Feasibility and acceptability of DVD and telephone coaching-based skills training for carers of people with an eating disorder

Feasibility and Acceptability of DVD and TelephoneCoaching-Based Skills Training for Carers of

People with an Eating Disorder

Ana R. Sepulveda, PhD1*Carolina Lopez, MSc1

Pam Macdonald, MSc1

Janet Treasure, MD, PhD, FRCP,FRCPsych2

ABSTRACT

Objective: The aims of this study were

(1) to describe the feasibility and accept-

ability of this skills-based training for carers

of people with eating disorders and (2) to

examine whether the anxiety, depression,

and expressed emotion involved in the

caregiving experience were reduced.

Method: Sixteen carers participated in

the study. Assessment measures includ-

ing the General Health Questionnaire,

the Hospital Anxiety and Depression

Scale, the Experience of Caregiving Inven-

tory, and the Family Questionnaire were

taken before and after the intervention.

Feedback and a measure of acceptability

measure were also collected.

Results: Participants expressed high

levels of satisfaction with most aspects

of the training. Also most of the

carers reported that the digital video

devices (DVDs) provided sufficient train-

ing and were helpful for their stress lev-

els. However, due to the small sample

size, the lessening of psychological dis-

tress and depression after the interven-

tion, did not reach formal levels of sig-

nificance according the self-report

measures.

Conclusion: The DVDs appear to be an

acceptable method of delivering infor-

mation and skills-based training for

carers. VVC 2008 by Wiley Periodicals, Inc.

Keywords: carers; eating disorders;

skills training; DVD; motivational inter-

viewing

(Int J Eat Disord 2008; 41:318–325)

Introduction

Carers’ Needs

Carers of people with eating disorders (ED),mostly parents, provide high levels of emotionaland practical support. Carers have high levels ofunmet needs and experience distress associatedwith this role.1–4 We have developed a model thatexplains the factors that contribute to difficultieswithin the caregiving role. Misunderstandingsabout ED such as their causes, consequences, andthe role of the family and of the individual, canlead to patterns of over protection, criticism or hos-tility.3,5,6 These problematic patterns of communi-

cation and reactions to the illness can hinder ratherthan help change. The interpersonal reaction to an-orexia nervosa (AN) is one of the maintaining fac-tors in the Maudsley model of AN.7 This modelposits that factors within the family such as highexpressed emotion, criticism, hostility, and overprotection can adversely impact on the illness.Unhelpful appraisals about caregiving can alsoimpact on carers’ distress and these may be modi-fied by providing carers with information and skillstraining. This may produce a beneficial outcomefor the sufferer themselves.

Empathic Support

In a study examining the quality of life of caregiv-ers of ED patients, de la Rie et al.8 found thatparents wanted information on all aspects of theED. They expected that professional support wouldhelp them gain insight into the illness and contrib-ute to a better understanding and/or acceptance ofthe problem. They also felt they were not able tocope with this on their own and expressed the needfor emotional support. Tierney9 suggests that talk-ing to parents of youngsters with AN can providevaluable insight into carers’ needs and experiences.The illness appeared to make parents feel disem-powered. Parents reported that their concerns were

Accepted 9 October 2007

1 Division of Psychological Medicine, Institute of Psychiatry,

King’s College London, London, United Kingdom2Department of Academic Psychiatry, Guy’s, King’s and

St. Thomas’s Medical School, London, United Kingdom

*Correspondence to: Dr. Ana R. Sepulveda, Department of

Academic Psychiatry, 5th Floor, Thomas Guy House, Guy’s

Hospital, London, SE1 9RT. United Kingdom.

E-mail: [email protected]

Supported by the Mental Health Foundation, Nina Jackson

Foundation for Research into Eating Disorders and the Institute of

Social Psychiatry.

Published online 4 January 2008 in Wiley InterScience

(www.interscience.wiley.com). DOI: 10.1002/eat.20502

VVC 2008 Wiley Periodicals, Inc.

