*Article* **Manualised Cognitive Behaviour Therapy for Anorexia Nervosa: Use of Treatment Modules in the ANTOP Study**

**Gaby Resmark 1,\*, Brigid Kennedy 1,2, Maria Mayer 1, Katrin Giel 1, Florian Junne 1, Martin Teufel 3, Martina de Zwaan <sup>4</sup> and Stephan Zipfel <sup>1</sup>**


Received: 16 October 2018; Accepted: 26 October 2018; Published: 29 October 2018

**Abstract:** Standardised treatment manuals facilitate therapy planning and enhance comparability for research purposes. Within the Anorexia Nervosa Treatment of Out Patients (ANTOP) study, the largest multisite outpatient intervention trial in anorexia nervosa (AN) to date, manualised enhanced cognitive-behavioural therapy (CBT-E) was offered as one treatment modality. The manual consisted of 9 modules, of which *Motivation, Nutrition, Formulation and Relapse Prevention* were compulsory. Homework worksheets were provided, to ensure the transfer of therapeutic improvements to daily life. This study investigated the use of modules and worksheets in order to explore practice styles of trained therapists in the treatment of AN. This secondary analysis was based on log-sheets (*n* = 2604) CBT-E therapists completed after each session. Frequencies of modules and worksheets used across all sessions were calculated. Relationships, such as that between use of module and duration of illness, were examined. The most commonly used module was *Motivation*. In patients with longer illness duration, the module *Self Esteem* seemed to be particularly important. The worksheet *Scales*, balancing the pros and cons of AN, was prioritised by therapists. The results underline the importance of motivational work in the treatment of AN, including validating the ambivalence experienced by most AN patients. With increasing duration of illness, resource-oriented elements, such as self esteem stabilisation, should be of focus.

**Keywords:** anorexia nervosa; cognitive behaviour therapy; manualised treatment; modules; worksheets

## **1. Introduction**

Treatment manuals for psychotherapeutic interventions guarantee that the path of treatment remains relatively focused, ensuring a standardised quality of therapy [1]. The clear structure associated with manualised treatment also increases transparency associated with the treatment, and with that, patient motivation [2]. Yet, the use of treatment manuals continues to be a controversial discussion point in the psychotherapy field [2]. Critics argue that use of manuals leads to rigid treatment, which neglects individual components of the patient's disorder, and reduces scope for therapist innovation [1,2].

Manuals exist for a vast array of treatments, including cognitive behaviour therapy (CBT) [3–5]. A convincing bank of evidence suggests that manualised CBT is effective in treating eating disorders [6–8]. Studies have shown that CBT can produce weight gain in anorexia nervosa (AN) patients [9], as well as improvements in eating disorder pathology for patients with AN [9], bulimia nervosa and eating disorders not otherwise specified [10]. A recently developed modified version of CBT, called enhanced cognitive behaviour therapy (CBT-E) [3], employs a transdiagnostic approach addressing all eating disorders. CBT-E has been shown to produce lasting improvements in body-mass index and eating disorder pathology in AN patients [11], and to be equally as effective as other "standard" treatment options [11,12].

One aspect which warrants consideration is the inclusion of modules in CBT treatment manuals. Modules are a form of building block for the treatment [4]; they outline the focal points of the planned treatment and seek to guide the therapy. Several modular CBT manuals have been developed to treat eating disorders; often, these manuals provide a wide selection of modules for therapists and patients to choose from [3–5,13]. Worksheets are another element often included as a supplementary resource to accompany modules; for example, in Wilhelm et al.'s CBT manual for body dysmorphic disorder [5] and in Legenbauer and Vocks' manual for anorexia and bulimia treatment [4]. Legenbauer and Vocks' manual [4], only available in German, is a practical manual designed for the cognitive behavioural treatment of eating disorders. The manual contains chapters addressing specific concepts related to eating disorders, such as motivation. Each chapter is accompanied by specific activities and detailed worksheets to assist the therapy. Worksheets can be used in-session and administered as homework, and facilitate the transfer of therapeutic progress into daily life. Similarly, Fairburn's CBT-E manual considers "Next Steps", an alternative term for homework, to be an integral component of treatment [3]. Most CBT manuals provide a rather clear structure, but should be seen as a guide, rather than an inflexible, predetermined protocol [14].

While past research has demonstrated that modular treatment manuals can produce positive treatment effects in eating disorder patients, to the authors' knowledge, no research has investigated the actual *implementation* of such manuals. Hence, there is an absence of research investigating the ways in which therapists execute manualised treatment. This study aimed to tackle this research gap, by investigating the practice styles of therapists administering a manualised CBT-E treatment to outpatients with AN. The manual of focus, written in German, was developed in 2007, prior to the publication of Fairburn's CBT-E manual [3]. It was written based on a 2-day workshop delivered by Fairburn. The manual was designed specifically for the ANTOP (Anorexia Nervosa Treatment of Out Patients) study, a German multisite randomised control trial in outpatients with AN [15,16]. The design and main outcome of the ANTOP study have been published elsewhere [15,16]. The present study sought to answer the following research questions:

