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http://hpq.sagepub.com/content/early/2011/03/25/1359105310396395The online version of this article can be found at:

 DOI: 10.1177/1359105310396395

published online 25 March 2011J Health PsycholKate Tchanturia

qualitative studyA brief emotion focused intervention for inpatients with anorexia nervosa: A

  

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Article

Introduction

Background

Anorexia Nervosa (AN) is a life threatening illness with the highest mortality rate of any psychiatric disorder (Treasure et al., 2010). Treatment outcomes are poor with 20 percent remaining chronically ill, often requiring repeated hospital admissions and remaining dependent on state benefits (Steinhausen, 1999). The development of new and effective treatments for AN are urgently needed.

Targeting the core maintaining factors of AN is an essential step in generating treatment advances (Shafran and de Silva, 2003). One model that highlights these factors is Schmidt

and Treasure’s (2006) cognitive-interpersonal maintenance model for AN. Within this model, emotion avoidance, cognitive rigidity,

1  King’s College London, Institute of Psychiatry, Division of Psychological Medicine, Section of Eating Disorders

2  Eating Disorders, South London and Maudsley NHS Foundation Trust

Corresponding author:Dr. Kate Tchanturia, P0 59 Section of Eating Disorders, Institute of Psychiatry, King’s College London, De Crespigny Park, London, SE5 8AF, UK. Email: kate.tchanturia@.kcl.ac.uk

A brief emotion focused intervention for inpatients with anorexia nervosa: A qualitative study

Claire Money2, Rebecca Genders 2,Janet Treasure1,2, Ulrike Schmidt1,2

and Kate Tchanturia1,2

AbstractCognitive  Remediation  and  Emotion  Skills  Training  (CREST),  a  brief  social  cognition  intervention,  was developed  for  inpatients with Anorexia Nervosa  (AN). CREST was  piloted  and  evaluated  in  28 Anorexia Nervosa patients on a specialist eating disorder inpatient unit. Content analysis was employed to qualitatively explore patients’ experience of the intervention. Results suggest that patients perceived CREST positively. Main themes identified were that patients’ valued education regarding the function of emotions and found learning strategies to manage and express emotions helpful. The clinical and research implications are discussed.

Keywordsanorexia nervosa, cognitive remediation and emotion skills training (CREST), emotion processing, inpatient treatment, qualitative research

Journal of Health Psychology1–12© The Author(s) 2011Reprints and permissions:  sagepub.co.uk/journalsPermission.navDOI: 10.1177/1359105310396395hpq.sagepub.com

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2  Journal of Health Psychology

pro-anorectic beliefs and the response of close others are put forward as core maintaining fac-tors and are suggested as the focus for new treatments for AN.

The aim of the current study was to evaluate a brief 10 session treatment package, which has been piloted in a specialist eating disorder (ED) inpatient unit to address one of the maintaining features of AN; namely emotion processing dif-ficulties. We were interested in patients’ per-spective about the acceptability and feasibility of this brief intervention that was targeting edu-cation and micro skills training for inpatients with AN. Emotions in AN have received increasing attention in the literature and there is a need to further understand the particular role they play in the development, maintenance and recovery from this disorder.

Emotions in AN

Addressing emotional skills in AN has histori-cal importance (Bruch, 1962), and recently two qualitative studies have explored the salient issues pertaining to emotions and social cogni-tion in AN. Kyriacou et al. (2009) conducted focus groups with AN patients, carers and clini-cians and identified difficulties in recognizing, understanding, expressing and tolerating emo-tions. With regards to treatment, one theme highlighted by patients and carers was a need for psycho-education on emotions. In addition, Fox (2009) explored individual AN patients accounts of their experience of emotions and emotion management. This study emphasized important themes including a poor development of meta-emotional skills and a sense of confu-sion about emotion states experienced. In par-ticular, difficulties with tolerating and managing anger and sadness were highlighted and patients often referred to early experiences where emo-tions were either overwhelming in the family environment or were avoided. This resulted in the avoidance or suppression of emotions and, in part, the AN served as a function to suppress and avoid feeling (Fox, 2009). There is some evidence that people with AN perceive illness

helping them to stop feeling emotions (Serpell et al., 1999).