318 International Journal of Eating Disorders 41:4 318–325 2008

REGULAR ARTICLE

not taken seriously at the onset of the illness. Theauthors found that parents in the study appreciatedfamily therapy because it gave them the opportu-nity to express themselves in a professionally medi-ated, neutral setting. Honey and Halse10 examinedparents’ actions in response to AN and how theseare shaped by causal beliefs. They suggest thatunderstanding parents’ actions and constructions/understandings of the illness can help professionalsdevelop collaborative partnerships with parentsand that parents’ behavior and actions can offer animportant resource for assisting recovery. Lobbanet al.11 reviewed research studies on carers’ con-struction of mental illness and found that thesecould affect the way carers responded to patientsand, in turn, patients’ own illness constructions.Barrowclough and Hooley12 suggest that relatives’beliefs about mental illness affected the emotionalclimate within the home and that carers’ attribu-tions also may influence patients’ outcomes.

Skills Training and Education for Carers

Our group has been working closely with carersto help family members in their caregiving role.The first stage of this line of research was the devel-opment of a 3 day multifamily workshop for fami-lies of inpatients. This was found to be as effectiveas individual family therapy. Carers particularlyliked the structure and training in reflective listen-ing (Whitney et al., personal communication). Toextend the intervention to carers not involved ininpatient care, the next phase was to provide edu-cation and skills training for carers in a workshopsetting consisting of six 2-h sessions.12 A writtenmanual outlined the curriculum of the work-shops.14 An exploratory randomised controlled trial(RCT) comparing the workshop participants withthose remaining on a waiting list, found significantreductions in carers’ distress and negative apprais-als of caregiving (Sepulveda et al., submitted). Thethird and current phase of the project involvedtransferring the educational content and skills(communication and motivational interviewing)from the workshops onto a series of five digitalvideo devices (DVDs).

This DVD project has been primarily designedfor clinical purposes. The rationale behind this de-velopment was to address issues of high demand,scarce resources, and geographical and time con-straints. It was hoped that the DVD format wouldbe a cost effective method of reaching a wideraudience allowing carers to flexibly strengthentheir knowledge base. Also, it is expected that theDVDs will be a tool easily available for clinicians,researchers, and for training purposes in the future.

The skills training within the workshops adopteda format of theory and instruction followed bydemonstration and practice through role play. TheDVDs were only able to convey the first two aspectsof this process using Power Point presentationsinterspersed with video clips. These conceptualvisual representations were utilized to demonstratethe application of these skills in a practical setting.Telephone coaching was also offered as an addedmeans of support for carers in working through thecomplex systems of interrelated feelings, thoughts,and actions entailed in the caregiving experience.This helpline method has been used with caregiv-ers of people with dementia,15 older people withdepression,16,17 and also among patients with dia-betes18 with promising results.

Telephone Coaching

Telephone interventions have risen in recentyears, particularly as supplementary measures tomore conventional counselling methods. Wellset al.19 used a telephone guided self-help programfor patients with binge eating disorder that supple-mented a self-help manual with participants com-menting favorably on the flexibility, accessibility,and autonomy offered by this type of intervention.Wisniewski and Ben-Porath20 proposed that adialectical, telephone-administered skill-coachingmodel based on behavior therapy would be a usefuladjunct to the treatment of ED in terms of reinforc-ing, improving, and assisting in the implementa-tion of skills for ED clients. The protocol followed asemistructured procedure that involved establish-ing the problem, evaluating what the client had al-ready tried to solve the problem, encouraging com-mitment and promoting motivation for setting anaction plan, as well as discussing any obstacles thatmay hinder progress. In general, the goal of tele-phone skills-coaching in our study was to empowerthe carers to make a decision regarding the currentcrisis and to take appropriate action.

Aims

The aim of this pilot study was to examine thefeasibility and acceptability of DVD-based skillstraining, supplemented with telephone coaching,for carers of a relative with an ED. The secondaryaim was to explore whether this training wouldlead to a change in carers’ attitudes to the illnessand a change in communication as well as reduc-tions in anxiety, depression, caregiving burden, andexpressed emotion. However, given the small sam-ple size and duration of the intervention, no signifi-cant differences in the outcome measures wereexpected. Nevertheless, an exploratory aim was to

DVD-BASED SKILLS TRAINING FOR CARERS IN ED

International Journal of Eating Disorders 41:4 318–325 2008 319

ensure that the initial carer characteristics or con-dition did not deteriorate with DVD-based delivery(i.e., anxiety or expressed emotion).

