means of measuring therapist competence, something that he says will be both challenging and controversial. This may all seem a long way from negotiating with the editor of a women’s magazine to include information on an unknown illness, but Chris’s passion today is just as strong. “People with eating disorders and other mental health problems wait for years before seeking help, if they ever do,” he says, “but we have treatments that can work in just months. My job now is to develop cost-effective, large-scale ways of training therapists across the world how to implement them.” 1. Russell G. Bulimia nervosa: an ominous variant of anorexia nervosa. Psychol Med 1979;9:429–48. 2. Fairburn CG, Cooper PJ. Self-induced vomiting and bulimia nervosa: an undetected problem. BMJ 1982; 284:1153–5. 3. Fairburn CG et al. Psychotherapy and bulimia nervosa: the longer-term effects of interpersonal psychotherapy, behaviour therapy and cognitive behaviour therapy. Arch Gen Psychiatry 1993;50: 419–28. 4. Fairburn CG et al. Transdiagnostic cognitive behavioral therapy for patients with eating disorders: a two-site trial with 60-week follow-up. Am J Psychiatry 2009;166:311–9.
Simple as CBT…
Cognitive behaviour therapy is a psychological talking therapy. It helps people recognise and alter problematic ways of thinking and behaving. It is effective in treating a number of mental health disorders, particularly depression, eating disorders and anxiety disorders.
Chris Fairburn explains the cycle of dysfunctional thoughts and behaviours behind eating disorders. Wellcome Images
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It is effective when given face-to-face. Simplified forms of CBT are of help in some cases and can be delivered via computer, over the phone or through self-help books.