Psychotherapy Research

ISSN: 1050-3307 (Print) 1468-4381 (Online) Journal homepage: http://www.tandfonline.com/loi/tpsr20

Implementation of transdiagnostic treatment for

emotional disorders in residential eating disorder
programs: A preliminary pre-post evaluation

Heather Thompson-Brenner, James F. Boswell, Hallie Espel-Huynh, Gayle

Brooks & Michael R. Lowe

To cite this article: Heather Thompson-Brenner, James F. Boswell, Hallie Espel-Huynh, Gayle
Brooks & Michael R. Lowe (2018): Implementation of transdiagnostic treatment for emotional
disorders in residential eating disorder programs: A preliminary pre-post evaluation, Psychotherapy
Research, DOI: 10.1080/10503307.2018.1446563

To link to this article: https://doi.org/10.1080/10503307.2018.1446563

Published online: 19 Mar 2018.

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Psychotherapy Research, 2018
https://doi.org/10.1080/10503307.2018.1446563

EMPIRICAL PAPER

Implementation of transdiagnostic treatment for emotional disorders in

residential eating disorder programs: A preliminary pre-post evaluation

HEATHER THOMPSON-BRENNER1, JAMES F. BOSWELL2, HALLIE ESPEL-HUYNH 3

,
GAYLE BROOKS4, & MICHAEL R. LOWE3
1
Department of Clinical Psychology, Boston University, Boston, MA, USA; 2Department of Psychology, University at Albany,
SUNY, Albany, NY, USA; 3Department of Psychology, Drexel University, Philadelphia, PA, USA & 4The Renfrew Center,
Coconut Creek, FL, USA
(Received 1 October 2017; revised 10 February 2018; accepted 23 February 2018)

Abstract
Objective: Data are lacking from empirically supported therapies implemented in residential programs for eating disorders
(EDs). Common elements treatments may be well-suited to address the complex implementation and treatment challenges
that characterize these settings. This study assessed the preliminary effect of implementing a common elements therapy on
clinician treatment delivery and patient (N = 616) symptom outcomes in two residential ED programs. Method: The
Unified Protocol for Transdiagnostic Treatment of Emotional Disorders was adapted to address ED and co-occurring
psychopathology and implemented across sites. Therapists’ treatment fidelity was rated independently to assess
implementation success. Additionally, longitudinal (pre-post) design compared treatment outcomes among patients
treated before and after implementation. Patient outcomes included ED and depressive symptoms, experiential avoidance,
anxiety sensitivity, and mindfulness. Results: Following training and implementation, clinicians demonstrated adequate
to good fidelity. Relative to pre-implementation, post-implementation patients showed significantly greater improvements
in experiential avoidance, anxiety sensitivity, and mindfulness at discharge (ps ≤ .04) and more favorable outcomes on ED
symptom severity, depression, and experiential avoidance at 6-month follow up (ps ≤ .0001). Conclusions: Preliminary
pilot data support the feasibility of implementing transdiagnostic common elements therapy in residential ED treatment,
and suggest that implementation may benefit transdiagnostic outcomes for patients.

Keywords: eating disorders; outcome research; integrative treatment models; mental health services research; residential
treatment

Clinical or methodological significance of this article: Limited data are available to guide evidence-based residential
treatment for eating disorders. This study represents a unique effort to adapt, implement, and test an evidence-based
therapy protocol across a large private network of intensive eating disorder treatment programs.

Eating disorder (ED) treatment in the United States
(US) is delivered on a continuum of frequency and
intensity depending on the patient’s severity of
symptoms, medical stability, and treatment history,
as outlined by the American Psychiatric Association
guidelines (APA, 2006). Outpatient psychotherapy
is recommended as the first line of treatment for
EDs, anorexia nervosa (AN), bulimia nervosa
(BN), binge eating disorder (BED), and otherwise
specified feeding and eating disorders (OSFED),
and is effective for many patients. However, a
subset with more severe and persistent symptoms
require more intensive treatment (i.e., intensive out-
patient or partial hospital treatment). When symp-
toms pose a threat to medical stability (i.e.,
extreme low weight, electrolyte imbalance, or
cardiac complications), short-term inpatient hospi-
talization may be required. Longer term residential
treatment is recommended for individuals with
EDs who are medically stable but have severe

Correspondence concerning this article should be addressed to Heather Thompson-Brenner, Boston University, 6 Bigelow Street, Cam-
bridge, MA 02139, USA. Email: heatherthompsonbrenner@gmail.com

© 2018 Society for Psychotherapy Research

2 Heather Thompson-Brenner et al.
symptoms or comorbidities that interfere with treat-
ment at less intensive levels of care (APA, 2006;
Friedman et al., 2016).
The provision of evidence-based psychotherapy is a
priority across all mental health treatment settings
(England, Butler, & Gonzalez, 2015), though residen-
tial psychotherapy programs face specific challenges in
this area. First, empirically supported therapy proto-
cols (ESTs) are typically designed to address a single
diagnosis or category, yet the typical patient in the
intensive setting meets criteria for two or more
severe comorbid psychiatric disorders (Ulfvebrand,
Birgegård, Norring, Högdahl, & von Hausswolff-
Juhlin, 2015). Residential treatment providers report
that ESTs for single disorders do not adequately
address the comorbidities of patients in residential
programs (e.g., Lowe, Bunnell, Neeren, Chernyak,
& Greberman, 2011). Second, residential programs
provide individual and group therapy multiple times
per day and multiple days per week, yet existing
ESTs are typically designed to be delivered once or
twice per week. Existing EST protocols provide little
guidance for the varied and cohesive adaptation
necessary for daily multi-modal administration in resi-
dential programs. Third, residential programs provide
intensive structural regulation and staff oversight of
patient behaviour, such that ED behaviours such as
restriction, bingeing, and purging, are difficult for a
patient to engage in. Yet ESTs often emphasize self-
monitoring, analyzing, and reducing behavioural
symptoms as a primary focus of therapy (Fairburn,
2008; Wonderlich et al., 2014). Residential treatment,
therefore, cannot focus primarily on behavioural
symptoms (e.g., self-harm, binge eating) that are
reduced or eliminated in the residential context.
Perhaps for these reasons, we are aware of no ESTs
developed specifically for ED treatment in residential
treatment, or adapted to provide the foundation of
multi-disciplinary interventions at that level of care.
Implementation research indicates that innovations
—including health science innovations—commonly
require substantial adaptation to fit the specific
environments in which the innovation is implemented
(Brownson, Colditz, & Proctor, 2012; McHugh &
Barlow, 2012). Implementation constitutes a particu-
lar dilemma for residential and other intensive psy-
chotherapy treatment programs. Because residential
programs differ in key ways from outpatient settings,
the adaptations required to fit ESTs to these environ-
ments may be so extensive that the research evidence is
no longer applicable. Furthermore, it is enormously
difficult to conduct controlled research in intensive
treatment environments. Patients are often severely
ill, treatment is enormously costly, randomization is
difficult, and funding is lacking. As a result, there are
few comparative treatment studies of comprehensive
multi-modal interventions employed in any intensive
treatment programs, and none in residential (see
Friedman et al., 2016 for narrative review). Residential
treatment providers find themselves without the
option to provide treatment that is adequately sup-
ported by research conducted in that setting, and
with minimal opportunity to collect evidence to
support the treatment they do provide.
The limited data on residential ED treatment out-
comes indicate that patients show large improve-
ments in ED and depressive symptoms from intake
to discharge (Friedman et al., 2016; Lowe, Davis,
Annunziato, & Lucks, 2003; Twohig, Bluett, Torge-
sen, Lensegrav-Benson, & Quakenbush-Roberts,
2015), though relapse is common, with up to 39%
of patients returning to full-threshold symptoms
within three years following discharge (Gleaves,
Post, Eberenz, & Davis, 1993). Although the
success rates from residential programs are not
widely published, the available data suggest that the
majority of patients make significant improvements
in global ED psychopathology during treatment
(Friedman et al., 2016; Twohig et al., 2016).
Multiple outpatient treatment protocols have
demonstrated efficacy for EDs in randomized con-
trolled trials (RCTs). Brief review suggests that cog-
nitive behavioural therapy (CBT) shows benefit
relative to control conditions for BN, BED, and
EDs not otherwise specified (e.g., Agras, Walsh, Fair-
burn, Wilson, & Kraemer, 2000; Fairburn et al.,
2015; Wilfley et al., 2002); interpersonal psychother-
apy (IPT) shows benefit relative to control conditions
for BN and BED (e.g., Wilfley et al., 2002); Family-
Based Treatment shows benefit relative to control
conditions for adolescents with AN (Lock et al.,
2010); Dialectical Behaviour Therapy shows benefit
for BED that is comparable to control conditions
(Bankoff, Karpel, Forbes, & Pantalone, 2012), and
Supportive Specialist Clinical Management shows
benefit relative to control conditions for AN (e.g,
Schmidt et al., 2015).1 Recovery rates in outpatient
RCTs vary by diagnosis, and variance is observed
among studies. Reviews suggest AN recovery rates
for successful approaches are commonly slightly
below 40%; recovery rates for BN are commonly
between 50% and 60%; and recovery for BED is
commonly between 60% and 70% (Hay, 2013).
Some of the treatment provided in residential ED
programs derives from outpatient RCT protocols
(Friedman et al., 2016; Frisch, Herzog, & Franko,
2006); however, research has shown that programs
tend to adopt an eclectic approach, drawing on
various combinations of techniques without an over-
arching theoretical framework, including interven-
tions with limited or no research support (Frisch
et al., 2006; Goode, 2016). The absence of a unifying