Method

Participants

We sampled four groups of carers: (1) Three carers

who had attended the workshop and expressed the need

for more help, (2) Three carers of people admitted to the

inpatient unit with no previous experience of carer work,

(3) Three carers of patients currently in the outpatient

department of South London and Maudsley), and (4)

Seven carers of people either not in current treatment or

in receiving support from other services (recruited from

the Institute of Psychiatry website and the Carers Associ-

ation (Beat)). Inclusion criteria stipulated that the carer

had to either be living with, or directly involved in the

care of a patient with an ED.

Structure and Content of the DVD

Carers were given the written manual at the beginning

of the intervention.15 DVDs were delivered in two packs

of 2 DVDs (DVD 1 & 2 and DVD 3 & DVD 4) and a last

pack with the final DVD (DVD 5). The specific content of

the DVDs is shown in Table 1. Supplementary telephone

coaching was given after each pack of DVDs were

received by the carer.

Coaching Intervention

Two individuals (one professional and one nonprofes-

sional) carried out the telephone coaching and collected

the feedback about the intervention. They were chosen

for their previous experience in dealing with people with

ED. The professional individual was a senior nurse of the

South London and Maudsley Trust (SLaM) with a vast

clinical experience in the ED field and trained in motiva-

tional interviewing whilst the other coach is an expert

carer who has participated in the workshops on several

occasions. She is a mother who has suffered from ano-

rexia herself and she is now recovered. Both had experi-

TABLE 1. Content of DVDs

Number Content of DVD

DVD 1: Interpersonal impactof eating disorders

The aim of the first DVD is to encourage carers to recognize and reflect on the possibility that their emotional andbehavioral response to the symptoms may play a role in maintaining or aggravating the illness. ‘‘Animal model’’is used as metaphors of maladaptive interpersonal relationships in a humorous manner (i.e., kangaroo asover-protective role or ostrich as emotional denying reaction). The model of carer coping13 is introduced and isused as a template to consider change. Carers are encouraged to consider first those areas within the model thatthey have direct control over (i.e., that a change in their behavior may lead the way into a change in the behaviorof the individual with an eating disorder. By grappling with the concept of change for themselves they developmore understanding about what the process of change (recovering from an ED) entails.

DVD 2: Supported eating The primary goal of the supported eating DVD is to help reduce medical risk and improve nutritional health. It drivesthe message home that ‘‘Eating is nonnegotiable–all living creates must eat to live.’’ DVD2 examines safetybehaviors that maintain eating disorder symptoms. The skills are exemplified by typical role-play scenarios. Theseshow therapists/actors tackling difficult issues such as how to establish supported eating patterns. The importanceof consistency is emphasized since, although the style and content of eating is of secondary importance, irregularmeals and strict rules about content can increase the risk of binge eating.

DVD 3: Communicationskills and cycle ofchange

The first aim of DVD3 is to promote the understanding of the concept of change and how to elicit change. Itfamiliarizes carers with the trans-theoretical model of change21 and the implications of this for (a) understandingthe perspective of the person with an eating disorder (b) shaping their behaviors and communication strategies tomatch the stage of change of the person with an eating disorder. Most people with eating disorders are not readyto change and direct advice is unhelpful whereas the strategies of motivational interviewing can maintaincommunication and help individuals gain more active engagement with change. Simple motivational techniquesare taught such as open questions, affirmations, reflective listening, and summarizing (OARS).22 These skills aresubstantiated by numerous scenarios depicting typical interactions in the home setting. The concept of‘‘developing discrepancy’’ is described by introducing conversations about the desire, ability (or confidence), thereasons for and need to change. The readiness ruler is introduced as a simple way of structuring conversationsabout change. Dealing with resistance to change and raising confidence to change are also covered in thisDVD.

DVD 4: Problematicbehaviors

This DVD exemplifies the skills required to help extinguish some common difficult behaviors that may presentsomeone with ED: obsessive compulsive behaviors, reassurance seeking, over exercise, purging, etc.

DVD 5: Analyzing behaviors This DVD clarifies some of the basic psychological principles underpinning behavior change. A functional analysisof behavioral interactions at home is introduced. Scenarios in which the antecedents, behavior and consequencesof a behavioral sequence are dissected and used to introduce this concept. Carers are encouraged to think in termsof their role in the setting of conditions or reactions to eating disorder behaviors. Often carers engage in behaviorsin which they inadvertently accommodate to and reinforce eating disorders symptoms or enable them, possiblyby removing negative consequences. Carers are asked to think about the positive and negative consequences ofbehavior and how positive consequences such as more attention (even negative attention) reward the behaviorand may allow it to continue whereas negative consequences, such as less attention or punishment, may reduce it.