Numerous experimental and self-report stud-ies have also found difficulties in affect recogni-tion and regulation in this population, with particular problems in recognizing, labelling and describing emotions, and with linking feel-ings to bodily sensations (e.g. Castro et al., 2010; Hambrook et al., 2010; Harrison et al., 2009; Jansch et al., 2009; Oldershaw et al., 2011; Russell et al., 2009; Schmidt et al., 1993). Moreover, patients with AN often suppress neg-ative feelings and subjugate their own needs in an attempt to preserve close relationships (Geller et al., 2000; Hartmann et al., 2009).

If emotional processing skills are impaired in AN, and there is some evidence that these difficulties may predict long-term outcome (Speranza et al., 2007), then it seems logical to target emotional difficulties in the comprehen-sive treatment of AN.

The CREST intervention

Cognitive Remediation and Emotion Skills Training (CREST) is a 10 session individual treatment for inpatients with severe AN, which targets thinking skills, emotion recognition, management and expression through psycho-education and skills-based strategies. This is a new area of intervention as other emotion focused treatments in AN, such as Dolhanty and Greenberg’s (2009) emotion focused therapy and Wildes and Marcus’s (2010) emotion acceptance behaviour therapy, tend to target patients in outpatient therapy. It is important to consider that in the early stages of inpatient treatment patients are often severely under-weight, with low levels of concentration, thus finding it difficult to engage in psychological therapy. Considering these factors, and the reported difficulties in keeping patients in treat-ment (Waller et al., 2009), brief and low inten-sity interventions may be useful for patients in the acute stage of illness. Evidence regarding the effectiveness of brief interventions for AN include Cognitive Remediation Therapy (CRT)

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Money et al. 3

(Tchanturia et al., 2007; 2008). Indeed the treat-ment package under investigation in the current study includes elements of CRT.

The first two sessions focus on thinking styles: bigger picture thinking and flexibility, and are derived from CRT (Tchanturia et al., 2007; 2008). This initial emphasis on meta-cognition also serves to target cognitive rigidity, an additional hypothesized maintaining factor for AN (Schmidt and Treasure, 2006). Although our main aim was to focus on emotions in this intervention we also wanted to build on previous work on CRT and encourage reflection on thinking styles, advan-tages of being more flexible and ‘think big’ ver-sus getting too caught up with details.

The following eight sessions target emotions with basic education regarding the function of emotions and a focus on emotion recognition, in particular labelling and identifying emotion states. In these sessions, materials and tasks are used to facilitate reflection on current and new strategies to manage, tolerate and express emotion. The intervention is not related to eating, weight or shape concerns and was intentionally designed to broaden the patient’s perspective of their current state and focus on everyday emotional skills. This manualized therapy was designed to be delivered by clinicians within the multi-disciplinary team.

An ‘end of therapy reflection’ form is com-pleted in the final session of CREST and pro-vides patients with the opportunity to reflect and consolidate what they have learnt during the sessions.

Aims and objectives

The objective of this study is to explore patients’ experiences of CREST. Qualitative methodology was employed to analyse patients’ subjective feedback in their end of therapy reflection forms.

Method

Content analysis

Content analysis involves analysing verbal or written data (Cole, 1988) by establishing

categories within the data, and counting the fre-quency with which they occur (Joffe and Yardley, 2003). These results can be used as evidence for the existence of a phenomenon and how frequently it occurs, and then used as a guide for action (Krippendorff, 1980). The pri-mary form of content analysis employed in this study was based on the ‘inductive’ method (Elo and Kyngas, 2007), as we sought to derive generic and sub-categories from the data alone, and were not searching for predefined catego-ries (‘deductive’ analysis).

The rational for adopting this method of qualitative analysis was to explore service users’ views regarding the acceptability and feasibility of this new 10 session intervention. This small scale study is part of a larger quantitative study which involves participants completing several neuro-psychological measures and self-report questionnaires. Therefore a methodology that would analyse ‘end of therapy reflection forms’ was used as it was the least time consuming and pressurizing for the patients involved.

Participants

Consecutive admissions to the inpatient unit of the South London and Maudsley NHS Foundation Trust ED Service were offered CREST. Twenty-eight patients completed CREST and were included in this study. All had a DSM-IV (American Psychiatric Association (APA), 1994) diagnosis of AN. One patient was male, and the mean age of the group was 25 (range 13–40). The mean Body Mass Index (BMI; kg/m2) before starting CREST was 14.7 (range 11.5–18.1). Eleven patients did not complete all 10 sessions of CREST and were not included in this study. The reasons for non-completion varied. Four patients were discharged from the ward before CREST was completed and seven decided to dis-engage from the inpatient treatment.