theory could also lead to combining interventions
that are theoretically incompatible (Lowe et al.,
2011). For example, some approaches argue for acti-
vating negative emotion (e.g., exposure), while others
argue for the elimination of emotional triggers, active
use of distraction, and other techniques to limit
emotional reaction. In addition, components of
ESTs for EDs are not designed to apply transdiagnos-
tically to the mood, anxiety, post-traumatic, or obses-
sive-compulsive disorders characteristic of the
residential population (Twohig et al., 2015).
Members of a recent US government sponsored task
force (Institute of Medicine Sponsored Committee on
Developing Evidence-Based Practice Standards for
Psychosocial Interventions for Mental Disorders)
argued that evidence-based practice (EBP) should not
be equated with the implementation of a specific
EST protocol alone (England et al., 2015), and the
members articulated an elements-based framework for
evidence-based practice standards. Within the
elements framework, the label shared specific element is
used to identify intervention strategies with research
support that cut across a variety of treatment
approaches and diagnostic categories (Chen, Boswell,
Schwartzman, & Iles, 2017). Examples of elements-
based treatment approaches already exist in the field
of psychological treatments (Chorpita, Daleiden, &
Weisz, 2005), and have been disseminated and
implemented with demonstrated success (e.g.,
Murray et al., 2014). Treatments termed transdiagnos-
tic integrate shared specific elements designed for
application across a broader range of co-occurring
emotional disorders with shared psychological fea-
tures. Although some transdiagnostic approaches
combine elements eclectically, other approaches
attempt to combine elements into a cohesive model.
The Unified Protocol for Transdiagnostic Treatment
of Emotional Disorders (UP; Barlow et al., 2011),
for example, combines evidence-based intervention
elements (e.g., cognitive reappraisal, exposure) into a
series of coordinated modules that can be delivered
flexibly. The broader UP model is CBT and
emotion-focused in orientation. The combined UP
elements have demonstrated efficacy in controlled
trials for diverse emotional disorders (Barlow et al.,
2017; Farchione et al., 2012), and its constituent inter-
vention elements map onto evidence from ED treat-
ment research (see Table I).
The UP targets psychological mechanisms that have
been shown to maintain negative affect across
disorders, such as emotion avoidance and anxiety
sensitivity (e.g., Boswell, Farchione, et al., 2013;
Sauer-Zavala et al., 2012). Multiple studies suggest
that negative affect, emotion avoidance, and anxiety
sensitivity are associated with the development and
maintenance of EDs (Fulton et al., 2012; Wildes,
Psychotherapy Research 3
Ringham, & Marcus, 2010; see Table I), as well as
the other anxiety and mood disorders that typically
co-occur with EDs (Boswell, Farchione, et al., 2013).
Multiple ESTs for EDs (e.g., DBT, integrative cogni-
tive–affective therapy, emotion-acceptance behaviour
therapy) are based on the rationale that patients with
EDs have difficulty with emotion regulation. These
treatments incorporate interventions for emotion
awareness and emotion acceptance, as well as CBT
methods for coping with emotion, as key elements of
the treatment approach (Wildes & Marcus, 2011;
Wonderlich et al., 2014). Although the UP has not
been tested in a RCT for individuals with primary
ED diagnoses, the common elements approach to evi-
dence-based practice does not follow the traditional
efficacy-to-effectiveness-to-implementation or bench-
to-bedside treatment development paradigm.
Implementing Evidence-Based Treatment
Elements
A private provider of residential treatment for EDs
has undertaken a multi-year, multicomponent effort
to improve the overall consistency and quality of
clinical care and clinical research, culminating in
the implementation of an adapted version of the UP
—a common elements, transdiagnostic treatment—
across 2 residential and 14 partial hospital/intensive
outpatient programs. In 2013, The Renfrew Center
clinical leaders chose the UP as a foundational evi-
dence-based treatment model for possible implemen-
tation. Between 2013 and 2016, the organization’s
implementation team has developed adapted proto-
cols for each level of care, defined UP-consistent
interventions to be delivered across a multi-disciplin-
ary care team (e.g., psychotherapy, nutrition, and
nursing), provided training to over 400 clinicians,
and implemented the program across sites. The
organization now refers to the adapted multi-modal
treatment as the “Unified Treatment Model”
(UTM). Any further reference to the UTM in this
manuscript refers to the organization’s systematic,
UP-derived treatment approach (applied in the
current study in the residential ED treatment
setting), and any reference to the UP refers to the
common elements therapy developed by Barlow et al.
This study specifically examined the naturalistic
outcome of the implementation of the UTM in two
residential ED treatment programs. Fidelity assess-
ment examined clinician adherence and competence.
Preliminary outcome assessment employed a quasi-
experimental design, examining patient improvements
in ED and depressive symptoms, as well as experien-
tial avoidance, anxiety sensitivity, and mindfulness,
before and after implementation. This approach may
4 Heather Thompson-Brenner et al.
Table I. UP common elements, techniques, and eating disorder research examples.
Common
elements Techniques
Motivation Identification of “pros” and “cons” of
enhancement change; identification of goals and
immediate steps for change
Function of Understanding of adaptive functions
emotions of emotions; 3-component model
(thoughts, behaviours, sensations);
antecedents, responses, and
consequences of emotions
Emotion Development of nonjudgmental,
awareness present-focused awareness
training
Cognitive Identification of subjectivity and
Appraisal and emotional influence on cognition;
reappraisal probability over-estimation and
catastrophizing; core negative
appraisals (downward arrow
technique)
Avoidance and Identification of maladaptive
emotion-driven avoidance and emotion-driven
behaviours behaviours; promotion of adaptive
alternatives
Interoceptive Engagement in exercises which evoke
awareness and physical sensations similar to those
tolerance of strong emotions (e.g.,
interoceptive exposure)
Emotion Construction of a hierarchy of avoided
exposures and distressing situations; planning
and engagement in exposures
Notes: Abbreviations: CBT-E: cognitive behaviour therapy-enhanced; ICAT: integrative cognitive behaviour therapy; DBT: dialectical
behaviour therapy; EABT: emotion acceptance behaviour therapy; IPT: interpersonal psychotherapy. Elements of this table are included in
Thompson-Brenner et al. (2018).
Basic supporting research (examples)
Individuals with EDs show low
motivation to change; motivation
and readiness predicts outcome in
EDs (Macdonald, Hibbs, Corfield,
& Treasure, 2012)
Individuals with EDs lack emotion
awareness and show negative beliefs
about emotion (Nowakowski,
McFarlane, & Cassin, 2013).
Negative affect is an ED risk factor
(Goldschmidt, Wall, Loth, &
Neumark-Sztainer, 2015; Meier
et al., 2015; Stice, 2002).
EDs are associated with poor
mindfulness and high emotion non-
acceptance relative to control grops
(Harrison, Sullivan, Tchanturia, &
Treasure, 2010; Svaldi,
Griepenstroh, Tuschen-Caffier, &
Ehring, 2012), and severity of these
variables are related to severity of
ED symptoms (Pisetsky, Haynos,
Lavender, Crow, & Peterson, 2017).
Negative cognitions such as thin-ideal
internalization are associated with
the development and maintenance
of behavioural EDs (Stice, 2002);
negative cognitions associated with
food, eating, perfectionism,
exercise, body image, are
components of eating disorders
EDs are characterized by avoidance of
emotion (Svaldi et al., 2012; Wildes
et al., 2010), as well as checking
(Mountford et al., 2006) and other
rituals (Tappe, Gerberg, Shide,
Rolls, & Andersen, 1998). ED
symptoms occur following negative
affect and function to temporarily
reduce negative affect (Engel et al.,
2013; Goldschmidt et al., 2014)
EDs are associated with low
interoceptive awareness (Fassino,
Pierò, Gramaglia, & Abbate-Daga,
2004; Klabunde, Acheson, Boutelle,
Matthews, & Kaye, 2013; Merwin,
Moskovich, et al., 2013; Merwin,
Zucker, Lacy, & Elliott, 2010;
Pollatos et al., 2008)
EDs are characterized by avoidance of
emotion (Svaldi et al., 2012; Wildes
et al., 2010), avoidance of viewing or
revealing the body (Reas, Grilo,
Masheb, & Wilson, 2005) and
avoidance of feared foods (e.g.,
Fairburn, 2008).
Treatment research (examples)
Motivational interviewing increases
motivation in EDs (Macdonald
et al., 2012) and is part of CBT-E
(Fairburn, 2008), ICAT
(Wonderlich et al., 2014)
Mindfulness and emotion awareness
exercises benefit patients with EDs
and are included in ICAT, CBT-
E, DBT (Bankoff et al., 2012),
EABT (Wildes & Marcus, 2011),
and ACT for EDs (Merwin,
Zucker, & Timko, 2013)
Mindfulness and emotion awareness
exercises show benefit for patients
with EDs (Wanden-Berghe, Sanz-
Valero, & Wanden-Berghe, 2010),
and related components are
included in DBT, ICAT, EABT,
and ACT
Cognitive therapy shows benefit for
shape and weight concerns
(Hilbert & Tuschen-Caffier,
2004), and related components
are included in CBT-E, EABT,
and ACT
Related interventions or
components are included in DBT,
EABT, ICAT, ACT, and IPT
(Wilfley et al., 2002)
Interoceptive practices, such as
appetite awareness training, have
shown benefit for individuals with
EDs (Craighead & Allen, 1995)
Related components are included in
CBT-E (e.g., weighing and
introduction of feared foods),
EABT & ACT, and AN-EXRP
(Steinglass et al., 2014)