SEPULVEDA ET AL.


ence delivering the collaborative workshops held in our

Unit.

The coaching sessions lasted for 30 min and were

delivered after each pack of DVDs (three sessions over a

period of 3 months was used). Audio recordings of the

coaching sessions were transcribed, supervised, and

analyzed.

Coaching Protocol

The coaching sessions followed the format of a semi-

structured interview including the following questions:

(1) Did you manage to watch the DVD? (2) Did you have

problems or difficulties with it? (3) Was there anything

that you did not understand? (4) What were the impor-

tant points that you learned from it, and what applied to

you? (5) How have you been able to implement strategies

from the DVD so far?

Procedure

Approval for the study was given by the Ethics Com-

mittee of the Institute of Psychiatry and written informed

consent was obtained from the participants. Carers

completed four self-report questionnaires at baseline.

The manual and DVDs 1 and 2 were first sent out and

2–3 weeks later, the first coaching session took place,

after which feedback forms were requested. This same

procedure followed with DVDs 3 and 4 and DVD 5. At the

end of the program, further self-report questionnaires

were distributed.

Measures

A battery of self-report questionnaires was completed

by carers. These included measures which explore

psychological wellbeing and caregiving experience as

follows:

1. The General Health Questionnaire23 is a 12-item

scale assessing general distress over the past few

weeks using a Likert 4-point scale (0, 1, 2, 3).

2. The Hospital Anxiety and Depression Scale24,25 is a

14-item instrument designed to detect the presence

and severity of anxiety and depression. The scoring

for both subscales ranges from 0 to 21. The subscales

have shown high internal consistency (0.80–0.93 for

anxiety and 0.81–0.90 for depression).

3. The Experience of Caregiving Inventory26 is a 66-

item (scored from 0 to 4) measure of stress, ap-

praisal, and coping in carers. Eight sub scales mea-

sure negative aspects of caregiving (ranges from 0

to 208) and have reliability ranging between 0.74

and 0.91. A higher score indicates more negative

appraisals. There are also two positive scales

(scores range from 0 to 56). Higher scores indicate

positive appraisals.

4. The Family Questionnaire27 is a self-report ques-

tionnaire of 20 items (scored from 1 to 4), designed

to measure the emotional climate in families (i.e.,

expressed emotion). It has shown good internal

consistency of subscales (ranging from 0.78 to

0.80 for emotional over-involvement (EOI) and

from 0.91 to 0.92 for criticism (CC). Higher total

score indicates higher expressed emotion for EOI

and CC.

After the completion of the program, the acceptability

of the intervention was determined with a telephone

interview asking five questions regarding the DVD train-

ing material (see description of the questions above), and

a written questionnaire which consisted of nine items

rated by means of a visual analogue scales (VAS; 1–10)

that covered the following themes: feasibility, interest,

utility and helpfulness of the DVDs (i.e., ‘‘How confident

do you feel in applying the new skills you have learned?’’

or ‘‘Are there aspects that were not as helpful or that you

think would be more difficult to apply in your everyday

life?’’), and a section for comments and feedback.

Quantitative and Qualitative Data Analysis

Nonparametric two-sided Wilcoxon paired tests were

used to compare self-report measures pre and postinter-

vention. All p values were two-tailed and statistical signif-

icance was set at p \ 0.05. Effect sizes were calculated

using Cohen’s d which indicate the strength of the inter-

vention. Demographic variables are described using pro-

portions, means (M) and standard deviations (SD). VAS

were analyzed using frequency scores.

A pilot thematic analysis of transcribed telephone con-

versations and written feedback was conducted. Verba-

tim quotations from parents’ feedback as presented in

the study have not been substantially altered; however, in

some cases quotes have been shortened. All identifying

information, such as names or locations has been

removed to protect anonymity.