Data collection

All patients included in this study completed 10 sessions of CREST and an end of therapy

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4  Journal of Health Psychology

reflection form in their final session with the therapist. This contained five open-ended ques-tions (see Tables 1–3). The patient and therapist both kept a copy of the reflection form. The therapist copy was given to a researcher who anonymized the reflections and then transcribed them into text files ready for data analysis. Patients receiving CREST provided informed consent. The study had been approved by the local ethics committee.

Data analysis

Two researchers separately read all text derived from the end of therapy reflections. They were blind to the identity of the respon-dents. Each question in the end of therapy reflection was analysed individually based on Elo and Kyngas (2007) and Joffe and Yardley (2003). After independently searching the data for codes or instances, the two researchers held a consensus meeting to agree on how these could be grouped together as categories, and to assign titles to categories. This process has been referred to as abstraction (Joffe and Yardley, 2003) and involves developing higher order, or main categories, then to group generic categories under these headings, and third to group together sub-categories where similar events or instances occur. In this study, the main categories had been predetermined by the questions asked in the end of therapy reflection. Therefore the researchers’ main task was to organize the data into generic cat-egories and sub-categories.

Reliability of methodology

Consistent with guidelines outlined by Elliott (1999), the first two authors undertook the ini-tial analysis separately and then agreed on categories with the Principal Investigator. All identified categories were included in the analysis. The data were then re-analysed to check for consistency and to allow the authors complete immersion and familiarization with the data.

Results

Tables 1–3 present the main results of the con-tent analysis that include the following: the main category (i.e. the reflection question); the generic and sub-categories which were derived from the data analysis; and quotes to illustrate the sub-categories.

Following is a summary of the key findings under their main category headings.

Main category: What have you learnt about yourself from this therapy?

Patients recognized that they either bottled up or avoided/blocked emotions (50%). One par-ticipant commented: ‘How I used to block my emotions and not be able to sit with them . . . .’ This complements research that suggests EDs serve the purpose of avoiding or regulating emotion (Davies et al., 2010; Kyriacou et al., 2009). Following CREST, patients reported that they were developing skills to express/commu-nicate emotions (25%) and felt more able to identify emotions and consider the positive function of emotion (39%).

Main category: Were there any aspects that were particularly helpful?

The analysis suggested that patients found learn-ing new strategies to manage emotions helpful (71%), in particular learning to label emotions correctly and acting on them early on as exempli-fied by one patient: ‘ . . . for me, looking at ways to reduce emotions getting to that extreme point by acting on feelings before they start to spiral out of control.’ This finding is important as learning new strategies to manage emotions may reduce com-pensatory ED behaviours, such as restriction, bingeing and purging. Learning about the function of emotions was also reported as being helpful (61%). In particular, education around emotions communicating needs was found to be beneficial as the following quote suggests: ‘The idea that each and every emotion is simply an indicator that I need something, or a guide to determine how I

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Money et al. 5

behave.’ This is a significant finding in the light of research which has found that people with AN suppress emotions and discount their own emo-tional needs due to a fear of them impacting negatively on relationships (Geller et al., 2000; Hambrook et al., 2010). Increasing patients’ rec-ognition and understanding that emotions signal important needs may help in encouraging patients to take corrective action to meet these needs rather than suppress them. This compliments a study by Graham et al. (2008) who found that appropriately expressing negative emotions is associated with positive relationship outcomes and can help elicit care and support.

Main category: Were there any aspects that were particularly unhelpful?

There was little that patients found unhelpful. One person commented on the manualized nature of the intervention and found it too struc-tured, and two patients (7%) commented that it was not personalized enough. Two patients (7%) also found the sessions that focused on thinking styles unhelpful, and four patients (14%) found sessions that explored recognizing emotions in others unhelpful.

Main category: What could be improved?

Nearly a third of the patients stated that more sessions would be helpful, and seven patients (25%) asked for a stronger focus on topics such as managing emotions, and the needs that emo-tions are communicating. This aspect of the intervention was addressed by exploring with the patient what needs a number of different emotions may be communicating. This was fur-ther extended by exploring how patients could act on and communicate these needs.

Main category: What strategies have you learnt to use in the future?

