The inpatient treatment for eating disorders based on CBT-E developed at Villa Garda Hospital. Garda (VR). Italy

1. Intensive CBT-E
Riccardo Dalle Grave, MD
Villa Garda Hospital
Department of Eating and Weight Disorders

2. The Villa Garda Clinical Service
Aims
• To develop a novel way of providing treatment that overcomes some of the
difficulties encountered in more conventional services
Goals
• Providing all patients with an evidence-based treatment (CBT-E), whatever their
ED diagnosis or age, and whether they are outpatients, day patients or
inpatients.
• The default is to deliver CBT-E on an outpatient basis (a transdiagnostic
evidence-based treatment), but some patients require more intensive treatment
(i.e. intensive outpatient or hospitalisation) and these patients embark upon
CBT-E while in hospital.
• Whenever possible, they continue with the CBT-E on discharge without any
interruption

3. CBT-E Multistep
Inpatient
Step 3
Intensive
outpatient
Outpatient
Step 2
Outpatient
post-inpatient
Step 1 Step 3
Every level of care is based on the same theory, and uses similar strategies and
strategies (more intensive in intensive outpatient and inpatient CBT-E)

4. Why a clinical service based on CBT-E?
Rational
• It is a treatment to treat most patients with
– Patients with any ED diagnosis (“transdiagnostic”)
– Adults and adolescents
– Complex patients
– Outpatients, day patients and inpatients
• Liked by patients
• Detailed treatment guide
• Good evidence base

5. The treatment guides
Fairburn CG: Cognitive Behaviour Therapy and Eating Disorders.
Guilford Press, New York, 2008
Dalle Grave, R. (2012). Intensive Cognitive Behavior Therapy for Eating
Disorder. Hauppauge NY, Nova Publisher
Dalle Grave, R. (2013). Multistep Cognitive Behavioral Therapy for
Eating Disorders: Theory, Practice, and Clinical Case. Lanham: Jason
Aroson

6. CBT-E in intensive settings of care
Rational
• A subgroup of patients does not respond to outpatient CBT-E
• A subgroup of patients has an eating disorder of clinical severity not manageable
with outpatient CBT-E
• Data on changing the nature of outpatient treatment (e.g., from CBT to IPT or
fluoxetine) are inconclusive.
• The ineffectiveness of outpatient CBT-E in some patients might depend by the
insufficiently intensity of care rather than by the nature of the treatment

7. CBT-E in intensive settings of care
Rational (cont.)
• CBT-E addresses the ED psychopathology – rather the DSM diagnosis
Ideal in an inpatient settings where patients have different DSM diagnosis
• CBT-E has a lasting effects
– It address the maintaining mechanisms of the ED psychopathology
– It help patients addressing setbacks and preventing relapse
Ideal in an inpatient setting where the main problem is the relapse after discharge

8. The various forms of intensive CBT-E
• Inpatient CBT-E
• Intensive outpatient CBT-E
– Both treatment have been developed at the Department of Eating and
Weight Disorders of Villa Garda Hospital (Italy) under the supervision of
Chris Fairburn
– These treatments can be adapted to meet the different health organization
and resources of the countries where are implemented

9. Inpatient CBT-E
Research findings
• Dalle Grave R, Calugi S, Conti M, Doll H, Fairburn CG. Inpatient cognitive behaviour therapy for
anorexia nervosa: A randomized controlled trial. Psychotherapy and Psychosomatics.
2013;82(6):390-8.
• Dalle Grave R, Calugi S, El Ghoch M, Conti M, Fairburn CG. Inpatient cognitive behavior therapy
for adolescents with anorexia nervosa: immediate and longer-term effects. Frontiers in
Psychiatry. 2014;5:14.

10. Characteristics
All Patients CBT-Ef CBT-Eb
Test
p
(N=80) (N=42) (N=38) (value)
Age, years 23.4 (6.9) 23.1 (6.8) 23.7 (7.0) -.41 .681
Gender, n (%) female 78 (97.5) 40 (95.2) 38 (100) 1.86 .173
Duration of eating disorder,
years, median (range)
5.0 (0-26.0) 4 (0-20.0) 5.0 (0-26.0) -.65 .517
Current other axis I disordera
- Major depressive episode, n
(%) present
45 (56.3) 25 (59.5) 20 (52.6) .38 .535
- Any anxiety disorder, n (%)
present
16 (20.0) 9 (21.4) 7 (18.4) .11 .737
Characteristics of the two samples at baseline.
Data are shown as mean (SD) unless otherwise indicated.
Dalle Grave et al. Psychotherapy and Psychosomatics. 2013;82(6):390-8.