Results

Participants

A total of 16 family members participated in thepilot study (13 females and 3 males). Two fathersdropped out of the study after receiving the first twoDVDs, due to work and family difficulties. Conse-quently, 14 carers completed the study. The meanage of carers was 52.1 years (SD 5 7.7; range: 41–66).Eight carers had diploma or degree level of educa-tion. Most of the carers were married or cohabiting(10/14) and 8/14 worked full or part time.



The patient group consisted of one male (7%) and13 females (93%) with a mean age of 17.2 years(SD 5 4.3; range 14–27). Ten carers (71.4%) were liv-ing with the patient. Eleven patients were reported tohave been diagnosed with AN and two with bulimianervosa (BN). The mean age at the time of diagnosiswas 16.4 years (SD 5 4 years) and the mean age atonset of the illness was 14 years (SD 5 3 years).

Acceptability

Table 2 shows the results of the satisfaction ques-tionnaire grouped by each DVD. The degree of sat-isfaction using this technology varied from 70 to80.9% (n 5 9–11) across the DVDs. The elementsendorsed most were those relating to the utility ofthe given information, and the ease of deliveringskills training in communication and emotionalregulation. The DVDs were judged to have given atleast enough in the way of practical skills by the90.8% of carers (n 5 10–13) and 85.6% of carers inaverage (n 5 11–13) found that DVDs were helpfulfor their stress levels.

The Impact of the Intervention on Carers’

Emotional Response and Caregiving Burden

Quantitative Analysis. Almost all the outcome meas-ures showed an improvement from baseline to post-intervention with effect sizes (d) ranging from 0.10 to0.53. However, none of these reached formal statisti-cal significance. Only general distress as measuredby the General Health Questionnaire decreased attrend levels (z521.73, p5 0.08, d5 0.26). The posi-tive sub scale of the ECI showed no change.

Qualitative Analysis. The recurring themes from thetelephone coaching analysis are summarized in thefollowing six subcategories: (1) carer role/needs, (2)carer approach, (3) impact of illness, (4) DVDstrengths (5) DVD weaknesses, (6) feedback fromtelephone coaching.

1. Carer role/Needs: Carers were able to under-stand that their interpersonal reactions andinteractions with the patient around the illnessmay have an impact on the outcome.

‘. . . and I have to fight against that because . . .otherwise I could over-protect . . . and I don’twant to do that either. Equally she’s goingthrough a difficult stage at the momentand I’m . . . I’m trying to find the right balance’(Father C)

‘I thought the ‘‘animal models’’ I could verymuch relate to because the way I was behavingand the way my wife was behaving as well-very much ostrich I think’ (Partner A)

‘And I do trust her and now she says to me ‘if Idon’t do it I will let you know’ whereas before Iwas so anxious that she was doing it that I’dquestion her – ‘have you done it?’ and of coursethen that just . . . it just destroyed her trust inme’ (Mother Y)

2. Carer communication: Carers were able tounderstand that joining in with ED talk mightnot be helpful.

‘I mean I never talk to D about things when she’seating or when she’s preparing her food or whenshe comes back from L. . .all these things that shefinds high anxiety times. I mean we sit andwatch television and just discuss the programmeor something like that’ (Mother Y)

‘When I speak to her I don’t ask her even how herweight is uh . . . despite the fact that Iwant to, de-spite the fact that I want to really know what’sgoing on with her . . . I know I mustn’t imposethat pressure on her because that’s not going tobe good for her’ (Father C)

3. Impact of the illness: Carers were able to acceptthe ED as an illness which alleviated the stigmaassociatedwith ED.

‘It does yeah because she, it advises her, . . . (onDVD) . . . the girl wasn’t able to go out ever and Ithink one of the things is you don’t want. . . you’re not ashamed but you think ‘oh whatare people going to say’ and I did find that atthe beginning when people said to me ‘oh howis D?’ ‘yeah she’s fine and just taking a breakfrom university’ never wanting to explainwhy . . . And now I just say ‘she’s got anorexiaand that’s what it is and you know she’s athome now till she gets better’ so it’s a lot easier’(Mother Y)

4. DVD strengths: The participants reported highsatisfaction with the animal analogies as thesewere a light-hearted and helpful way for carersto better understand their caring role. Role playwas also highly valued and deemed as neces-sary in recognising how to put knowledge intopractice.