A key finding was that patients found learning practical skills beneficial. Over 60 percent of

the patients reported that in future they would try to express their emotions by talking to peo-ple, for example someone said: ‘ . . . expressing emotions in relation to difficult situations – voice what I am thinking or feeling.’ Having a positive attitude was also commented on by 25 percent of the patients alongside labelling and acknowledging emotions. Also of significance in terms of strategies learnt was having an emo-tional awareness that included recognizing the benefits of experiencing emotions (22%). For example: ‘Negative emotions can have a posi-tive effect as they can alert me to the fact that something needs to change and inspire me to take positive action.’ Exercises which increased patients’ awareness of the functions of emo-tions, in particular negative ones, asked patients to consider why we have negative emotions and how they can be helpful (e.g. anger helps us to stand up for ourselves). These findings also support studies that have looked into positive outcomes from emotional awareness and coach-ing training (Dolhanty and Greenberg, 2009; Farrell and Shaw, 1994).

Therapists who conducted CREST found the experience to be extremely valuable in initiating a non-threatening, collaborative relationship. CREST provided therapists an opportunity to engage patients early on in an inpatient admission, and begin to explore and reflect on the nature and function of emotions alongside considering strategies to manage and express emotions. It was felt that CREST enabled thinking about feeling, which in turn paved the way for more in-depth psychological work to be carried out once CREST was completed.

Discussion

The aim of this study was to gain an in-depth understanding of AN patients’ experience of an emotion focused intervention on an inpatient unit. The data appears to offer important insights and information into patients’ percep-tion and experience of CREST. It also draws attention to areas of the therapy that may be

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6  Journal of Health Psychology

Tabl

e 1.

Res

ults

 from

 con

tent

 ana

lysi

s on

 ref

lect

ion 

ques

tion 

1: W

hat 

have

 you

 lear

nt a

bout

 you

rsel

f fro

m t

his 

ther

apy?

Mai

n ca

tego

ryG

ener

ic C

ateg

ory

Sub 

Cat

egor

yFr

eque

ncy

Exam

ple

Wha

t ha

ve y

ou

lear

nt a

bout

yo

urse

lf fr

om

thi

s th

erap

y?

Thi

ngs 

I hav

e le

arnt

 ab

out 

mys

elf

Bott

le u

p em

otio

ns8

‘How

 I de

al w

ith e

mot

ions

 - t

hat 

I bot

tle t

hem

 up 

until

 the

y ex

plod

e.’

Bloc

k/av

oid 

my 

emot

ions

 6

‘How

 I us

ed t

o bl

ock 

my 

emot

ions

 and

 not

 be 

able

 to 

sit 

with

 the

m.’

It’s 

ok t

o ex

pres

s yo

ur fe

elin

gs6

‘It’s 

ok t

o ta

lk a

bout

 you

r pr

oble

ms, 

it m

akes

 you

 feel

 bet

ter 

afte

rwar

ds.’

Not

 get

ting 

need

s m

et5

‘ . . 

. run

 into

 diff

icul

ties 

whe

n I d

on’t 

look

 aft

er o

wn 

need

s.’G

ood 

at c

arin

g fo

r ot

hers

5‘I 

have

 als

o le

arnt

 tha

t I a

m a

 gre

at fr

iend

 to 

othe

rs b

ut n

ot 

a gr

eat 

frie

nd t

o m

ysel

f.’Sk

ills 

I hav

e be

gun 

usin

gEx

pres

sing

/com

mun

icat

ing 

mor

e7

‘ . . 

. bet

ter 

at b

eing

 abl

e to

 exp

ress

 feel

ings

 – m

ore 

open

 in 

com

mun

icat

ing 

posi

tive 

and 

nega

tives

.’Po

sitiv

e in

tent

ions

 of n

egat

ive 

emot

ions

 6

‘Neg

ativ

e fe

elin

gs a

ren’

t al

way

s ba

d – 

they

 tea

ch/p

rote

ct.’

Iden

tifyi

ng e

mot

ions

5‘H

ow t

o na

me 

emot

ions

 and

 how

 to 

find 

the 

righ

t w

ords

 fo

r ho

w I’

m fe

elin

g.’Lo

ok a

t th

e bi

gger

 pic

ture

4‘ .