11. Mean body mass index (BMI) and eating disorder psychopathology (global
EDE-Q) over 20 weeks of treatment and 12-month of follow-up in completers
12
13
14
15
16
17
18
19
20
Before
treatment
After
treatment
6-month
follow-up
12-month
follow-up
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Before
treatment
After
treatment
6-month
follow-up
12-month
follow-up
CBT-Ef
CBT-Eb
BMI EDE global
Completers: CBT-Ef, n=37, 88.1%; CBT-Eb, n=35, 92.1% (p = .550)
Dalle Grave et al. Psychotherapy and Psychosomatics. 2013;82(6):390-8.

12. Inpatient CBT-E for adolescents with anorexia nervosa (n = 26/27)
Dalle Grave et al. Frontiers in Psychiatry. 2014;5:14.
Characteristics
Age, years 16.0 (1.1)
Duration of eating disorder, years, 2.0 (0-7)
Body mass index centile 2.7 (4.3)
BMI centile of <1.0. 16 (59.6%)

13. Inpatient CBT-E
Differences with outpatient CBT-E
• Multiple therapists
• Assisted eating
• Some CBT-E elements are delivered in group

14. Inpatient CBT-E
Indications
• Poor response to well-delivered outpatient-based treatment
• Presence of features that make outpatient eating disorder treatment
inappropriate (inpatient CBT-E)
– Very low weight
– Rapid weight loss
– Marked medical complications (e.g., pronounced edema, severe electrolyte
disturbance, hypoglycaemia)
– Significant suicide risk
– Severe interpersonal problems

15. Inpatient CBT-E
Contraindications
• Daily substance abuse (intermittent drug abuse of alcohol, cocaine or
ecstasy is not considered a contraindication)
• Acute psychotic disorders

16. Traditional inpatient ED treatments
Use of multiple therapists
• Generally, intensive treatments are not theory-driven and are administered
by a “multidisciplinary eclectic team”
– The psychologist may adhere to a psychoanalytic or systemic theory
– The dietitian may adopt some behavioural procedures and strategies
– The physicians may follow a biomedical prescriptive model
Each team member follows his/her theory and therapeutic practice, pursuing
therapeutic goals related to his/her professional role
• Problems
– Contradictory information
– Team conflicts
– Difficult to produce substantial improvements in treatment
– Difficult to replicate and disseminate the treatment to other units

17. Inpatient CBT-E
Use of multiple therapists
• All the therapists are fully trained in cognitive behaviour theory and therapy
for eating disorders (non-eclectic approach)
• All the therapists share the same treatment philosophy and the same
language
• The personal formulation integrates each staff member's contribution to
treatment
• The treatment fidelity is monitored
– Weekly review meeting with patient (round table)
– Weekly team meeting
– Peer supervision
– Sessions recording

18. Inpatient CBT-E
Use of multiple therapists (cont.)
• CBT Psychologist
– Address the over-evaluation of control over eating, shape and weight, and implement the
"broad" CBT-E modules.
• CBT Nurse
– Has the usual tasks of a nurse in a hospital unit and oversees the weighing of the patient
• CBT Dietitian
– Addresses the modification of eating habits and weight, and assisted eating
• CBT Physician/Psychiatrist
– Treats the medical complication of the patients and is responsible for the medications
prescription

19. Inpatient CBT-E
Preparation
• 3 to 8 sessions (some aspects are similar to the Step One of CBT-E for
underweight patients)
– Assess the indications for the treatment
– Engage the patient
– Educate about the psychobiological effects of being underweight and consider
the implications
– Create a personalized formulation with the inclusion of malnutrition symptoms
– Discuss the pros and cons of change (regaining weight) and to start the
impatient CBT-E
– Assess the patient availability to play an active role in the treatment
– Information about the treatment

20. Inpatient CBT-E
Preparation (cont)
Information for patients
• The unit
• The cognitive behavioural theory
• The treatment
• Attitudes and commitment required
– Treatment as an opportunity to make a “fresh start” and to
build a “new life”
– Treatment as a priority
– Starting well
– Active role in the treatment
– Responsibility towards other patients
• Patients receive a pamphlet describing the treatment
www.villagrada.it

21. Inpatient CBT-E
General Organization
Place%
Stage%
Weeks%
(If%additional%‘external’%maintaining%
mechanisms%have%emerged)%