‘I found them really, really useful and the thingsI foundmost useful are the role play’ (Mother Y)

‘I appreciated the idea of the dolphin in particu-lar, kind of nudging . . . because I . . . the timeswhen I have been talking to my wife and itsworked . . . a kind of when we have been movingin that kind ofmood if you like’ (Partner A)

SEPULVEDA ET AL.


‘The DVDs still carry lots of powerful messagesand give carers hope that things can get better ifthey really put theirminds to it!’ (Mother T)

5. DVD weaknesses: Carers mentioned difficultiesin applying this knowledge to their own circum-stances. There were also several technicalissues thatwere discussed.

‘. . . I do think there’s an awful lot to under-stand . . . really a lot there to understand and Idon’t know just as a normal person that youcould get it right’ (Mother Y)

‘but the patients were all sort of calm em . . .which is not . . . they weren’t being stroppy orkicking or so I think you would need . . . it wasn’trealistic, a true representation of the situationreally and actually cajoling them into gettingthem sitting down to the sitting down position’(Mother J)

‘The messages are clear, it’s putting the techni-ques into practice that is difficult . . . it is quitedifficult to use these DVDs in isolation withoutsome face to face interactionwith’ (Mother T)

6. Feedback from telephone coaching: Participantsindicated that phone coaching helped them todevelop skills and recognise their own discrep-ancies in response to the illness and within theirinteractions with the patient. Phone coachingalso helped carers to better understand andappreciate the importance of commitment andreadiness for change in the process of imple-menting changes andmaking progress.

‘the DVDs 4 and 5 really helps the carer to seehow the collaborative skills work in practice. Istill believe that a back up phone coaching isessential as there are so many behaviours thatcarers find so difficult to deal with and you can-

TABLE 2. Quantitative feedback relating to the DVDs based on VAS

DVD 1N514

DVD 3N5 14

DVD 5N5 12

SupportedEatingN5 13

ProblemBehaviorsN5 14

What proportion of the DVDs did you manage to watch?One to little 1 1 1About half 1Most to all of it 13 13 11 13 13

How useful did you find the information?Not at all to a little 1Useful 3 3Very/extremely useful 11 14 11 10 14

How difficult did you find using the DVDs?Very easy/easy 10 11 12 9 11Fine 4 2 4 2Difficult/very difficult 1 1

How useful was the information for your caregiving experience?Not at all/a littleUseful 4 2 2 5Very/extremely useful 10 12 10 8 14

How helpful was the DVD for your stress levels?Not at all/a little 3 1 1 2 3Helpful 2 3 3 3 4Very/extremely helpful 9 10 8 8 7

How helpful was the focus on emotional levels (animal models)?Not at all/a littleHelpful 1 2 1Very/extremely helpful 13 14 10 12 14

How helpful was the communication training?Not at all/a little 1Helpful 3 1 2 3 1Very/extremely helpful 11 13 10 10 12

Did the DVD provide enough practical skills?Too little/little 1 1 2 1 1Enough 6 8 2 7 5A lot/too much 7 5 8 5 8

Did the DVD meet your expectations?Not at all/less than I expectedExpectations met 7 4 4 6 5More than I expected/exceeded 7 10 8 7 9% acceptancea n5 10

(72.2%) very goodn5 11

(80.9%) very goodn5 10

81.4% very goodn5 9

70% very Goodn5 11

80.9% very good

a Total rate only consider categories over the average.



not hope to cover all of them in thisDVDpackage’(Mother T)

‘It is crucial to have some sort of back up support/help line so carers can at least talk about some ofthe issues raised’ (Mother L)

Discussion

The main aim of this exploratory pilot study was toexamine the acceptability and effectiveness of amanual supplemented with DVD-based skills train-ing and coaching for carers of relatives with ED.This modality of training has been developed toexamine better ways to effectively transfer profes-sional skills to carers.

Overall, carers found the DVD training programhighly acceptable and useful. The high acceptancerate of this pilot study also shows that carers ofpeople with ED seem highly motivated to receivesupport and take an active part in helping their rel-atives to recover. This would appear to support pre-vious research.8,9,28 The DVD technology is consid-ered a flexible tool as it can easily disseminateinformation and help teach carers necessary skillsto continue their caregiving role.

