Elsevier

Clinical Psychology Review

Volume 58, December 2017, Pages 125-140
Clinical Psychology Review

Review
The empirical status of the third-wave behaviour therapies for the treatment of eating disorders: A systematic review

https://doi.org/10.1016/j.cpr.2017.10.005Get rights and content

Highlights

  • The empirical standing of the third-wave behavior therapies for the treatment of eating disorders was evaluated.

  • Large improvements in symptoms were made following each third-wave therapy.

  • None of the third-wave therapies meet criteria for an empirically-supported treatment for eating disorders.

  • CBT should be provided to individuals with eating disorders, with IPT considered an alternative.

Abstract

Although third-wave behaviour therapies are being increasingly used for the treatment of eating disorders, their efficacy is largely unknown. This systematic review and meta-analysis aimed to examine the empirical status of these therapies. Twenty-seven studies met full inclusion criteria. Only 13 randomized controlled trials (RCT) were identified, most on binge eating disorder (BED). Pooled within- (pre-post change) and between-groups effect sizes were calculated for the meta-analysis. Large pre-post symptom improvements were observed for all third-wave treatments, including dialectical behaviour therapy (DBT), schema therapy (ST), acceptance and commitment therapy (ACT), mindfulness-based interventions (MBI), and compassion-focused therapy (CFT). Third-wave therapies were not superior to active comparisons generally, or to cognitive-behaviour therapy (CBT) in RCTs. Based on our qualitative synthesis, none of the third-wave therapies meet established criteria for an empirically supported treatment for particular eating disorder subgroups. Until further RCTs demonstrate the efficacy of third-wave therapies for particular eating disorder subgroups, the available data suggest that CBT should retain its status as the recommended treatment approach for bulimia nervosa (BN) and BED, and the front running treatment for anorexia nervosa (AN) in adults, with interpersonal psychotherapy (IPT) considered a strong empirically-supported alternative.

Introduction

In the context of eating disorders, there are few empirically-supported treatments, defined as specific treatments shown to be effective in controlled research trials (Chambless & Hollon, 1998). High quality systematic reviews have demonstrated that specific forms of cognitive-behavioral therapy (CBT) are efficacious for a range of eating disorder presentations in the short and long-term (e.g., Brownley et al., 2016, National Institute of Clinical Excellence, 2017). There is also evidence that there are no statistically significant outcome differences between CBT and interpersonal psychotherapy (IPT) at long-term follow-up periods (Linardon, Wade, De la Piedad Garcia, & Brennan, 2017a). International clinical guidelines for eating disorders now recommend the use of psychological treatments that show strong empirical support, although some recommendations are also non-evidence based and likely reflect the particularities in healthcare systems (e.g., availability of outpatient services, amount of therpists trained in a particular theoretical orientation etc.; see Hilbert, Hoek, & Schmidt, 2017). From eight available clinical guidelines that recommend psychological treatments for eating disorders, all recommend CBT for bulimia nervosa (BN) and binge eating disorder (BED), and six recommend CBT for anorexia nervosa (AN). Four clinical guidelines recommend IPT for BN and BED, and two recommend IPT for AN. Family-based therapy, particularly for adolescents, is recommended by six and four guidelines for AN and BN, respectively. Other interventions recommended less frequently by clinical guidelines include psychodynamic therapy and MANTRA (see Hilbert et al., 2017).

Although the efficacy of specific psychological treatments, such as CBT, IPT, and FBT, has been demonstrated in numerous randomized controlled trials (RCTs), there is still room for improvement in treatment retention and outcomes. For example, attrition, relapse, and/or partial response is common in RCTs evaluating CBT and IPT (e.g., Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000), although there is evidence to suggest that treatment outcome and retention rates are improving when new and enhanced versions of CBT (CBT-E) are delivered (Fairburn et al., 2015).1 Some authors have therefore argued that a broader range of effective eating disorder treatments are needed (Wonderlich et al., 2014). The “third-wave” behavioral therapies have been suggested as potential alternatives for the treatment of eating disorders (Juarascio, Manasse, Schumacher, Espel, & Forman, 2017).

In general, while third-wave behaviour therapies have retained many of the same components as “second wave” CBT (e.g., self-monitoring, exposure and response prevention), they also use new methods and assumptions to achieve improvements in psychological functioning and clinical change (Hayes, 2004). Whereas CBT directly targets the content and validity of cognitive processes, third-wave therapies target the function or awareness of cognitions and emotions (Hofmann & Asmundson, 2008). Consequently, third-wave therapies emphasise strategies that foster acceptance, mindfulness, metacognition, and psychological flexibility, and reduce experiential avoidance (Hayes, Villatte, Levin, & Hildebrandt, 2011). This means that third-wave therapies target response-focused emotion regulation strategies, i.e., strategies that modulate the expression or experience of emotion regulation after its initiation, whereas CBT targets antecedent-focused emotion regulation strategies, i.e., strategies that prevent the emotion response from being activated (Hofmann & Asmundson, 2008).