be called a Type 1 Effectiveness-Implementation
Hybrid Design (Curran, Bauer, Mittman, Puyne, &
Stetler, 2012). In Type 1 designs, the effectiveness of
clinical interventions with strong face validity and a
strong base of indirect evidence (e.g., from different
yet associated populations) that support the applica-
bility to a new setting or population is examined,
while also observing and gathering information on
implementation (see Thompson-Brenner et al., 2018
for implementation details).
Method
Patients and Procedure
Fidelity assessment was conducted with all clinicians
providing group treatment using the UTM following
training and implementation. Through the study
period, residential patient-participants completed all
standard intake procedures for residential treatment,
including screening and assessment of EDs, co-
occurring problems, and medical/behavioural stab-
ility. All routinely presenting residential patients
(100% female) were required to complete a standard
battery of computerized self-report assessments for
internal outcome monitoring purposes. Only patients
consenting to have their data used for research (N =
744) were considered for inclusion in the present
study. Exclusions included: (1) previous admission
during the data collection period (n = 19); (2)
length of stay less than 7 days (n = 27); or (3) intake
Eating Disorder Examination—Questionnaire
Global Score considered invalid (total score less
than 0.50, which is more than 1 SD below the non-
clinical norm and unlikely to be accurate (n = 20);
or greater than 10% of items incomplete, n = 62).
These exclusions yielded a final sample size of 616
eligible for analyses (pre-implementation: n = 331;
post-implementation: n = 285). See Participant
Flow diagram (Figure 1) for further detail.
Treatment
Patients in both implementation phases received 24-h
residential treatment, which included highly struc-
tured daily activities, supervised meals, and snacks,
frequent therapeutic group sessions, and individual
meetings with psychotherapists, dietitians, and psy-
chiatrists. Though daily/weekly frequency and inten-
sity of all modes of treatment remained consistent
before and after implementation, the content of
group and individual therapy and the theoretical
approach taken across modalities was modified.
The decision to implement a transdiagnostic,
common elements approach (the UP) as opposed to
a specific EST for EDs was made by the clinical
Psychotherapy Research 5
leaders within the organization. Between 2011 and
2013, the clinical leadership team met regularly to
consider the benefits and limitations of different
ESTs for EDs for application to residential treatment.
They identified limitations to all of the available ESTs
for EDs, which were developed and tested primarily
in outpatient academic settings. Several common
ESTs for EDs (e.g., CBT and FBT) were identified
by the clinical leadership to have limited application
because of their focus on food intake and behavioural
symptoms, which are structurally regulated in resi-
dential treatment. Some of the available ESTs
(CBT, FBT, and IPT) were perceived to inade-
quately address some of the most common and
severe co-occurring disorders (e.g., post-traumatic
stress disorder, obsessive-compulsive disorder, and
social anxiety disorder). A NIMH-funded attempt
to implement components of CBT for BN within
the organization had previously not succeeded (see
Lowe et al., 2011) due in part to the therapists’ per-
ception of its limitations for the population and
incompatibility with the environment. The clinical
leadership contemplated using different components
from various ESTs to create their own composite
approach, but they feared that this eclectic combi-
nation would feel unwieldy and confusing to the
patients, that it would be impossible to train all the
staff to competency in so many different approaches,
and that this tactic would likely fail to unify treatment
across their programs and levels of care.
When the clinical leadership became aware of the
UP and the research to support it, although there
was no RCT demonstrating its specific efficacy with
primary EDs, it was perceived to have many benefits.
It was principle-based, modular, and transdiagnostic,
all of which allowed for adaptation and delivery in
heterogeneous groups. Consistent with the intent of
common elements therapies, there was extensive
additional psychopathology and treatment-outcome
research to support the application of the elements
to ED symptoms; similar interventions are in fact
included in ESTs for EDs (see Table I). However,
the UP had the advantage of a unifying, theoretical,
empirically supported rationale for each of the inter-
ventions and common elements, in that it was
focused on increasing emotion awareness, reducing
emotion avoidance, and improving emotion regu-
lation. Importantly, this emotion focus of the UP was
felt to be compatible with the existing organizational
culture, and UP consultants (including the first and
second authors, who both had extensive prior train-
ing in the UP and extensive experience with EDs),
emphasized their willingness to participate in a colla-
borative process to adapt the protocol as the basis of
group and individual psychotherapy across levels of
care, as well as the foundation to integrate multi-
6 Heather Thompson-Brenner et al.
Figure 1. Participant recruitment and retention.
disciplinary care at each level (see Thompson-
Brenner et al., 2018).
Pre-implementation. Pre-implementation patients
received treatment developed over time by clinicians
within the organization, who evolved their own idio-
syncratic approaches at each site (the two residential
sites that are the focus of this study, as well as mul-
tiple partial-hospital/intensive outpatient programs
that comprise the larger treatment network). The
organization’s clinical leadership instructed clinicians
to support patients’ relational connectedness, self-
empowerment, emotion expression, and self-
directedness, an approach which the organization
described as “feminist-relational.” Group and indi-
vidual therapy were regularly supervised, and super-
vision focused on recovery from ED symptoms and
comorbid conditions within this feminist-relational
framework. Groups included daily process groups,
topic-focused groups on ED symptoms, creative
arts therapy, nutritional counseling, and trauma-
and substance use-focused therapy groups. It was
intended that each patient would develop empower-
ment via their process of identifying the relationship
between emotions and ED symptoms, and by identi-
fying a personal path to recovery. No manualized
treatment approach had been established. Other
clinical interventions (e.g., nutrition counseling,
expressive therapies) were developed and structured
by the relevant department head or individual clini-
cians, with training and supervision within their
department.
Post-implementation. The adaptations made to the
original protocol in the development of the UTM
are summarized here (see Table I and Thompson-

