Eating Behaviors 30 (2018) 1–4

Contents lists available at ScienceDirect

Eating Behaviors
journal homepage: www.elsevier.com/locate/eatbeh

Feasibility of group Cognitive Remediation Therapy in an adult eating T

disorder day program in New Zealand
Marion E. Roberts
Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
Department of General Practice and Primary Healthcare, Faculty of Medical and Health Sciences, University of Auckland, New Zealand

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: To explore the feasibility of integrating group Cognitive Remediation Therapy (gCRT) into an eating
Eating disorders disorder day program in Auckland, New Zealand.
Cognitive Remediation Therapy Method: A consecutive series of 28 patients took part over an 8-month period in the context of a service audit.
Feasibility Main outcome measures were the Detail and Flexibility Questionnaire (DFlex) and qualitative feedback from
Set-shifting
patients.
Weak coherence
Results: Significant shifts in self-report inefficient cognitive style were observed pre/post gCRT with large effect
sizes (Cohen's dav) for both cognitive rigidity and attention to detail outcomes. Patient feedback was positive,
with themes of enjoyment, increased insight, and positive social interaction/esteem boosting in the context of
the group emerging.
Conclusions: Support for the acceptability, adaptation, expansion, practicality, and limited-efficacy testing of
gCRT in an Australasian day program setting has been found, suggesting integration of this module into existing
day treatment programs is merited. Larger scale trials may help delineate the clinical characteristics of good
responders.

1. Introduction
The cognitive interpersonal maintenance model of anorexia nervosa
(AN) outlines cognitive, socio-emotional, and interpersonal constructs
hypothesised as both predisposing and perpetuate factors of the illness
(Schmidt & Treasure, 2006; Treasure & Schmidt, 2013). In response to
the body of literature highlighting the role of cognition as presented in
the interpersonal model, Cognitive Remediation Therapy (CRT) for AN
was developed. CRT for AN is a brief, time-limited pre-treatment in-
tervention initially designed to target neurocognitive inefficiencies in
inpatients, while engaging them in the process of therapy (Davies &
Tchanturia, 2005; Tchanturia, Davies, & Campbell, 2007). CRT targets
both poor set-shifting (cognitive rigidity) and weak coherence (detail
focus to the exclusion of global integration). Both of these processing
styles have been well documented in the AN literature (Lang, Lopez,
Stahl, et al., 2014; Roberts, Tchanturia, Stahl, et al., 2007; Westwood,
Stahl, Mandy, et al., 2016; Wu, Brockmeyer, Hartmann, et al., 2014),
and implicated as underlying endophenotypes and/or maintaining
factors of AN (Holliday, Tchanturia, Landau, et al., 2005; Lopez,
Tchanturia, Stahl, et al., 2008; Roberts, Tchanturia, & Treasure, 2013;
Tenconi, Santonastaso, Degortes, et al., 2010; Treasure & Schmidt,
2013).
Over the past decade, evidence for the acceptability and efficacy of
individual CRT in the inpatient setting has been gathering, through case
reports (Davies & Tchanturia, 2005), case series (Tchanturia et al.,
2007), and more recently randomised controlled trials (Tchanturia,
Lounes, & Holttum, 2014). Overall, research suggests that individual
CRT is an acceptable intervention for both patients and therapists, can
bring about an increase in treatment motivation, and can facilitate
some gains in both meta-cognition and capability to remediate biases in
neurocognitive profile (for a systematic review, see Tchanturia et al.,
2014). Various adaptations of individual CRT have since been devel-
oped (Lang, Treasure, & Tchanturia, 2015; Lock, Agras, Fitzpatrick,
et al., 2013; Raman, Hay, & Smith, 2014; van Noort, Kraus, Pfeiffer,
et al., 2016). Common to all qualitative studies is the high acceptability
of CRT from both patient and therapist perspectives (Easter &
Tchanturia, 2011; Tchanturia, Giombini, Leppanen, et al., 2017;
Whitney, Easter, & Tchanturia, 2008).
A group protocol for adolescent AN has more recently been man-
ualised (Maiden et al., available online from www.katetchanturia.com).
A pilot study including 30 adolescents with AN reporting the “flexibility
group” to be interesting and acceptable to adolescents, with a small
increase in self-reported cognitive flexibility found at follow-up
(Pretorius, Dimmer, Power, et al., 2012). A later case series of nearly