There are some differences of opinion regarding the therapeutic interventions that fall under the category of third-wave behaviour therapies (Kahl, Winter, & Schweiger, 2012). However, a general consensus is that acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), compassion mind training/compassion-focused therapy (CFT), mindfulness-based interventions (MBI), functional analytic therapy (FAP), schema therapy (ST), and metacognitive therapy (MT)2 all fall under the third-wave behaviour therapy umbrella (Hayes, 2004, Hayes et al., 2011, Öst, 2008). These specific therapeutic interventions will therefore form the basis of this review.

Numerous systematic reviews and meta-analyses have examined the efficacy of third-wave therapies for several common mental health conditions. Dimidjiian and colleagues recently synthesised the evidence from all the available meta-analyses (k = 26) of third-wave therapies (Dimidjian et al., 2016). Most meta-analyses were based on third-wave therapies for mood and anxiety disorders, with only a small number considering personality, substance abuse, and eating disorders. From their synthesis, Dimidjiian and colleagues concluded that specific third-wave treatments such as ACT, DBT, MBIs, and BA are supported by numerous RCTs, which, when combined, demonstrate a large within-groups effect size (i.e., pre-post symptom change), and a moderate between groups effect size (using mainly wait-list controls or treatment as usual as a comparison). Meta-analyses have also been performed comparing ACT to CBT, and these meta-analyses have reported no significant outcome differences between these treatments for anxiety disorders, general mental health conditions, and depressive symptoms (A-tjak et al., 2015, Bluett et al., 2014, Hayes et al., 2006, Ruiz, 2012).

The efficacy of third-wave therapies for eating disorders is much less clear. Two meta-analyses of specific third-wave therapies have been conducted. First, Lenz, Taylor, Fleming, and Serman (2014) evaluated the effectiveness of DBT for BED and BN by calculating within- (pre-post change) and between-groups (comparing DBT to wait-lists or TAU conditions only) effect sizes for eating disorder behaviours. Large within-groups (k = 4, d = 1.43) and between-groups (k = 4, d = 0.82) effect sizes were observed, leading the authors to conclude that DBT is a potentially effective treatment for eating disorders. Second, Godfrey, Gallo, and Afari (2015) reviewed studies that administered any form of MBI to treat binge eating in BED and non-clinical samples. Nine MBI studies, 6 DBT studies, and 4 ACT studies were included, and their meta-analysis was based on all interventions combined. Large (g = 1.12) within-groups and moderate (g = 0.70) between-groups effects favouring MBIs over wait-lists or TAU conditions were observed. Overall, these findings suggest that specific third-wave therapies such as DBT and MBIs are potentially effective treatments for BN and BED, at least in comparison to wait-list or TAU.

Despite the limited evidence of third-wave therapies for eating disorders, research has shown that clinicians are using third-wave techniques at least as often as they are using techniques derived from evidence-based therapies (e.g., CBT) to treat eating disorders. For example, Cowdrey and Waller (2015) found that the percentage of clients with eating disorders who reported that their therapist utilized mindfulness (77%) was typically larger than the percentage who reported their therapist used CBT-specific techniques such as food monitoring records (53%), weekly weighing (39%), and regular eating (82%). The use of third-wave therapies rather than empirically supported treatments raises concerns that those seeking treatment are not being provided with the most effective therapies. Therefore, a critical synthesis of the available literature on all third-wave eating disorder treatments studied to date is timely and pertinent.

This study therefore aims to examine the efficacy of third-wave therapies for eating disorders by (1) computing pre- to post-treatment and pre-treatment to follow-up effect sizes, and (2) comparing third-wave therapies to wait-lists, active controls, and empirically supported eating disorder treatments (i.e., CBT and IPT). Based on the available literature, we aim to investigate whether each specific third-wave therapy meets the criteria required for an empirically-supported treatment for eating disorders proposed by Chambless and Hollon (1998). Chambless and Hollon (1998) differentiated between (a) empirically-supported treatments that are specific in their mechanisms of action, i.e., therapy outperforms a pill or alternative evidence-based treatment in multiple RCTs conducted by different research teams, (b) efficacious therapies, i.e., therapy outperforms no treatment in multiple RCTs conducted by different research teams, and (c) possibly efficacious therapies, i.e., therapy outperforms no treatment in one study or by more than one study conducted by the same team.