22. Inpatient CBT-E map
Stage One
(weeks 1-4)
Starting well
Engaging and educating patients
Self-monitoring, collaborative weekly weighing, and building the personal formulation
Assisted meals
Stage Two
(weeks 5-6)
Taking stock
Reviewing the progress and planning Stage Three
Adjunctive
modules
Clin perfectionism
Core low self-esteem
Interpersonal
problems
Body image
Self-evaluation
Body checking
Body avoidance
Feeling fat
Stage Three
(weeks 7-17)
Dietary
restraint
Dietary restriction
Dietary restraint
Events, mood
and eating
Problem solving
Mood intolerance
Stage Four
(weeks 18-20)
Ending well
Identifying the residual problems and the procedures to use after discharge
Developing strategies and procedures to prevent the relapse
Organizing the post-inpatient treatment
Building the post-inpatient plan
Da Dalle Grave, 2013

23. Inpatient CBT-E
Core procedures
1. Creating a personalized formulation
2. Establishing self-monitoring
3. Monitoring and interpreting the weight
4. Monitoring the course of the treatment
5. Assisted eating
6. Non-assisted eating
7. The weekly review meeting
8. Individual CBT-E sessions
9. Group treatment sessions
10. Exercise sessions

24. Inpatient CBT-E
Core procedures
1. Creating a personalized formulation
2. Establishing self-monitoring
3. Monitoring and interpreting the weight
4. Monitoring the course of the treatment
5. Assisted eating
6. Non-assisted eating
7. The weekly review meeting
8. Individual CBT-E sessions
9. Group treatment sessions
10. Exercise sessions

25. Core procedures
Assisted eating
• Over the first six weeks or until patients reach a BMI > 18.5
• Three meals and a snack each day (breakfast, lunch, mid-afternoon snack
and dinner)
• Assistance of the CBT dietitian (or CBT nurse)

26. Core procedures
Assisted eating (cont)
The patient’s role
• “Active role” in applying the cognitive behaviour strategies during the meals
– Your role is nor just eating, but also applying the cognitive behaviour
strategies to to handle your eating disorder mindset
– If you eat passively, when you will consume the meals by yourself, you
will not be able to handle your eating disorder mindset

27. Core procedures
Assisted eating (cont)
CBT-E strategies to address the meals
• Eating all the planned food
– “The eating plan will help you to feel in control during the weight restoration you may
predict the rate of weight regain”.
• Eating without being influenced by internal signals of hunger, and fullness
– “Try to eat without being influenced by internal signals of hunger, feeling full, because
they are altered by your underweight state”.
• Eating without being influenced by preoccupations on eating and food
– “Say to yourself that these are the expression of the eating problem mind-set that you
want to change”.

28. Core procedures
Assisted eating (cont)
CBT-E strategies to address the meals (cont)
• Distancing the behaviour from thoughts and preoccupation on eating and food
– “Do not follow the thoughts of your eating problem mindset - make the
opposite”.
• Avoiding the use of rituals at the table
– "Try to adopt the mindset of an athlete before high jumping. He concentrates on
the technique to use and not on the fear of failing or on how high the bar may
be”.
• Using the self-monitoring record in real time
– “If you have difficulties during the meals write the strategies you should apply in
your monitor record”

29. Core procedures
Assisted eating (cont)
The dietitian/nurse’s role
• Support and encouragement
• Cognitive behavior strategies
– de-centering from internal states and problematic thoughts
– distancing the behavior from thoughts
– dissuading from practicing any atypical methods of food intake and rituals
to control eating

30. Core procedures
Assisted eating (cont.)
Managing the moments following the meals
• After the assisted eating you are encouraged to remain in the sitting room and for an
hour to apply alternative activities (e.g., read, watch TV, study, listen to music, use
the internet, etc..) for managing the impulse to adopt compensatory behaviours (i.e.,
exercising, self-induced vomiting)
• In this hour you are encouraged to avoid the use of the bathroom

31. Core procedures
Non-assisted eating
• When the period of assisted eating over
– Patients start gradually eating outside the unit
– The treatment addresses dietary restraint as outpatient CBT-E
• At discharge patients should be able to maintain their weight in a normal
range following flexible dietary guidelines

32. Core procedures
The weekly review meeting (round table)
• Once a week between patient and all his or her therapists at a round table
– To discuss the various elements of the treatment and their relationship to one
another are discussed
• This permits all the team members to have a complete picture of the patient’s eating
disorder and to avoid the delivery of contradictory messages
• Patients interpret their BMI graphic and suggest, using the intensive CBT-E weight
regain CBT-E guideline, the diet changes for weight regain (1 kg per week) or
maintenance
• Revision of the state of the personal formulation
Rational
• Maintaining fidelity to the treatment and ensuring cross-therapist consistency in its
implementation
• Encouraging patients to become a “therapist” of their eating problem