E-mail address: marion.roberts@auckland.ac.nz.

https://doi.org/10.1016/j.eatbeh.2018.04.004
Received 4 July 2017; Received in revised form 13 April 2018; Accepted 30 April 2018
Available online 02 May 2018
1471-0153/ © 2018 Published by Elsevier Ltd.
M.E. Roberts
100 patients across 20 groups delivered in inpatient/intensive day
program settings over a 5-year period replicated findings of high ac-
ceptability of CRT in a group format, together with increased motiva-
tion to change and a significant improvement in self-reported rigidity
and detail focus (Tchanturia, Larsson, & Brown, 2016).
Treatment research of group CRT is less developed than individual
CRT. Data to date comes exclusively from European and American co-
horts, meriting an investigation in the Australasian context. Feasibility
studies provide a practical framework within which to investigate and
understanding the practicalities of disseminating evidence-based
treatment into community clinical settings, particularly those without
the resources of a research team. The current study aims to assess five
key aspects of feasibility (Bowen, Kreuter, Spring, et al., 2009) within a
specialist adult day program for eating disorders in New Zealand;
adaptation, expansion, practicality, acceptability, and limited-efficacy
testing.
2. Material and methods
2.1. Participants
A consecutive series of 28 patients admitted to the day program at
Thrive Eating Disorders Service in Auckland, New Zealand over an 8-
month period (August 2015–March 2016) were assessed as part of a
service audit. All participants met DSM-IV criteria for AN or BN. On
consultation with the local ethics committee (HDEC online), formal
ethical approval was not required due to the nature of the study being
part of a service audit. Permission was gained from the Thrive service
manager, and informed verbal consent was obtained from each patient
before their first CRT session.
2.2. Measures
2.2.1. Detail and Flexibility Questionnaire (DFlex)
The DFlex (Roberts, Barthel, Lopez, et al., 2011) is a 24-item self-
report measure, assessing two 12-item subscales of attention to detail
and cognitive rigidity as they manifest in everyday life. Moderate to
strong construct validity was reported in the original validation study,
when compared to appropriate subscales of the Autism Quotient
(Baron-Cohen, Wheelwright, Skinner, et al., 2001; Roberts et al., 2011).
Internal consistency in the current sample was low on admission
(Cognitive rigidity α = 0.48; detail focus α = 0.68) but excellent on
discharge (α = 0.91; α = 0.94). The DFlex has previously been used as
a CRT outcome measure (Tchanturia et al., 2016).
2.2.2. Eating Disorders Examination-Questionnaire (EDE-Q)
The EDE-Q is a 28-item measure of eating disorder psychopathology
adapted from the clinician-rated Eating Disorders Examination
(Fairburn & Beglin, 1994). Evidence for strong psychometric properties
including convergent validity have been found (for a systematic review,
see Berg, Peterson, Frazier, et al., 2012).
2.2.3. Depression Anxiety & Stress Scale-21 (DASS-21)
The DASS-21 (Lovibond & Lovibond, 1995) is a 21-item self-report
measure that delineates mood disruption into depression, anxiety and
stress symptoms. Internal consistency is high (α = 0.79–0.93) amongst
women with an eating disorder (Eshkevari, Rieger, Longo, et al., 2014).
2.2.4. Qualitative questionnaire
A feedback questionnaire was administered at discharge, where
patients were asked four open-ended questions: how they found CRT in
general, what they enjoyed most, anything they did not enjoy, and if
they would suggest any changes.
2
Eating Behaviors 30 (2018) 1–4
2.3. Procedure
2.3.1. Treatment setting
Thrive Eating Disorders Service is a publically funded specialist
group-based treatment program for eating disorders. Patients are seen
by a multi-disciplinary team for group work (physiotherapy, occupa-
tional therapy, psychological therapy, nutrition education) and sup-
ported meals up to five days per week. Patients have weekly individual
psychological sessions (drawing from CBT, motivational interviewing
and psychodynamic approaches) and individual dietetic sessions.
Weekly medical monitoring is conducted by staff nurses (weight and
basic observations), with psychiatric medication review provided as
appropriate.
2.3.2. Intervention
Manualised group Cognitive Remediation Therapy (gCRT) was de-
livered on a weekly basis as part of the standard Thrive day program
treatment on a rotating basis within an open group. The intervention
consisted of eight 60-minute sessions, with the topics comprising two
rotations of three themes (bigger picture thinking, switching, multi-
tasking) plus motivational summary sessions at the end of each rota-
tion. Some amendments were made to the original adolescent protocol
(Maiden et al., available online from www.katetchanturia.com) to en-
sure that the intervention was developmentally and culturally appro-
priate (see Online Supplementary Table 1). A 5–10 self-reflective
component was added to the end of each session.
2.3.3. Data collection and analysis
Patients completed questionnaires on admission and discharge, with
the qualitative feedback questionnaire on discharge only. Inspection of
histograms indicated that data was normally distributed, therefore
paired-sample t-tests were run for the main outcome measure (DFlex).
Given the small sample size, Cohen's dav effect sizes (for dependent or
repeated measures) are reported (Lakens, 2013) as an additional in-
dicator of the strength of the difference in scores pre/post intervention.
3. Results
3.1. Audit metrics
Twenty-eight admissions (24 = AN; 4 = BN) were made into the
day program during the audit timeframe, with 16 patients (12 = AN;
4 = BN) completing 4 or more of the 8 gCRT sessions, and 12 patients
(12 = AN; 0 = BN) completing between 1 and 3 group sessions.
Reasons for not completing four or more sessions were as follows;
transferred to residential treatment (n = 4), transferred to outpatient
treatment (n = 6), timing of session clashed with individual psycholo-
gical session (n = 2). Patients completing three or fewer gCRT sessions
were excluded from further analysis, due to having participated in less
than half of the intervention. One additional AN patient was excluded
from the analysis, as no questionnaires were completed. Therefore,
further analyses includes data from the 15 patients that completed four
or more CRT group sessions (“audit cases”).
Of the 15 audit cases, an average (median) of 8 gCRT sessions
(quartiles 5–10) were completed (median unique sessions = 6; quartiles
5–7).
3.2. Participant characteristics
See Table 1 for demographic details of the audit cases. Most cases
presented as AN binge/purging type (n = 7; 46.7%) or AN restricting
type (n = 4; 26.7%). The remaining four cases were BN (26.7%). One
case was male (AN). Wide variance in the duration of eating disorder
illness was observed, with a range of 1–28 years (age range
19–48 years). Similarly, given inclusion of all patients admitted to the
day program (both AN and BN cases), wide variance in BMI was seen at
M.E. Roberts Eating Behaviors 30 (2018) 1–4