The original criteria for empirically-supported treatments proposed by Chambless and Hollon (1998) were selected over more recent criteria (e.g., proposed by Tolin, McKay, Forman, Klonsky, & Thombs, 2015). As newer criteria have been criticised (for a full commentary, see Chambless, 2015), and the Chambless and Hollon (1998) criteria are still the most commonly implemented in psychological treatment research (e.g., Steinert, Munder, Rabung, Hoyer, & Leichsenring, 2017), we used the original criteria for establishing the empirical status of the third-wave therapies.

Section snippets

Method

This review was conducted in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009).

Study characteristics

Table 1, Table 2 present the characteristics of the RCTs and non-RCTs, respectively. In total, 15 used a transdiagnostic sample and nine a BED sample, two a BN sample, and one study sampled individuals with AN. Fourteen studies evaluated DBT, six evaluated MBIs, three evaluated CFT, two evaluated ACT, and two evaluated ST. In Table 3, we describe the underlying theoretical model of each of these third-wave therapies that have been tested in individuals with eating disorders. Thirteen studies

Discussion

This systematic review examined the empirical standing of the third-wave behaviour therapies for the treatment of eating disorders. Findings show that while third-wave therapies resulted in symptom improvements and were more efficacious than wait-list controls, third-wave therapies were general not superior to active psychological comparisons. Each third-wave therapy resulted in moderate to large improvements in eating disorder and general psychological symptoms from pre-treatment to

Conclusion

This study was the first to evaluate the empirical standing of third-wave therapies for the treatment of eating disorders, by both qualitatively synthesising the available findings of third-wave therapies in RCTs and quantitatively estimating the size of these treatment effects. Although there is promising preliminary evidence of the potential efficacy of specific third-wave therapies for certain eating disorders, no third-wave therapy currently meets formal criteria for an empirically

Conflict of interest

We wish to confirm that there are no conflicts of interest with this publication.

Role of funding sources

This project is supported through the Australian Government's Collaborative Research Networks (CRN) program. The CRN program had no involvement in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.

Contributors

The first and last author was responsible for conceptualising the paper, conducting the statistical analyses and drafting and editing the manuscript. Author 2 was responsible for conceptualising the paper, and drafting and editing the manuscript. Authors 3 and 4 were also responsible for drafting and editing the paper. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed.

Acknowledgements

We would like to thank Professor John Gleeson, Dr. Keong Yap, and Ms. Kylie Murphy for their valuable feedback on earlier versions of this manuscript. This project is supported through the Australian Government's Collaborative Research Networks (CRN) program. CGF holds a Principal Research Fellowship from the Welcome Trust (046386).

References (109)

  • S.C. Hayes et al.

    Acceptance and commitment therapy: Model, processes and outcomes

    Behaviour Research and Therapy

    (2006)
  • S.G. Hofmann et al.

    Acceptance and mindfulness-based therapy: New wave or old hat?

    Clinical Psychology Review

    (2008)
  • A.S. Juarascio et al.

    Developing an acceptance-based behavioral treatment for binge eating disorder: Rationale and challenges

    Cognitive and Behavioral Practice

    (2017)
  • S.N. Katterman et al.

    Mindfulness meditation as an intervention for binge eating, emotional eating, and weight loss: A systematic review

    Eating Behaviors

    (2014)
  • C. Kröger et al.

    Dialectical behaviour therapy and an added cognitive behavioural treatment module for eating disorders in women with borderline personality disorder and anorexia nervosa or bulimia nervosa who failed to respond to previous treatments. An open trial with a 15-month follow-up

    Journal of Behavior Therapy and Experimental Psychiatry

    (2010)
  • P.C. Masson et al.

    A randomized wait-list controlled pilot study of dialectical behaviour therapy guided self-help for binge eating disorder

    Behaviour Research and Therapy

    (2013)
  • V.V.W. McIntosh et al.

    Psychotherapy for transdiagnostic binge eating: A randomized controlled trial of cognitive-behavioural therapy, appetite-focused cognitive-behavioural therapy, and schema therapy

    Psychiatry Research

    (2016)
  • L.-G. Öst

    Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis

    Behaviour Research and Therapy

    (2008)
  • D.L. Safer et al.

    Outcome from a randomized controlled trial of group therapy for binge eating disorder: Comparing dialectical behavior therapy adapted for binge eating to an active comparison group therapy

    Behavior Therapy

    (2010)
  • R. Shafran et al.

    Mind the gap: Improving the dissemination of CBT

    Behaviour Research and Therapy

    (2009)
  • C.F. Telch et al.

    Group dialectical behavior therapy for binge-eating disorder: A preliminary, uncontrolled trial

    Behavior Therapy

    (2000)
  • W.S. Agras et al.

    A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa

    Archives of General Psychiatry

    (2000)
  • S. Alfonsson et al.