Brenner et al., 2018, for additional details). Given
that patients in residential treatment may start with
severe nutritional impairment and associated cogni-
tive limitations that require weeks to resolve, the
larger group of modules was structured into three
sequential, progressive phases that could be repeated
as necessary: the first phase focuses on motivation
enhancement, basic emotion awareness, and self-
monitoring (interventions that patients with the
aforementioned severe problems can productively
engage in); the second phase focuses on developing
skills in cognitive flexibility, reducing avoidance and
emotion-driven behaviours, and tolerating the phys-
ical sensations of emotion (which are moderately
stressful but highly therapeutic, and lay the ground-
work for the third phase); and the third phase
includes individualized and group exposure for
food, body image (e.g., mirror exposure), and co-
occurring emotional problems (e.g., panic; see also
Table I). Movement through the phases is based on
the shared clinical judgment of the treatment team,
including observing active engagement in groups,
practicing of skills, and compliance with the treat-
ment plan. Patients who exit the treatment program
prematurely may not complete all treatment phases.
All post-implementation patients attended two
UTM groups per day, UTM-consistent individual
therapy, UTM-consistent meal support, and other
components (e.g., nutrition counseling, expressive
therapies) by clinicians trained in the UTM. Individ-
ual therapy was structured by the clinicians consistent
with UTM principles and training, by clinicians
trained in the UTM (who conducted the structured
and manualized groups), but focused on issues ident-
ified by the clinician as of primary importance to the
patient.
Therapist Training
An increased focus had been placed on training and
supervision several years prior to the implementation
of the UTM (see Thompson-Brenner et al., 2018).
A Training Department had been established, and
residential therapists had received regular trainings
in eclectic EBPs had been instituted in the two years
prior to the implementation of the UTM. No
additional supervision hours were added during the
implementation, though the recording of sessions for
supervision was added. Additional training immedi-
ately pre-implementation was focused on the UTM.
All therapists at both residential sites had completed
the following training activities prior to fidelity data
collection: (a) introductory didactic education from
UP experts (certified UP trainers and fidelity asses-
sors); (b) review of a comprehensive treatment
manual (unpublished) with psychoeducational text
Psychotherapy Research 7
and group exercises for every group in each stage; (c)
28 h of didactic and experiential (e.g., role-play) com-
ponents for each part of the UTM manual; and (d)
one-to-one coaching as needed and ongoing supervi-
sion supplemented by review of session recordings.
This ongoing supervision was led by internal site
supervisors. These supervisors also received supervi-
sion from the certified UP experts. A variety of direct
care providers were trained, including group and indi-
vidual therapists (Masters and Doctoral level), nurses,
psychiatrists, and nutritionists. Staff who did not
engage in therapy as their primary activity (e.g., nutri-
tionists) primarily completed training activities (a)
and (b). Group and individual therapists received
additional training, supervision, and consultation,
(c) and (d), yet all staff received consultation by core
supervisors and trainers on an ongoing basis. When
turnover or new hiring occurred throughout
implementation stages, new employees received
similar training via live web-based interface with
members of the Training Department and on-site
supervision by fully trained clinicians.
Some basic demographic information was col-
lected from direct-care staff who participated in the
training(s) on a volunteer basis. It is important to
emphasize that staff were not required to provide
demographic information and the following
summary is intended to be snapshot of the provider
characteristics based on the individuals (N = 122)
who provided information at the time of the training.
The majority identified as female (91.8%) and White
(80.3%). The mean age = 37.52 years (SD = 13.20),
and the mean years of post-training experience =
9.70 (SD = 10.61).
Fidelity Assessment
An observer-rated fidelity assessment tool was devel-
oped from existing scales for the UP (Barlow et al.,
2011), and adapted and revised based on group
therapist, supervisor, and patient feedback following
a limited pilot implementation phase. Data were col-
lected by audiorecording group therapy sessions, for
which separate consent was provided. A set of adher-
ence items was developed for each UTM group
across the three treatment stages. Similar to existing
approaches (e.g., Barber, Liese, & Abrams, 2003;
Boswell, Gallagher, et al., 2013), the final version of
the assessment tool included the following domains:
(a) dichotomous adherence items, that is, presence/
absence of prescribed interventions in a given
group; (b) an overall adherence quality rating of the
session (e.g., “As a whole, did the facilitators respon-
sively deliver model-appropriate interventions con-
sistent with the overarching treatment goals?”); (c)
intervention-specific quality ratings, that is,
8 Heather Thompson-Brenner et al.
dimensional ratings between 1 “very low” to 5 “very
high” for the specific manualized interventions; and
(d) general competence items, for example, rapport,
collaboration, session management, rated between 1
“poor” to 5 “excellent.” Scores were calculated by
dividing the number of observed prescribed items
by the total number of possible adherence items for
that group, resulting in a percent score between 0
and 100. Scores of 80% or greater are conventionally
considered “good” (Boswell, Gallagher, et al., 2013).
Fidelity ratings were conducted by two trained
graduate student research assistants, and supervised
by a certified UP therapist and trainer (second
author) who had collaborated on the development
of the fidelity monitoring tool (the fidelity monitoring
tool and more extensive results are available from the
second author upon request). Raters were not associ-
ated with the treatment or implementation pro-
cedures. Once threshold reliability was achieved
through training and practice (intraclass correlation;
ICC = .80), raters were randomly assigned groups
to rate independently, without knowledge of the
treatment site or session date. Weekly meetings
were convened to achieve consensus and the supervi-
sor assisted with lingering discrepancies. Group ses-
sions were sampled with the goal of having
recordings for each of the three program stages as
well as the earlier, middle, and later phases of the
implementation relative to implementation date at
each site. Each phase covered approximately three
months. This designation was admittedly somewhat
arbitrary, yet split the time into relatively even tertiles.
A total of 58 groups were independently rated.
Twenty-two groups were from the early implemen-
tation phase, 16 from the middle, and 20 from the
late. Thirty-eight groups/recordings were conducted
at the southeastern site and 20 were conducted at the
northeastern site. Interrater reliability was examined
using the kappa statistic (Cohen, 1960) for categorical
ratings (e.g., presence or absence of an adherence
item), and ICCs for dimensional ratings. Across
items and group sessions, the average kappa was κ
= .88 (range = .79–1.00), which is considered excel-
lent. For the dimensional adherence quality items,
the average ICC[2,2] = .81 (range = .76–.89), which is
in the good to excellent range (Shrout & Fleiss,
1979). Interrater agreement for the general compe-
tence items was also excellent, average ICC[2,2] = .86
(range = .81–.87); ICC [2,2] overall group ratings
= .90. Consensus ratings were used in all analyses.
Patient Assessment Procedures
Intake/baseline data from the pre-implementation
group were collected beginning in April 2014 until
date of implementation (October 2014 at one site
and March 2015 at the other site). Intake/baseline
data from the post-implementation group were
collected from the site’s date of implementation
until October 2015. Data collection ended when
the pre-implementation and post-implementation
group sizes were roughly equivalent. Patient data
were collected at intake, discharge, and 6-months
post-discharge. Intake and discharge surveys were
completed on-site. All patients who had completed
the discharge survey were contacted by email and
provided a secure web link for remote completion
of the 6-month follow-up assessment. Patients
received $30 Amazon gift cards for completion of
all three assessments. All research activities were
approved by institutional review boards at The
Renfrew Center and Drexel University.
Patient Symptom Measures
The outcomes included two symptom domains and
three domains posited as mechanisms of action in
the UP/UTM (Bentley et al., 2016).
ED symptom severity. The Eating Disorder Examin-
ation-Questionnaire Global scale (Fairburn & Beglin,
1994) is a 28-item self-report scale used to assess the
ED symptom severity during the past 28 days. Global
severity scores range from 0 to 6 (sample α = .93),
with higher scores indicating greater severity. The
EDE-Q has demonstrated good convergence with
clinical interview assessment (Black & Wilson, 1996).
Depressive symptoms. The Center for Epidemiologic
Studies—Depression scale (CES-D; Radloff, 1977)
was used to assess depressive symptoms during the
past week. The 20 items produce scores ranging
from 0 to 60, with higher scores indicating higher
severity (sample α = .91).
Experiential avoidance. The Multidimensional
Experiential Avoidance Questionnaire (MEAQ;
Gámez, Chmielewski, Kotov, Ruggero, & Watson,
2011) is a 62-item self-report measure of experiential
avoidance across 6 domains (behavioural avoidance,
distress aversion, repression/denial, distraction/sup-
pression, procrastination, and distress endurance).
Total scale scores range from 62 to 372 (sample α
= .89); higher scores indicate more avoidance.
Mindfulness. Mindfulness is defined in the UTM as
“present-focused, non-judgmental awareness of
emotion,” and was assessed with the Southampton
Mindfulness Scale (SMQ; Chadwick et al., 2008).
It has 16 items such as, “Usually when I experience
distressing thoughts and images, I just notice them
and let them go.” Scores range from 0 to 96
(sample α = .89), with higher scores indicating
greater mindfulness and thus less psychopathology.