Table 1 4. Discussion
Participant characteristics (n = 15).
Age 25.07 (8.25) This study aimed to assess the feasibility of group Cognitive
Age of eating disorder onset 16.6 (3.11) Remediation Therapy (gCRT) as an additional group intervention in a
Duration of illness (years) 8.67 (8.21) specialist adult eating disorder day program setting in Auckland, New
Lowest BMI (AN/BN) 14.38 (0.78)/17.10 (2.88) Zealand.
Highest BMI (AN/BN) 21.33 (4.32)/23.93 (4.09)
a
Comorbid MDD n (%) 11 (73.3%)
a
Comorbid anxiety n (%) 8 (53.3%) 4.1. Adaptation, expansion & practicality
a
Comorbid alcohol/drug abuse n (%) 5 (33.3%)
a
Self-harm history n (%) 4 (26.75%) Minor adaptations to the Maudsley treatment manual were easily
a
implemented, in the context of expanding the treatment into a non-UK
Presence of comorbid diagnoses taken from referral information.
setting. The addition of a self-reflective component to the end of the
session received positive feedback from patients and was observed by
Table 2
the therapist to be a beneficial addition in this adult cohort, meeting
Paired-samples pre/post intervention descriptive outcomesa.
CRT aims of reflecting on and personalising session content. This is
Pre-gCRT Post-gCRT Cohen's dav likely the first paper to report on cultural adaptations of gCRT in the
context of expansion to a different cultural setting. While a small pilot
DFlex - detail focusb
43.12 (5.84) 34.81 (12.80) −0.89e
DFlex - cognitive rigidityc 47.30 (4.76) 38.90 (10.05) −1.14e of gCRT with seven patients in Japan has been published (Kuge, Lang,
DASS-21 - depression 8.64 (6.58) 5.00 (4.67) −0.65d Yokota, et al., 2017), no discussion of cultural adaptations for Japanese
DASS-21 - anxiety 10.00 (4.82) 5.00 (3.92) −1.14e patients was included.
DASS-21 - stress 10.45 (5.72) 6.36 (4.27) −0.82d The format of gCRT was a good practical fit within the day program
EDE-Q - dietary restraint 2.29 (1.87) 0.96 (0.90) −0.96e
EDE-Q - eating concern 3.00 (1.63) 1.04 (0.85) −1.58e
schedule given session duration, relevance of content across AN and BN
EDE-Q - shape concern 4.30 (1.52) 2.70 (1.61) −1.03e patients, and the open group format meeting service need. Limited fi-
EDE-Q - weight concern 3.76 (1.57) 2.16 (1.61) −1.01e nance was required for set-up costs. Perhaps the largest resource chal-
EDE-Q global 3.34 (1.48) 1.72 (1.16) −1.23e lenge to services new to gCRT is the initial training and ongoing su-
BMI - AN (n = 11) 16.63 (0.53) 17.25 (0.99) +0.78d
pervision for the clinician. As therapist stance and approach is critical
BMI - BN (n = 4) 21.5 (1.36) 21.45 (0.97) −0.04
to competent delivery of gCRT, appropriate training and supervision
a
5 cases had missing discharge data (no discharge questionnaires were should be prioritised to ensure integrity of the treatment.
completed) and were excluded from this analysis (all cases had intact BMI data
on discharge). 4.2. Acceptability
b
Cohen's dav re-run excluding the male participant (dav = −0.84), then ex-
cluding the BN participants (dav = −0.61). Qualitative feedback from patients indicated that gCRT was a well-
c
Cohen's dav re-run excluding the male participant (dav = −1.19), then ex- accepted intervention. The qualitative themes observed here are con-
cluding the BN participants (dav = −1.17). sistent with previous findings, for example themes of interactive &
d
Moderate effect. practical elements, knowledge/reflection, and approach to group/re-
e