33. Inpatient CBT-E
Modules
CBT-Ef
• Underweight and dietary restriction
• Dietary restraint
• Excessive and compulsive exercising
• Purging
• Body image
• Events, moods and eating
• Setbacks and mindset
3 key strategies:
1. Identification
2. Education
3. Procedures to address the
maintaining mechanism
CBT-Eb
• Clinical perfectionism
• Core low self-esteem
• Interpersonal problems

34. Inpatient CBT-E
Program’s elements to reduce relapse
• CBT-E modules to address the eating disorder psychopathology … plus
• Open unit
• Day treatment
• Involvement of other significant
• Ending well

35. Program’s elements to reduce relapse
Open unit
• Inpatient CBT-E is provided in a specialized unit for the treatment of eating disorders
• The unit is ‘open’, and patients in a stable medical condition are free to go outside it
• Significant others are free to visit the patient at any time other than mealtimes and
when treatment sessions are occurring

36. Program’s elements to reduce relapse
Open unit (cont)
• The unit atmosphere is psychological rather than medical, and not
institutional
– The staff does not wear medical scrubs and uniforms
– Patients are free to decorate their room

37. Program’s elements to reduce relapse
Day treatment
• During the day treatment stage patients are helped to identify triggers of
their eating disorder mindset that are not present on the unit.
– These are then addressed in treatment
• Gradual decrease of the treatment intensity
– The treatment evolves towards the outpatient treatment

38. Program’s elements to reduce relapse
Involvement of significant others
• With the patient’s consent if they can facilitate the treatment
• Three sessions after the individual CBT-E sessions
• Goal
– Create a positive stress-free home environment for the patient's return

39. Program’s elements to reduce relapse
Ending well
1. Identifying the residual problems and the procedures to use after
discharge
2. Developing strategies and procedures to prevent relapse
3. Organizing the post-inpatient treatment
4. Building the post-inpatient plan

40. Ending well
Identifying the residual problems
• EDE
• CIA
• Monitor records
• Personalized formulation of the residual problems
Identifying the procedures to use after discharge
• Self-monitoring
• Weekly weighing plus..
• Procedures individualized on the basis of the patient’s problems

41. Ending well
Trigger
Return of
mindset
Return of the ED characteristics
(a setbacks)
Prevent the triggers
- Proactive problem
solving
Identify immediately
the trigger
- Weight and shape
triggers
- Eating triggers
- Events and moods
triggers
Decentring immediately
Make the right thing
“Make the opposite”
Identify immediately the setbacks
It is a lapse (not a relapse)
Back immediately on the track
Developing strategies and procedures to prevent relapse

42. Ending well
Organizing the post-inpatient treatment
Education on the period after discharge
• At the end of the inpatient treatment there are some residual problems that
need to be addressed
• The first period after discharge is the most risky for relapse
– Transition from an intensive to a low intensive treatment
– Change of the therapist and often the nature of the treatment
– Exposure to multiple environmental triggers (family environment, school or
work, lack of friends and social support)
• It is fundamental to develop specific skills to prevent relapse

43. Ending well
Organizing the post-inpatient treatment (cont)
Information about the post-inpatient CBT-E
• Aims
– Addressing the residual problems
– Developing skills to prevent relapse
• Advantages
– Maintenance of the same treatment
– High initial intensity
– Time limited (20 sessions in 20 weeks )
• Weeks 1 to 4: two sessions a week
• Weeks 5 to 12: one session a week
• Weeks 13 to 20: one session biweekly

44. Ending well
Organizing the post-inpatient treatment (cont)
Nature of the post-inpatient CBT-E
• Similar to the Stage Three of the standard CBT-E
– Self-monitoring
– Collaborative weekly weighing
– Regoular eating
– Modules (their use depend by the residual problems of the patient)
• Body image
• Diatary restraint
• Events, moods and eating
• Adjunctive modules (CBT-Eb)
• Setbacks and minsets
• Concluding the treatment (similar to the Stage Four of the standard CBT-E)
• Follow-up session after 20 weeks

45. Ending well
Building the post-inpatient plan
• A written post-discharge maintenance plan is jointly built with the patients
– My life after discharge
• School/work
• Residence
• Interpersonal relationships
• Interests to marginalize my eating problem
– My outpatient therapy
– Problems which I have to focus on after discharge
– How I will minimize the risk of relapse