RESUMEN DE LA LECCIÓN SEIS

The study provided useful and novel insights into how this group of women experienced CBT for the treatment of bulimia nervosa. For instance, concerns regarding losing and regaining control seemed to be central to all participants’ reflections. These concerns seemed to impact on help-seeking, therapy engagement and the relationship with the therapist. Also, all women described a pervasive sense of isolation regarding their eating issues due to internalised stigma and/or experiences of being turned away by others for their eating difficulties. Feelings of shame and loneliness seemed to common experiences shared by all. Previous research has indicated that although CBT can help some clients to make and maintain positive behavioural changes regarding eating difficulties, it may not make long- lasting and fundamental changes to the person’s identity. Since eating issues seem to become egosyntonic over time, exploring and working with identity concerns may help practitioners to encourage therapeutic changes that relate to the person’s way of being, rather than just focus on reducing specific behaviours and thought patterns concerning food and weight. This may be particularly important when working with adolescents and young adults, whose identities are still developing. For instance, working to strengthen the role of different life domains, such as education and relationships, while enhancing the individuals’ self-understanding may help to build more positive self-concepts and reduce the grip of eating issues. Alternative theoretical and therapeutic frameworks may provide helpful viewpoints to understanding and working with these difficulties, thus enhancing the treatment experience and outcomes.

Clinicians, including Counselling Psychologists, who are trained in multiple psychological and psychotherapy models are potentially very well placed to work with these concerns. Alongside this knowledge and clinical experiences, CoP values of recognising each individual’s unique needs and circumstances, and thriving to provide a service that would meet these requirements should mean that each person is provided with the support that is most appropriate to them. For example, developing and utilising individual formulations drawing from relevant theories and therapy approaches, jointly negotiating therapeutic goals and tailoring interventions to address the individual needs of each client are some of the ways in which the training, knowledge and CoP values could be demonstrated in clinical work.

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Solely relying on treatment protocols, such as CBT-E, may mean that the client’s complex needs are not met and the therapy further alienates the client. Allowing space and time to explore potential issues relating to early life experiences, emerging identity and struggles associated with the specific life stages, for example, alongside considering the role of food and eating behaviours in the presenting issues could facilitate a more conducive therapeutic environment. In addition, this particular client group seems to be vulnerable to feeling and/or being rejected and misunderstood by others, and due to the shame associated with the issues may isolate themselves or use covert tactics to avoid feeling exposed. These are important points to bear in mind when providing therapy for issues evoking shame and other difficult emotions, as clients may try and minimise their issues and disengage from therapy – implicitly or explicitly. Thus, being aware of and compassionate to the difficulties that treatment may bring up, as well as the emotional challenges of being involved in therapy for eating issues, can help to build rapport and thus positively influence the outcome. Therapy frameworks that incorporate relational interventions and focus on the role of interpersonal factors in understanding and working with psychological distress can also prove invaluable in creating an environment in which the client can be helped to work on their difficulties holistically. For instance, IPT for EDs (IPT-ED; Champion & Power, 2012) already has an evidence-base supporting its effectiveness for the treatment of eating issues. It focuses on understanding the role of interpersonal difficulties in the development and maintenance of these difficulties. The work involves gaining insight into the identified interpersonal problem and what is maintaining it, such as lack of intimacy, interpersonal role disputes, role transitions and/or interpersonal deficits. The interpersonal issue is then addressed by using IPT techniques including role plays and decision analysis. Overall, the relationship between the therapist and the client can be used as a platform for helping the client gain a deeper understanding of their patterns of relating to their internal experiences, as well as individuals around them. For example, the therapist may wish to make interpretations and reflect on the therapy relationship with the client. They can also help the client name and explore their emotional struggles and thus demonstrate that emotional experiences can be worked with, rather than pushed away or dissociated from. A therapeutic environment that is experienced as safe by the client may help to alleviate the sense of isolation and feelings of shame, and allow for these feelings to be worked with during the therapy process. It may also assist the client to consider more fundamental questions relating to their way of being and relating. Thus, existential psychotherapy (Spinelli, 2005) may also be relevant to clients that can and wish to go deeper into their understanding of themselves. In summary, there are various frameworks that could be utilised with psychological difficulties that are expressed through

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issues with food and eating, and many of them move beyond the CBT focus on problematic thoughts and behaviours.

It is important to mention that many clinicians, especially those working in the NHS, need to demonstrate commitment to evidence-based practice; many are required to work within frameworks that allow short-term and medium-term work only. In the context of eating issues, such as bulimia, many services now focus on delivering CBT-E in line with Fairburn’s (2008) recommendations. Thus, the pressures to limit the breadth and depth of the therapeutic work may be externally imposed upon clinicians. Even if the therapeutic framework is externally stipulated to the clinician, they should remain committed to aiming to provide a therapeutic experience to the clients. In these cases clinical supervision may be a space in which multiple theoretical approaches are utilised to think about the client, even when the clinical work may mainly utilise a particular therapy model or a specific treatment protocol.

Counselling Psychologists can also demonstrate the values of CoP by challenging the stigma associated with eating issues within health care and other services. For instance, adopting an active stance in educating current and future professionals in various contexts to better equip them to respond to individuals displaying signs of disordered eating may help to reduce this stigma. This may also help the professionals to make better informed decisions about signposting and referrals.

As discussed in Chapter 2, as opposed to the assertions by Fairburn (2008), research has indicated that flexibility in using the CBT treatment manuals for bulimic difficulties has not been associated with worse outcomes regarding symptom reduction (Turner et al., 2015). There is also an emerging evidence-base for non-CBT approaches. As noted previously, focusing on changes in the criteria associated with specific diagnoses has limitations in terms of evaluating treatment effectiveness. Considering alternative evidence to the studies highlighted by the treatment guidelines is important, as the current guidelines recommend the use of CBT-E due to the existing evidence-base while neglecting evidence for other approaches and for non-manualised CBT practices.