Large effect. laxed atmosphere in a large case series of gCRT in inpatient/day patient
services (Tchanturia et al., 2016). Similarly, current themes map well
the start of gCRT (see Table 2) with a range of 15.7–22.7. with those identified in a letter analysis of 70 young people following
individual CRT, namely engaging aspects of CRT, identifying thinking
skills, and relevance to real-life situations (Giombini, Nesbitt, Waples,
3.3. Pre-post intervention outcomes
et al., 2017). Earlier formal qualitative studies assessing the accept-
ability of individual CRT mirror these same topics (Whitney et al.,
As outlined in Table 2, decreases in both subscales of the DFlex were
2008; for a systematic review, see Tchanturia et al., 2017).
found with large effect sizes. These decreases were significant based on
paired-sample t-tests for both detail focus (t = 2.64, p = 0.027) and
4.3. Limited efficacy-testing
cognitive rigidity (t = 2.78, p = 0.021). Reporting these same results
using the common language effect size (McGraw & Wong, 1992), after
Significant changes with large effect sizes for both cognitive rigidity
controlling for individual differences the likelihood of a lower score at
and detail focus indicate that measurable change in thinking style was
discharge was 79.8% for detail focus, and 81.1% for cognitive rigidity.
noted by the patient. This shift was particularly evident for cognitive
When the four BN cases were excluded from the analysis, no difference
rigidity, which was more highly endorsed on admission. It is also no-
was observed for the strength of change (Cohen's dav) in cognitive ri-
table that the variance in both cognitive rigidity and detail focus was
gidity, however a modest drop for detail focus was observed (large to
more than double at discharge compared to admission, suggesting that
moderate effect).
there may be a subset of patients that the intervention was particularly
Similarly, decreases in mood and eating disorder psychopathology
potent for. A larger scale trial may help delineate characteristics of this
measures across day program treatment were found, indicating the
responsive subgroup, through an appropriately powered investigation
gains patients made across day treatment as a whole.
of clinical features such as duration of illness, BMI, comorbidity,
treatment motivation, formally assessed neurocognitive profile, and
3.4. Qualitative feedback baseline DFlex score.
The strength of the change in DFlex subscales in the current cohort
Formal qualitative analysis of the discharge questionnaire has not is notably larger than the largest case series of gCRT to date (Tchanturia
been undertaken due to the small sample size. In general, patients de- et al., 2016). While clinical characteristics across the samples were si-
scribed the group with positive adjectives such as “fantastic”, “inter- milar (mean age & BMI), the dose of intervention was stronger in the
esting”, “helpful” and “insightful”. Themes of CRT being enjoyable current cohort (8 sessions vs. 4–6 sessions). Additionally, the current
(playing the games, social interaction/discussion), increasing insight cohort were all in an intensive day program, compared to patients from
into personal cognitive style, and the group being a safe therapeutic either an intensive day or inpatient setting. Taken together, this may
environment emerged. suggest that CRT in group format is most potent in a day program