Anxiety sensitivity. The Anxiety Sensitivity Index
(Reiss, Peterson, Gursky, & McNally, 1986)
measures negative beliefs about the physical sen-
sations, cognitions, and behaviours associated with
the experience of anxiety. It is used to assess difficulty
tolerating anxiety among subjects with a range of
anxiety disorders (Taylor, Koch, & McNally, 1992).
The 16 items yield scores ranging from 0 to 64;
higher scores indicate greater anxiety sensitivity
(sample α = .87).
Patient diagnoses. Primary diagnoses were estab-
lished via a two-step procedure. Trained assessors
conducted intake interviews over the phone prior to
admission, which included structured assessment of
each diagnostic criterion for ED diagnosis. Co-occur-
ring symptoms were assessed in the intake interview.
Following admission, the ED and co-occurring diag-
noses were confirmed by a semi-structured psychia-
tric interview administered by a psychiatrist. BMI
was assessed at intake and discharge using electronic
medical scales. Self-reported weight was obtained at
6-month follow-up (6MFU), and BMI was calcu-
lated using intake height.
Data Analysis
Analyses of fidelity and patient outcome were con-
ducted using two statistics software packages: SPSS
v. 23 and R v. 3.1.2 (lm and lme4 packages). Two sep-
arate analyses were conducted for each patient
outcome variable—one to evaluate the effect of
implementation on patient outcomes from admission
to discharge, and one to assess this effect from admis-
sion to 6MFU. For all analyses, patients were cate-
gorized into the “pre-implementation” or “post-
implementation” phase groups based on admission
date.
Analysis of clinical outcomes at discharge. The effect
of implementation on outcomes from admission to
discharge was assessed using multiple linear
regression models. Five separate models were used
to evaluate effects for each hypothesized treatment
mechanism (MEAQ, SMQ, and ASI) and ultimate
symptom outcomes (EDE-Q Global and CES-D).
Discharge scores for each respective outcome were
regressed on intake scores (to control for intake/base-
line severity); covariates included baseline EDE-Q
score, age, site, admission BMI, number of comorbid
diagnoses at admission (square-root transformed),
and length of stay (days). The effect of implemen-
tation on patient outcomes was evaluated using a
dummy-coded indicator (pre- vs. post-implemen-
tation). If less than 10% of the total items were
missing on a measure, individual missing items
were singly imputed using the mean of the other
scale items. Pretreatment differences between
Psychotherapy Research 9
groups were evaluated using independent samples t-
tests for continuous variables, and Pearson’s Chi-
Square tests for categorical variables. Independent
samples t-tests were used to compare baseline charac-
teristics of patients who did and did not complete the
discharge survey. For these analyses, admission and
discharge scores on the outcome of interest, plus
data for all covariates, were required for a partici-
pant’s data to be included. Of the full sample, 430
participants (69.8%) had sufficient data for inclusion.
Analysis of clinical outcomes at 6MFU. Hierarchical
linear mixed models (HLM), or multilevel models,
were used to examine the effect of implementation
on patient outcomes over time. HLM allowed for
analysis of nested data (i.e., baseline, discharge, and
follow-up observations nested within patients) and
the ability to include patients with partially missing
outcome data (Gelman & Hill, 2007; Kreft, Kreft,
& de Leeuw, 1998). The models accounted for data
collected at baseline, discharge, and 6MFU. Each
outcome was evaluated in a separate model using
the lme4 package in R, and all models were estimated
using maximum likelihood. Significance of fixed
effects was determined from p-values calculated
using a Satterthwaite normal-approximate distri-
bution. Maximal models were assumed for all var-
iance model parameters, or random effects. Final
models included fixed intercept effects of baseline
EDE-Q score, age, site, admission BMI, comorbid
diagnoses, and length of stay (covariate slope effects
if they contributed significantly to model fit).
Within-person change from admission to 6MFU
was assessed by adding fixed and random intercept
and slope effects of time on outcome. Time was
scaled in weeks and square-root transformed, to
account for the commonly occurring non-linear
relationship between time and patient progress (i.e.,
pronounced change in scores early on during the
study period (and during treatment), with declining
rates of change during the follow-up period;
Gibbons et al., 1993). Finally, fixed intercept and
slope effects of implementation phase were included
to assess the effect of implementation phase on
patient improvement over time. Extent to which
patients met criteria for reliable and clinically signifi-
cant change on the EDE-Q was assessed using the
Jacobson–Truax formula for the Reliable Change
Index and guidelines for determining a cutoff for
“clinically significant” improvement (Jacobson, Foll-
ette, & Revenstorf, 1984; Jacobson & Truax, 1991).
Given overlapping distributions between the present
sample and non-clinical norms for the EDE-Q (Fair-
burn & Beglin, 1994), the clinically significant change
cutoff score was set at halfway between the two means
(midpoint between Mnorm = 1.55 and Mclinical sample
= 4.14: 2.84).
10 Heather Thompson-Brenner et al.