 . . i

t’s a

lrig

ht n

ot t

o w

orry

 abo

ut t

he li

ttle

 det

ails

 bei

ng 

perf

ect 

and 

to lo

ok a

t th

e bi

gger

 pic

ture

.’Em

otio

ns a

re fl

uid

4‘ .

 . . t

hat 

emot

ions

 are

 flui

d an

d ch

ange

 thr

ough

out 

the 

day.’

Oth

er p

eopl

e’s 

pers

pect

ives

3‘B

eing

 mor

e aw

are 

of o

ther

 peo

ple’

s pe

rspe

ctiv

es’

Ack

now

ledg

ing/

acce

ptin

g em

otio

ns3

‘ . . 

. it 

is o

k an

d ac

cept

able

 to 

feel

 sad

 at 

times

.’

Skill

s I w

ould

 like

 to 

use

Be m

ore 

asse

rtiv

e3

‘Nee

d to

 be 

asse

rtiv

e.’

Be m

ore 

open

 3

‘Tha

t I n

eed 

to fo

cus 

on c

omm

unic

atin

g m

y em

otio

ns t

o th

ose 

arou

nd m

e.’

Be m

ore 

posi

tive 

3‘I 

wou

ld li

ke t

o be

 mor

e po

sitiv

e. B

eing

 mor

e pr

o-ac

tive 

can 

mak

e po

sitiv

e th

ings

 hap

pen.

’

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Money et al. 7

Tabl

e 2.

Res

ults

 from

 con

tent

 ana

lysi

s on

 ref

lect

ion 

ques

tion 

2 an

d 3:

 Wer

e th

ere 

any 

aspe

cts 

that

 wer

e pa

rtic

ular

ly h

elpf

ul? 

Part

icul

arly

 unh

elpf

ul?

Mai

n ca

tego

ryG

ener

ic C

ateg

ory

Sub 

Cat

egor

yFr

eque

ncy

Exam

ple

Wer

e th

ere

any

aspe

cts

whi

ch w

ere

part

icul

arly

hel

pfu

l?

Emot

iona

l str

ateg

ies 

lear

ntLa

belli

ng 5

‘Loo

king

 mor

e sp

ecifi

cally

 at 

diffe

rent

 em

otio

ns 

(e.g

. lab

ellin

g).’

Act

ing 

befo

re e

mot

ions

 sp

iral

 4‘A

lso 

for 

me 

look

ing 

at w

ays 

to r

educ

e em

otio

ns 

gett

ing 

to t

hat 

extr

eme 

poin

t by

 act

ing 

on fe

elin

gs 

befo

re t

hey 

star

t to

 spi

ral o

ut o

f con

trol

.’C

omm

unic

atin

g fe

elin

gs 3

‘ . . 

. tal

king

 abo

ut y

our 

prob

lem

s ca

n ac

tual

ly h

elp 

you 

deal

 with

 the

m.’

Non

-spe

cific

 str

ateg

ies 

 3‘S

trat

egie

s to

 man

age 

diffi

cult 

situ

atio

ns t

hat 

occu

rred

 dur

ing 

the 

wee

k.’

Rec

ogni

zing

 the

 pos

itive

 in

tent

ions

 of e

mot

ions

  3

‘Loo

king

 at 

emot

ions

 in a

 diff

eren

t w

ay e

.g. p

ositi

ve 

mea

ning

s of

 neg

ativ

e em

otio

ns.’

Lear

ning

 abo

ut e

mot

ions

Rel

atio

n to

 nee

ds 

 7‘T

he id

ea t

hat 

each

 and

 eve

ry e

mot

ion 

is s

impl

y an

 indi

cato

r th

at I 

need

 som

ethi

ng, o

r a 

guid

e to

 de

term

ine 

how

 I be

have

.’A

war

enes

s of

 ow

n di

fficu

lties

  5

‘ . . 

. bei

ng m

ore 

awar

e of

 the

 issu

es a

nd d

iffic

ultie

s th

at n

eed 

atte

ndin

g to

.’Fl

uidi

ty o

f em

otio

ns 4

‘Kno

win

g th

ere 

are 

diffe

rent

 em

otio

ns t

hat 

we 

feel

, it 

is o

k to

 hav

e ot

her 

emot

ions

 rat

her 

than

 just

 fe

elin

g th

e sa

me 

all t

he t

ime.

’A

spec

ts o

f the

 app

roac

hR

efle

ctio

n tim

e 6

‘Hav

ing 

time/

spac

e to

 ref

lect

 on 

emot

ions

 and

 w

hat 

they

 act

ually

 mea

n to

 me 

in e

very

day 

life.

’D

oing

 hom

ewor

k 5

‘Hom

ewor

k al

low

s tim

e to

 com

e up

 with

 goo

d ex

ampl

es/r

efle

ct m

ore.

’Em

path

y of

 the

rapi

st 4

‘I w

as m

et w

ith a

 ver

y ca

ring

 and

 com

pass

iona

te 

appr

oach

 and

 som

eone

 list

enin

g to

 how

 it w

as 

for 

me.

’St

ruct

ure/

 the

mes

 3‘S

truc

ture

/hav

ing 

them

es t

o ea

ch s

essi

on.’

All 

sess

ions

 wer

e he

lpfu

ln/

a 6

‘To 

be h

ones

t ev

ery 

sess

ion 

has 

been

 ben

efic

ial.’

Wer

e th

ere

any

aspe

cts

whi

ch w

ere

part

icul

arly

unh

elp

ful?

Asp

ects

 of t

he a

ppro

ach

Initi

ally

 too

 bas

ic 3

‘Fir

st fe

w s

essi

ons 

seem

ed a

 litt

le b

asic

.’N

ot p

erso

naliz

ed 

 2‘T

asks

 [w

ere]

 sta

tistic

 bas

ed r

athe

r th

an p

erso

nal 

base

d.’

Too 

stru

ctur

ed 1

‘Som

etim

es t

oo s

truc

ture

d.’

Ende

d to

o qu

ickl

y 1

‘ . . 

. it 

cam

e to

 an 

end 

too 

quic

kly.’

(Con

tinue

d)

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8  Journal of Health Psychology

considered for change that will be helpful in the future development of the intervention.

Overall summary

Our qualitative findings suggest that CREST is an acceptable intervention for an inpatient group of AN patients. In a population that is known to have difficulty in correctly identify-ing and expressing emotion (Castro et al., 2010; Davies et al., 2010; Harrison et al., 2009; Jansch et al., 2009; Oldershaw et al., 2011,), CREST could be a helpful step in providing information about basic (micro) emotion processing skills. Alongside enhancing these skills, CREST had a secondary benefit of increasing assertiveness with over a third of patients reporting this being a strategy they would use in the future. This highlights an improvement in patients’ confi-dence and perceived ability to express thoughts and emotions. This is an area that Kyriacou et al. (2009) and Fox (2009) highlighted that patients with AN have difficulty with. This could also have a positive impact on reducing inter-personal problems known to be difficult to this population (Fairburn et al., 2003; Hartmaan et al., 2009; Schmidt and Treasure 2006) and encourage more social interaction.

With reports of high drop-out rates in treat-ment (Waller et al., 2009) and difficulties in engaging patients with AN, CREST provides an opportunity to engage patients in a brief, low intensity therapeutic intervention and to build rapport at the outset of an inpatient admission. CREST encourages inter-session work and this was responded to positively with patients com-menting on valuing the reflection time and enjoying a specific task-based approach. This is important on an inpatient unit where patients are often severely underweight (BMI < 15) and are thought to struggle to engage with in-depth psychological work initially (Schmidt and Treasure, 2006; Whitney et al., 2008).

There are two recently reported innovative treatments targeting emotions in AN (Dolhanty and Greenberg, 2009 – case study; Wildes and Marcus, 2010 – case series). The first is called M

ain 

cate

gory

Gen

eric

 Cat

egor

ySu

b C

ateg

ory

Freq

uenc

yEx

ampl

e

Cer

tain

 tas

ks/ s

essi

ons

Faci

al e

xpre

ssio

ns 4

‘Did

n’t 

gain

 a lo

t fr

om t

he fa

cial

 exp

ress

ions

 ex

erci

ses.’

CRT

 ses

sion

s 2

‘Not

 sur

e at

 firs

t – 

thin

king

 abo

ut t

hink

ing.’

Phys

ical

 man

ifest

atio

ns 

 2‘N

ot h

elpf

ul lo

okin

g at

 how

 em

otio

ns fe

el in

 the

 bo

dy.’