    Group behavioral activation for patients with severe obesity and binge eating disorder: A randomized controlled trial

    Behavior Modification

    (2015)
  • J.G. A-tjak et al.

    A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems

    Psychotherapy and Psychosomatics

    (2015)
  • R.A. Baer et al.

    Mindfulness and acceptance in the treatment of disordered eating

    Journal of Rational-Emotive and Cognitive-Behavior Therapy

    (2005)
  • A.T. Beck et al.

    An inventory for measuring depression

    Archives of General Psychiatry

    (1961)
  • D.D. Ben-Porath et al.

    Dialectical behavior therapy: Does it bring about improvements in affect regulation in individuals with eating disorders?

    Journal of Contemporary Psychotherapy

    (2014)
  • D.D. Ben-Porath et al.

    Differential treatment response for eating disordered patients with and without a comorbid borderline personality diagnosis using a dialectical behavior therapy (DBT)-informed approach

    Eating Disorders

    (2009)
  • M. Borenstein et al.

    Introduction to meta-analysis

    (2009)
  • K.A. Brownley et al.

    Binge-eating disorder in adults. A systematic review and meta-analysis: Treatment effectiveness

    Annals of Internal Medicine

    (2016)
  • S. Byrne et al.

    A randomised controlled trial of three psychological treatments for anorexia nervosa

    Psychological Medicine

    (2017)
  • D.L. Chambless

    Bringing identification of empirically supported treatments into the 21st century

    Clinical Psychology: Science and Practice

    (2015)
  • D.L. Chambless et al.

    Defining empirically supported therapies

    Journal of Consulting and Clinical Psychology

    (1998)
  • E.Y. Chen et al.

    An adaptive randomized trial of dialectical behavior therapy and cognitive behavior therapy for binge-eating

    Psychological Medicine

    (2016)
  • E.Y. Chen et al.

    Dialectical behavior therapy for clients with binge‐eating disorder or bulimia nervosa and borderline personality disorder

    International Journal of Eating Disorders

    (2008)
  • E.Y. Chen et al.

    Comparison of group and individual cognitive-behavioral therapy for patients with bulimia nervosa

    International Journal of Eating Disorders

    (2003)
  • Z. Cooper et al.

    Using the internet to train therapists: A randomised comparison of two scalable methods

    Journal of Medical Internet Research

    (2017)
  • C. Courbasson et al.

    Outcome of dialectical behaviour therapy for concurrent eating and substance use disorders

    Clinical Psychology & Psychotherapy

    (2012)
  • C.M. Courbasson et al.

    Mindfulness-action based cognitive behavioral therapy for concurrent binge eating disorder and substance use disorders

    Eating Disorders

    (2010)
  • P. Cuijpers et al.

    Interpersonal psychotherapy for mental health problems: A comprehensive meta-analysis

    American Journal of Psychiatry

    (2016)
  • P. Cuijpers et al.

    Pre-post effect sizes should be avoided in meta-analyses

    Epidemiology and Psychiatric Sciences

    (2016)
  • L.R. Derogatis et al.

    The SCL-90 and the MMPI: A step in the validation of a new self-report scale

    The British Journal of Psychiatry

    (1976)
  • C.G. Fairburn

    Cognitive behavior therapy and eating disorders

    (2008)
  • C.G. Fairburn et al.

    Scaling up psychological treatments: A countrywide test of the online training of therapists

    Journal of Medical Internet Research

    (2017)
  • C.G. Fairburn et al.

    Assessment of eating disorders: Interview or self-report questionnaire?

    International Journal of Eating Disorders

    (1994)
  • C.G. Fairburn et al.

    Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: A two-site trial with 60-week follow-up

    American Journal of Psychiatry

    (2009)
  • C.G. Fairburn et al.

    Three psychological treatments for bulimia nervosa: A comparative trial

    Archives of General Psychiatry

    (1991)
  • C.G. Fairburn et al.

    Psychotherapy and bulimia nervosa: Longer-term effects of interpersonal psychotherapy, behavior therapy, and cognitive behavior therapy

    Archives of General Psychiatry

    (1993)
  • C. Gale et al.

    An evaluation of the impact of introducing compassion focused therapy to a standard treatment programme for people with eating disorders

    Clinical Psychology and Psychotherapy

    (2014)
  • D.M. Garner et al.

    Comparison of cognitive-behavioral and supportive-expressive therapy for bulimia nervosa

    The American Journal of Psychiatry

    (1993)
  • Cited by (159)

    • Eating disorders: Understanding their symptoms, mechanisms, and relevance to gastrointestinal functional and motility disorders

      2023, Handbook of Gastrointestinal Motility and Disorders of Gut-Brain Interactions, Second Edition
    View all citing articles on Scopus
    View full text