3
M.E. Roberts
setting and when following the full eight session protocol.
4.4. Limitations
The current study is a small investigation of feasibility in a com-
munity clinical setting, and as such there are a number of limitations.
While preliminary support for the efficacy of the intervention was
found, this must be set in the context of small study numbers (and
therefore basic statistical analysis), high attrition (due to clinical deci-
sion-making), a single self-report scale as the main outcome measure,
and the absence of neuropsychological testing which may have in-
formed objective rather than subjective change. The main outcome
measure (DFlex) showed low internal consistency at baseline, which
needs to be considered when interpreting findings. Unfortunately, in-
ternal consistency could not be calculated for the DASS-21 and EDE-Q
due to misplaced raw data. Typical of a clinical setting, the sample was
also highly heterogeneous particularly in terms of patient presentation
(AN/BN), age and duration of illness. Participants were not excluded
based on clinical characteristics, as in assessing feasibility it was of
interest whether the intervention would be appropriate for all patients
included in the group treatment setting. However, it should be noted
that AN and BN likely have different neuropsychological profiles (Lang,
Roberts, Harrison, et al., 2016; Roberts et al., 2013; Wu et al., 2014)
and may therefore respond differently to the intervention. For example,
the smaller effect size for detail focus on exclusion of the four BN cases
suggests those with BN may have made a bigger improvement in detail
focus than those with AN.
4.5. Conclusion
In sum, this preliminary study suggests gCRT is a feasible addition
to a group day program for eating disorders. Future work should shift to
randomised controlled trials as has been done with individual CRT.
Larger scale studies may help identify a potential subgroup of good
responders to gCRT, in order to inform treatment planning. It would be
of interest to investigate whether treatment response correlates more
highly with subjective (self-report) cognitive inefficiencies as they
practically manifest, or objective neurocognitive profile.
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.eatbeh.2018.04.004.
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