Random effects pattern mixture modeling DSM-5 diagnostic criteria midway through the
(Hedeker & Gibbons, 1997) was conducted to study period.
assess potential sources of bias introduced by attrition
at 6MFU (59%) relative to discharge (29%). A
dummy-coded “dropout” indicator variable was Clinician Fidelity
created to denote whether a patient had completed
The average percent group adherence was 88.17 (SD
the 6MFU assessment battery. Interaction terms
= 17.46, range = 40–100%), which is considered
between dropout, time, and implementation phase
“good.” No significant differences in average adher-
were added simultaneously to each respective
ence were found between the sites or groups
outcome model. Likelihood ratio tests were used to
sampled from the early, middle, and late implemen-
determine whether addition of these terms jointly
tation periods. The average quality rating for individ-
resulted in significant improvement of model fit.
ual manualized interventions was 3.43 (SD = 0.87),
Significance suggests the presence of a systematic
which is in the “adequate to good” range. No signifi-
relationship between patient treatment response
cant differences were found between sites. There was
and the likelihood of completing the 6MFU assess-
a significant effect of implementation phase on adher-
ment. Significance of the individual time x implemen-
ence-intervention quality ratings, F(2, 55) = 4.19, p
tation phase x dropout term indicates whether that
= .02, h2p = .13. Pairwise comparisons indicated that
relationship differed depending on implementation
average quality was significantly higher in later
phase.
implementation phase groups (M = 3.85, SD =
0.60) compared to early groups (M = 3.14, SD =
0.88; Mdiff = 0.71, CI = 0.21: 1.22). The average
Results
overall group quality rating was 3.41 (SD = 0.99),
Participant Characteristics considered in the “adequate to good” range.
Results from ANOVAs indicated the effects of treat-
Patient ages ranged from 13 to 63 (M = 25.59; SD =
ment site and implementation timing (early, middle,
10.76), and the average admission BMI was 22.31
or late implementation) were not statistically signifi-
(SD = 10.76). Most patients were White (86.5%),
cant. The average competence rating for general skills
with the remainder identifying as Hispanic (5.5%),
such as rapport, collaboration, and session manage-
Multiracial (3.1%), Asian/Pacific Islander (2.1%),
ment (across items and groups) was 3.75 (SD =
African-American (1.5%), or other (1.7%). The
0.85), in the “adequate to good” range. No signifi-
most common ED diagnosis was AN (n = 230;
cant site differences were found. There was a signifi-
37.3%), followed by BN (n = 201; 32.6%), ED-
cant effect of implementation phase on general
NOS or OSFED (n = 160; 26.0%), and BED (n =
competence scores, F(2, 55) = 3.38, p = .04, h2p
25; 4.1%). Of patients diagnosed with AN, 157
= .11. Pairwise comparisons indicated competence
(68%) were specified as restricting subtype and 73
was significantly higher in the later phases (M =
(32%) were binge–purge subtype. Ninety-one
4.13, SD = 0.49) compared to middle (M = 3.47,
percent of patients also met criteria for at least one
SD = 1.02; Mdiff = 0.66, CI = 0.11: 1.20) and early
Axis I co-occurring disorder. Major depressive dis-
phase groups (M = 3.61, SD = 0.89; Mdiff = 0.51,
order was the most common co-occurring diagnosis
CI = 0.01: 1.02).
(66.3% of patients), followed by anxiety disorders
(38.5%). The treatment groups did not differ signifi-
cantly on age, admission BMI, number of comorbid
Effect of Implementation on Patient
diagnoses, race/ethnicity, or baseline scores on
Outcomes from Admission to Discharge
outcome measures. Patients in the pre-implemen-
tation group had significantly longer lengths of stay Results from multiple linear regression indicated that
than the post-implementation group (MPre = 31.31 individuals in the post-implementation group had
days; SD = 15.09; MPost = 27.13; SD = 10.41; t significantly lower experiential avoidance (b =
(456.94) = 3.57, p < .001). A larger proportion of −12.34, SEb = 3.91, p = .003), lower anxiety sensi-
patients from the pre-implementation group were tivity (b = −2.24, SEb = 1.10, p = .04), and higher
treated at the northeastern US location (χ 2(1) = mindfulness (b = 4.75, SEb = 1.52, p = .002) at dis-
7.96, p = .005; implementation occurred later at this charge, relative to pre-implementation patients (see
site). Significantly more patients in the pre- Tables II and III). Effect sizes (Cohen’s d ) for the
implementation group received a diagnosis of ED- difference between admission and discharge scores
NOS/OSFED, versus AN-binge/purge subtype, were calculated to estimate the magnitude of
BN, or BED (χ 2(4) = 19.88, p = .001). This differ- improvement made during treatment. In general,
ence was due to a shift from use of DSM-IV to pre-implementation patients made small to medium
 Psychotherapy Research 11
Table II. Clinical outcomes pre- and post-implementation.

Discharge 6MFU
Admission (n = 440) (n = 266)
(n = 616)
Implementation phase M (SD) M (SD) d M (SD) d

Eating Disorder Examination-Questionnaire

Pre-implementation 4.14 (1.31) 2.50 (1.31) 1.25 3.15 (1.62) 0.67
n = 331 n = 230 n = 149
Post-implementation 4.14 (1.35) 2.54 (1.23) 1.24 2.46 (1.16) 1.33
n = 285 n = 210 n = 124
Center for Epidemiological Studies—Depression Scale
Pre-implementation 37.12 (12.36) 25.84 (12.36) 0.91 27.55 (13.37) 0.74
n = 302 n = 256 n = 150
Post-implementation 37.72 (12.08) 24.34 (11.67) 1.13 17.70 (12.05) 1.13
n = 262 n = 206 n = 126
Multidimensional Experiential Avoidance Questionnaire
Pre-implementation 229.21 (38.75) 212.15 (42.09) 0.43 212.88 (43.89) 0.39
n = 214 n = 239 n = 123
Post-implementation 231.81 (40.36) 198.56 (46.38) 0.76 161.13 (51.48) 1.52
n = 249 n = 204 n = 125
Southampton Mindfulness Questionnaire
Pre-implementation 30.97 (15.79) 37.02 (15.89) 0.38 36.69 (13.39) 0.39
n = 250 n = 236 n = 139
Post-implementation 30.19 (15.89) 42.58 (17.51) 0.74 34.80 (13.93) 0.31
n = 259 n = 203 n = 125
Anxiety Sensitivity Index
Pre-implementation 32.27 (12.51) 30.58 (13.11) 0.13 28.71 (12.14) 0.29
n = 251 n = 239 n = 134
Post-implementation 32.06 (12.82) 27.54 (13.33) 0.35 25.57 (12.69) 0.51
n = 262 n = 204 n = 124

improvement in mechanisms (ds = 0.13–0.43),
whereas post-implementation patients made
medium to large improvements (ds = 0.35–0.76; see
Table II).
No significant effect of implementation on eating
disorder symptoms (b = −0.14, SEb = 0.10, p = .18)
or depressive symptoms (b = −0.93, SEb = 1.05,
p = .38) from admission to discharge was detected.
For these outcomes, effect sizes were large in both
groups (ds = 0.91–1.25), suggesting marked clinical
improvement in both groups. Individuals who failed
to complete discharge assessments did not differ sig-
nificantly from assessment completers on any of the
outcome measures at intake/baseline (ps > .16).
Implementation had no significant effect on BMI out-
comes at discharge for patients admitted underweight
(b = −0.12, SEb = −0.13, p = .35). Rates of reliable
and clinically significant change in ED symptoms
from admission to discharge did not show significant
differences between the pre-implementation and
post-implementation groups (χ 2(3) = 4.36, p = .22).
Effect of Implementation on Patient
Outcomes at 6-month Follow Up (6MFU)
Significant fixed effects of time on each of the hypoth-
esized mechanisms were detected (ps < .002),
indicating that experiential avoidance, anxiety sensi-
tivity, and mindfulness improved across both pre-
implementation and post-implementation treatment
groups at 6MFU. Length of stay also had a significant
effect on ED (b = −0.004, SEb = 0.001, p = .004) and
depressive symptoms (b = −0.03, SEb = 0.01,
p = .02); longer stays were associated with greater
symptom reduction. A significant fixed effect of site
on within-person change was observed for experien-
tial avoidance (b = 3.35, SEb = 1.20, p = .006),
suggesting that rates of improvement differed signifi-
cantly between the two sites for this measure alone.
The fixed effect of time x implementation phase on
experiential avoidance was significant (b = −9.19,
SEb = 1.13, p < .0001), indicating that individuals in
the post-implementation group tended to experience
greater reductions in experiential avoidance than pre-
implementation patients at 6MFU. No significant
effect of implementation phase on within-person
change in mindfulness was detected (b = −0.41,
SEb = 0.40, p = .30), and the effect on anxiety sensi-
tivity approached significance (b = −0.48, SEb =
0.29, p = .10). Significant fixed slope effects of
implementation were detected for both ED (b =
−0.13, SEb = 0.03, p = .0001) and depressive symp-
toms (b = −1.86, SEb = 0.31, p < .0001); patients
treated post-implementation tended to make greater
 12
Heather Thompson-Brenner et al.
Table III. Fixed parameter estimates for outcomes from admission to discharge.

Experiential avoidance Mindfulness Anxiety sensitivity Depression Global eating pathology

Parameter b SEb p b SEb p b SEb p b SEb p b SEb p

Intercept 60.17 14.73 < .0001 34.94 5.23 < .0001 9.39 3.25 .004 8.78 2.99 .004 0.29 0.29 .33
Age −0.24 0.18 .17 −0.03 0.07 .66 −0.12 0.05 .01 −0.11 0.05 .02 0.01 0.005 .09
Comorbiditya 2.92 3.87 .45 −3.35 1.50 .03 1.17 1.09 .29 1.85 1.04 .08 0.04 0.10 .67
Admission BMI 0.25 0.26 .35 −0.003 0.10 .97 0.09 0.07 .24 −0.04 0.07 .59 0.002 0.007 .80
LOS (days) 0.16 0.19 .40 −0.17 0.07 .02 0.08 0.05 .13 0.12 0.04 .009 0.01 0.004 .007
Siteb −4.12 4.01 .30 3.69 1.56 .02 −4.35 1.13 .0001 −3.79 1.07 .0005 −0.29 0.10 .007
Baseline score on outcome variable 0.64 0.05 < .0001 0.43 0.05 < .0001 0.62 0.05 < .0001 0.38 0.05 < .0001 – – –
Baseline ED severity 1.25 1.58 .43 −1.72 0.63 .007 0.47 0.44 .29 0.67 0.46 .15 0.51 0.04 < .0001
Implementation Phase (Post) −12.34 3.91 .002 4.75 1.52 .002 −2.24 1.10 .04 −0.93 1.06 .38 0.14 0.10 .18
a
Refers to total number of comorbid non-ED diagnoses; variable was square-root transformed and centered prior to entry into model.
b
Represents effect for patients treated at the southeastern US facility, relative to northeast US facility. BMI = body mass index (kg/m2); LOS = length of stay; ED = eating disorder. Statistically
significant effects are printed in bold-face for ease of reading.

Table IV. Fixed parameter estimates for outcomes from admission to 6-month follow-up.

Experiential avoidance Mindfulness Anxiety sensitivity Depression Global eating pathology

Parameter b SEb p b SEb p b SEb p b SEb p b SEb p

Intercept 214.37 8.89 < .0001 36.11 3.11 < .0001 29.62 2.61 < .0001 26.81 2.29 < .0001 2.85 0.26 < .0001
Age −0.19 0.16 .24 −0.04 0.06 .52 −0.06 0.05 .22 −0.02 0.04 .55 −0.007 0.005 .16
Comorbiditya 12.13 3.37 .0004 −4.74 1.19 < .0001 2.91 1.00 .004 5.33 0.85 < .0001 0.29 0.10 .004
Admission BMI 0.36 0.24 .14 −0.03 0.08 .70 0.13 0.07 .06 0.10 0.06 .10 0.02 0.007 .02
LOS (days) 0.33 0.15 .02 −0.10 0.05 .04 0.09 0.04 .04 0.19 0.04 < .0001 0.02 0.005 < .0001
Siteb −6.69 4.20 .11 3.02 1.27 .02 −3.78 1.06 .0004 −0.75 0.90 .41 −0.24 0.10 .02
Implementation Phase (Post) 1.82 4.09 .66 2.26 1.52 .14 −1.18 1.21 .33 1.22 1.05 .25 0.14 0.12 .24
Timec −4.09 0.87 < .0001 1.14 0.28 < .0001 −0.65 0.20 .001 −0.79 0.42 .06 −0.08 0.05 .09
Time ∗ Site 3.36 1.20 .006 – – – – – – – – – – – –
Time ∗ LOS – – – – – – – – – −0.03 0.01 .02 −0.004 0.004 .004
Time ∗ Implementation Phase (Post) −9.42 1.12 < .0001 −0.41 0.40 .30 −0.48 0.29 .10 −1.85 .31 < .0001 −0.13 0.03 .0001
a
Refers to total number of comorbid non-ED diagnoses; variable was square-root transformed and centered prior to entry into model.
b
Represents effect for patients treated at the southeastern US facility, relative to northeast US facility.
c
Scaled in weeks and square-root transformed to account for non-linear change trajectories. BMI: body mass index (kg/m2); LOS: length of stay; ED: eating disorder. Fixed slope effects of covariates
(i.e., interactions with time) were only included in final models if they significantly improved model fit. Statistically significant effects are printed in bold-face for ease of reading.