Emot

ion 

switc

hing

 1‘D

idn’

t ta

ke t

hat 

muc

h fr

om e

mpt

ion 

switc

hing

 se

ssio

n – 

alre

ady 

awar

e of

 sw

itchi

ng e

mot

ions

.’N

o as

pect

s un

help

ful

n/a

10‘N

one 

– le

arne

d so

met

hing

 from

 eve

ryth

ing.’

Tabl

e 2.

(Co

ntin

ued)

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Money et al. 9

Tabl

e 3.

 Res

ults

 from

 con

tent

 ana

lysi

s on

 ref

lect

ion 

ques

tion 

4 an

d 5:

 Wha

t co

uld 

be im

prov

ed? W

hat 

stra

tegi

es h

ave 

you 

lear

nt t

o us

e in

 the

 futu

re? 

Mai

n ca

tego

ryG

ener

ic C

ateg

ory

Sub 

Cat

egor

yFr

eque

ncy

Exam

ple

Wha

t co

uld

be

imp

rove

d?M

ore 

sess

ions

Long

er t

hera

py 8

‘The

 the

rapy

 her

e is

 the

 bes

t I’v

e en

coun

tere

d, t

he o

nly 

criti

cism

 is t

here

 isn’

t m

ore 

of it

.’Fo

llow

 up 

sess

ions

 1‘ .

 . . a

 follo

w u

p co

urse

 of C

RES

T w

ould

 be 

high

ly b

enef

icia

l.’Ta

ilore

d m

ore 

to 

indi

vidu

alM

ore 

in d

epth

 4‘T

akin

g th

e th

erap

y to

 a m

ore 

in d

epth

 leve

l, re

latin

g em

otio

ns t

o an

 und

erly

ing 

thin

king

 and

 bel

iefs

 and

 wor

king

 fr

om t

hat 

leve

l.’M

ore 

pers

onal

ized

 2‘If

 it w

as p

erso

naliz

ed, t

ailo

red 

to m

e/in

divi

dual

 rat

her 

than

 ge

neri

c to

 all.’

Mor

e on

 cer

tain

 top

ics

Man

agin

g em

otio

ns 

 2‘M

ore 

stra

tegi

es –

 wha

t to

 do 

in e

mot

iona

l situ

atio

ns.’

Emot

ions

 and

 nee

ds 2

‘Mor

e ab

out 

emot

ions

 and

 the

ir r

elat

ions

hip 

to n

eeds

.’Le

ss o

n ce

rtai

n to

pics

Faci

al E

xpre

ssio

n 2

‘A fe

w le

ss in

trod

ucto

ry s

essi

ons 

e.g. 

look

ing 

at fa

ces.’

Not

hing

 cou

ld b

e im

prov

edn/

a 4

‘Not

hing

. I fo

und 

the 

num

ber 

of s

essi

ons 

to b

e ju

st r

ight

 an

d th

e le

ngth

 of s

essi

ons 

appr

opri

ate.

’W

hat

stra

tegi

es h

ave

you

lear

nt t

o u

se in

th

e fu

ture

?

Hav

ing 

emot

iona

l aw

aren

ess

Bene

fits 

of e

mot

ions

 6‘N

egat

ive 

emot

ions

 can

 hav

e a 

posi

tive 

effe

ct a

s th

ey c

an 

aler

t m

e to

 the

 fact

 tha

t so

met

hing

 nee

ds t

o ch

ange

 and

 in

spir

e m

e to

 tak

e po

sitiv

e ac

tion.

’Bo

ttlin

g up

 is n

ot h

elpf

ul 4

“Rem

embe

ring

 bot

tling

 up 

does

n’t 

get 

me 

anyw

here

 apa

rt 

from

 frus

trat

ed a

nd a

ngry

”Pr

actic

al S

kills

Talk

ing/

Com

mun

icat

ing

17‘ .

 . . e

xpre

ssin

g em

otio

ns in

 rel

atio

n to

 diff

icul

t si

tuat

ions

 – 

voic

e w

hat 

I am

 thi

nkin

g or

 feel

ing.’

Bein

g m

ore 

asse

rtiv

e 9

‘Bei

ng m

ore 

asse

rtiv

e by

 spe

akin

g up

 mor

e w

hen 

need

ed.’

Hav

ing 

a po

sitiv

e at

titud

e  7

‘Foc

usin

g on

 pos

itive

 thi

ngs 

– re

flect

ing 

on p

ositi

ves 

and 

bein

g pr

o-ac

tive 

at m

akin

g po

sitiv

e th

ings

 hap

pen.

’La

belli

ng 6

‘Abl

e to

 iden

tify 

feel

ings

 mor

e ac

cura

tely.

’G

ettin

g ne

eds 

met

 6‘A

skin

g fo

r he

lp w

hen 

I nee

d it.

’A

ckno

wle

dgin

g em

otio

ns 6

‘Ack

now

ledg

ing 

how

 I fe

el.’

Look

ing 

at t

he b

igge

r pi

ctur

e 5

‘I ha

ve le

arnt

 to 

look

 at 

the 

bigg

er p

ictu

re w

hen 

I am

 feel

ing 

anxi

ous 

or w

orri

ed a

bout

 a c

erta

in s

ituat

ion.

’In

terv

ene 

befo

re 

emot

ions

 spi

ral

 3‘T

o tr

y an

d de

al w

ith e

mot

ion 

befo

re it

 get

s ou

t of

 con

trol

.’

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10  Journal of Health Psychology

Emotion Focused Therapy (EFT) that targets case formulation and incorporates a gestalt approach. The second is Emotion Acceptance Behaviour Therapy that incorporates thinking from both acceptance and commitment based therapies and mindfulness based therapies. Both approaches target emotional processing in relation to eating disorders, and involve in-depth work and a long commitment varying form 24 sessions to eighteen months of weekly therapy. CREST differs from these therapies in that it targets inpatients and is a brief prelimi-nary intervention, collaborative and psycho-educational in style and aimed at facilitating engagement early on in an inpatient admission. The hope being that this will encourage and enhance further more in-depth psychological work once the groundwork of basic emotion processing skills has been addressed.

The use of a qualitative approach enriched our understanding of what patients specifically found more and less helpful about this emotion focused intervention. The thoughts and experi-ences of the patient are essential elements, which can significantly influence adherence and outcome of treatment, and need to be care-fully gauged and addressed when developing a therapeutic intervention. With a growing inter-est in conducting research that is congruent with paradigms and methods that are more closely related to practice (Morrow, 2007), the use of content analysis provided a rich source of data derived from the subjective experiences of patients. This would not have been possible with a quantitative methodology alone.

Limitations

The study was conducted on one ward, and future studies may consider implementing and evaluating such an intervention across multiple sites to explore its generalizability. Only patients who completed all sessions of CREST were included in this study, thus potentially biasing the sample. It would have been helpful to have reflection forms for those patients who did not complete CREST. Some of the reasons

given for discontinuing CREST included not seeing any therapeutic value in exploring emo-tions and not seeing the benefit of using a man-ualized intervention as it was viewed as not being individualized enough. This could be a consideration for the future development of CREST. Considering the pathology of this patient group is also important when interpret-ing these findings. Patients may aim to please, perhaps making critical reflections difficult, particularly as the reflection forms were com-pleted with and given directly to the therapist at the end of the final session. However, some negative comments were given, suggesting openness and frankness on the part of the patients. To increase patients’ willingness to give feedback, therapists were explicit in explaining the importance of feedback to aid the development of the intervention.

Recommendations

This study highlighted the acceptability and feasibility of an emotion focused therapy, with over half of the patients suggesting further ses-sions would be beneficial. After evaluating this data and taking into consideration patients’ comments, the CREST manual has undergone some revision with more emphasis on skills and emotion expression. Having been piloted, it would be helpful to trial CREST in comparison to treatment as usual to assess if this interven-tion adds therapeutic value. Qualitative analysis may be supplemented with standardized self-report measures or experimental tasks to pro-vide a firmer evidence base for emotion focused interventions in the AN population.

Conclusions

Recent studies have highlighted the particular difficulty patients with AN have in recognizing and managing emotions. The preliminary find-ings of this study suggest that this emotion focused therapy is of value in an inpatient set-ting and patients generally responded positively to the simple and collaborative style. This kind

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Money et al. 11

of intervention may be instrumental in fostering engagement and rapport, allowing patients to start to think about their own emotion process-ing style and learn new ways of managing and expressing emotion.

Funding

This work is part of the ARIADNE programme (Applied Research into Anorexia Nervosa and Not Otherwise Specified Eating Disorders), funded by a Department of Health NIHR Programme Grant for Applied Research (grant number RP-PG-0606-1043). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. This work was also supported by the NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, King’s College London.

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