long-term symptom improvements than pre-
implementation patients measured at 6MFU (see
Table IV). Among those admitted underweight
(BMI < 18.5), BMI change did not differ significantly
pre- vs. post-implementation.
Reliable and clinically significant change on ED
symptom severity from admission to 6MFU were as
follows for the pre-implementation group: 9.4% dete-
riorated reliably, 29.5% had no change from baseline
admission scores, 26.2% improved reliably but did
not reach clinical significance, and 34.9% achieved
clinically significant improvement. For post-
implementation, 2.4% deteriorated, 20.2% had no
change, 12.9% had reliable but not clinically signifi-
cant improvement, and 64.5% experienced clinically
significant improvement. This difference in frequen-
cies of outcome was significant (χ 2(3) = 25.83, p
< .0001). Examination of residuals indicated this
result was driven by a significantly greater proportion
of patients experiencing reliable and clinically
significant improvement in the post-implementation
group (zresid = 2.59) than pre-implementation (zresid
= −2.36).
Assessment of Risk of Bias from Attrition
Results from pattern mixture modeling indicated that
joint addition of the dropout terms (including inter-
actions with time and implementation phase) signifi-
cantly improved model fit for all outcomes (ps ≤ .04).
To determine whether the dropout-outcome pattern
differed systematically between the treatment
groups, estimates for specific model parameters
were further examined. Relative to those who failed
to complete the 6MFU survey, study completers
appeared to have more severe symptoms at discharge,
but also to improve more across measures from base-
line to discharge. Across measures, however, there
were no significant differences in dropout patterns
between the pre-implementation and the post-
implementation groups, suggesting they might be
reasonably compared within the context of this attri-
tion effect. This pattern held for EDE-Q scores,
CES-D scores, experiential avoidance, and mindful-
ness (p values comparing drop outs vs. completers
ranged from <.0001 to .04); p values for interactions
between this effect and implementation group all
>.05). For anxiety sensitivity, neither the fixed inter-
cept effect of dropout nor its interactions with time or
implementation phase were significant (ps > .14).
Missing data patterns indicated that certain patients
were more likely than others to complete 6MFU, but
attrition did not have a systematic effect on associ-
ations between implementation phase and change
over time (complete results available upon request).
Psychotherapy Research 13
Discussion
This study aimed to investigate key implementation
and patient outcomes (Proctor et al., 2011) in the
context of a comprehensive psychotherapy
implementation effort in residential ED treatment
settings. Therapist adherence and competence were
assessed to examine feasibility of program-wide train-
ing in the common elements protocol, and patient
outcomes were examined before and after the adap-
tation and implementation of an emotion-focused,
evidence-based treatment in two residential treat-
ment centers. Following clinician training and super-
vision, results from independent ratings of group
session recordings demonstrated “adequate to
good” average levels of adherence, competence, and
overall group quality across sites, implementation
phases, and program stages. Furthermore, results
from self-report questionnaires regarding patient
outcome showed that individuals who were treated
in the post-implementation phase showed signifi-
cantly more improvement in key variables than
those treated pre-implementation. Taken together,
these findings suggest that implementation of a trans-
diagnostic, common elements approach for residen-
tial ED treatment is both feasible and effective.
Clinician fidelity in applying the new treatment
program represents a key preliminary implemen-
tation outcome. Although the observed adequate
fidelity is encouraging, it is important to emphasize
that the full range of adherence and competence
(low/poor to high/excellent) was observed. Though
mean adherence was consistent over time, interven-
tion quality and general competence significantly
improved between early and later implementation
phases. Informally, after being presented with some
of the results, coders speculated that therapists
appeared to rely more heavily on written manual
materials early in the implementation period, poten-
tially to the detriment of quality and competence.
As therapists gained more experience and supervision
with the new model they delivered the interventions
with greater skill. Future work may address
between- and within-therapist variability in fidelity,
fine-grained analysis of trends over time, and
relationships with patient outcomes.
The implementation effort also appeared to yield
improved patient outcomes. Post-implementation
UTM patients showed larger reductions in ED and
depressive symptoms at the 6MFU assessment,
based on multilevel models examining the trajectory
of change across the baseline, discharge, and 6MFU
observations. Examination of mean ED symptom
levels suggest that patients treated using the UTM
maintained similar ED symptom levels from discharge
to follow-up, whereas pre-implementation patients
14 Heather Thompson-Brenner et al.
experienced some worsening of ED symptom severity
during that time. Examination of mean depressive
symptom levels suggest that patients treated using
the UTM continued to see improvement in
depression from discharge to follow up, whereas pre-
implementation patients did not. Significant differ-
ences pre- vs. post-implementation were also
observed on domains of emotional functioning
specifically targeted by the intervention. At discharge,
post-implementation patients showed significantly
greater improvements in experiential avoidance,
anxiety sensitivity, and mindfulness relative to pre-
implementation patients. At follow-up, significant
differences in improvement in experiential avoidance
were still observed between groups. Improvements
in treatment effects that were observed post-
implementation were clinically significant as well. At
follow-up, a significantly greater proportion of
patients treated in the post-implementation period
(64.5%) experienced clinically significant improve-
ment on ED symptom severity.
It is important to consider possible reasons that the
UTM treatment showed larger effects on ED and
depressive symptoms at follow-up but not at dis-
charge. Structured, intensive residential treatment
produces large effects in both of these domains
between admission and discharge (Friedman et al.,
2016), because symptoms such as restriction, binge
eating, purging, etc., are prohibited or discouraged
in residential treatment. Residential treatment also
works directly on depression by removing social iso-
lation and social stressors, and by regulating sleep
and eating patterns. Following discharge, patients
often return to the behaviours that constitute and con-
tribute to deterioration in these domains (Lowe et al.,
2003). However, reduced experiential avoidance may
have contributed to the observed benefits in ED sever-
ity and depression at follow-up, consistent with UTM
goals. Additional research examining mediation
models will help to further explain these results.
Other factors in the pre-post cohort design may
have accounted for the observed results. The atten-
tion to training and supervision increased in the tran-
sition to the new treatment model, and it is possible
that these changes accounted for observed differences
between the pre- and post-implementation group.
However, the observed changes in the specific mech-
anisms addressed in the UTM suggest there may
have been more targeted, intended effects. In a
multi-modal program, it is also difficult to identify
which of the practices (e.g., UTM group therapy vs.
other UTM training and practices) account for
observed changes. Though site differences were not
observed in clinician fidelity, significant differences
in patient outcome were observed between the two
sites, with patients from one residential treatment
site demonstrating better outcomes than the other.
Site differences were observed prior to the implemen-
tation as well as post-implementation, and clinical
improvement pre- to post-implementation was
observed at both sites. Other variables not assessed
in this study must account for better observed
outcome in one location. Previous research suggests
that site differences are to be expected in psychother-
apy research in general, as well as specifically in
implementation studies (Bickman et al., 2014).
These analyses controlled for many possible factors
observed to influence outcome in prior studies,
such as BMI, age, number of co-occurring disorders,
and baseline/intake severity. Further research is
needed to explain factors accounting for observed
site differences.
Results concerning other predictors of outcome at
discharge and 6MFU were also of note. Longer
length of stay significantly predicted better
depression and ED outcome at discharge and better
outcomes across all variables at follow up. Previous
research on length of stay—like other treatment
intensity variables in uncontrolled research—is regu-
larly confounded with patient severity, meaning that
the patients who receive more treatment are often
those who have worse symptoms or have not fully
responded. Therefore, although the benefit of more
treatment may be real, it is hard to identify in the
context of lesser observed improvement or higher
symptom scores. Though baseline/intake rates of a
variety of psychopathology scores were controlled,
the confounding influence of third party payers—
who may approve more treatment specifically
because a patient has not yet responded adequately
—could not be controlled. Therefore, the finding
that longer length of stay specifically predicted
outcome at six months following discharge is particu-
larly intriguing, though it requires further research
with additional controls.
Limitations
There are many limitations to this study. Patients
were not randomly assigned to pre-implementation
and post-implementation groups, and cohort
effects may exist. We did not control for therapist
variables or therapist effects in our models. The
implementation process was multi-faceted, and a
direct causal relationship between the application
of the UTM and improved patient outcomes
cannot be assumed. Mediational analyses with a
larger sample are needed to determine whether
changes in emotion function variables are mechan-
isms of change for EDs and depression. All patients
were female, and most patients were White, limiting

generalizability. There are also limitations associ-
ated with the response rate; a certain proportion
of patients did not complete discharge assessments,
and another larger proportion did not complete
follow-up assessments. Numerous factors contribu-
ted to attrition, including severe nutritional/cogni-
tive impairment at admission, precluding research
consent and admission survey completion, the
unfunded nature of the research study, and
sudden discharges driven by transfer to other facili-
ties or unexpected termination of insurance cover-
age. Although the effects of non-completion were
examined through pattern analysis, results are
limited in generalizability due to attrition. Diagnosis
reliability, follow-up weight, and follow-up height
were not independently verified.
Conclusion
Evidence-based psychotherapies are rarely
implemented as the cohesive foundation for psy-
chotherapy and adjunctive treatment in residential
ED treatment programs, and there are many obstacles
to controlled research in this context. Using a quasi-
experimental design, this study provides preliminary
evidence for the feasibility of achieving clinician fide-
lity and the effectiveness of a research-informed, theor-
etically integrated, common elements transdiagnostic
treatment. These preliminary data may inform future
practice and research efforts in the area of residential
treatment implementation.
Note
1
The extensive outpatient ED RCT literature has been reviewed
and analyzed in detail in (Bulik, Berkman, Brownley, Sedway,
& Lohr, 2007; Hay, 2013; Shapiro et al., 2007).
ORCID
Hallie Espel-Huynh http://orcid.org/0000-0001-
8456-3465
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