The secondary aimwas to reduce the psychologicaldistress and the anxiety levels in carers and toimprove the negative aspects of caregiving and thelevels of expressed emotion at the end of the interven-tion. Carers reported themselves being helped by theDVDs to reduce their stress levels in the acceptabilitymeasure. However, due to the small sample size self-report measures showed only a reduction of distressat trend levels and no significant decrease of depres-sion, anxiety, and expressed emotion. It is hoped thatthe materials promote an element of self-reflectionon those specific family dynamics that may be work-ing to exacerbate someof the eating disordered symp-toms.4 Further research is required to examine howdifferent strategies delivered via DVD can be imple-mented to improve emotional well-being and howthesemight affect parental coping abilities.11

We supplemented the training by telephonecoaching. The aim of this aspect of the interventionwas to instil motivational interviewing skills andelicit ‘‘change talk’’ from the carers. By using reflec-tive listening and open questions, it was hoped thatcarers would recognize unhelpful behaviors anddevise action plans to address them. Personal coach-ing was used specifically for feedback, suggestionsand concerns regarding DVD content. Severalthemes emerged from the telephone coaching.These included topics related to the carer role and/

or carer needs, approach and communication,impact of illness on the family, and stigma. The pro-cess of moving from initial exposure to ideas about achange in patterns of interpersonal interaction toimplementation and long-term practice dependsheavily on carers’motivation, abilities and support.

The feedback highlights several areas for improve-ment regarding the material used in this type oftraining for carers. Consequently, DVDs 1 and 3 wereadapted and revised by providing more practicalexamples and the manual updated based on thefeedback obtained from the participants. Moreover,a number of amendments to the current form of thewhole intervention are underway in order to improveoutcome, particularly to strength practical skills andto reduce the levels of distress. These include offer-ing a group meeting after the DVD-based skill train-ing to provide the opportunity to reflect on the expe-riences of others, to develop further goals to imple-ment change in carers’ behavior and to support asocial network among caregivers. The coaching pro-tocol has been refined to ensure that more time isgiven to eliciting change talk and commitmentincluding detailed implementation plans as des-cribed by Wisniewski and Ben-Porath.20 An introduc-tory phone call explains the principles of coachingand some of the expectations of the intervention, i.e.that the instigation of change will require them tomake small goals towards exhibiting more ‘‘dolphin-like’’ behaviors. They are also made aware that thisintervention will not remove all the family pain butthat it is, hopefully, a step in the right direction.

There are several limitations in this study. Thesample size was too small to allow for sufficientpower needed to detect statistically significantchanges, however, we were able to demonstratethat there were some clinically meaningful signs ofchange as suggested by both the self-report and thequalitative feedback. However, it is also possible thatthese changes result from non specific effects. Also,we did not obtain information from the patientsthemselves. A randomised trial is currently under-way introducing the changes described above.

The future of distance skills training is promisingespecially with constant advances in digital tech-nology. This type of approach may be an importantfirst step in broadening the reach of specialist serv-ices such as ED.

Conclusion

This report describes the preliminary results of astudy evaluating digital video technology as a tool

SEPULVEDA ET AL.


for implementing collaborative skills-based train-ing for carers of relatives with an eating disorder.This DVD-based skills training had high accept-ability amongst carers of relatives with ED. Posi-tive feedback was received with regards to rele-vance and usefulness of this new form of inter-vention. The challenge that remains is to developtraining methods for carers that are sufficientlyuser-friendly, that create interest and motivation,and that encourage exploration, reflection andlong-term improvements in the relationshipbetween themselves and the sufferer, ideallyameliorating the emotional climate within thefamily context. It is possible that a mixture of dis-tance learning and face-to-face contact will berequired.

Dr. Sepulveda is supported by a post-doctorate SLAMand Mental Health Foundation fellowship at the Instituteof Psychiatry, London. C. Lopez is a PhD student sup-ported by a Chilean government fellowship and NinaJackson Fundation. We would like to acknowledge anumber of colleagues who made important contributionsto the development of these DVDs: V. Kamerling andP. Sacks as expert carers; W. Whitaker, L. Richards,M. Grover, J. Whitney, O. Kyriacou, W. Blake, M. Rooneyand the clinicians and nurses from the Bethlem Hospitalwho contributed in the role- play. We are also grateful toGill Todd and Pat Sacks for the supportive and usefulhelp with the phone coaching. Thanks also to J. Barrerafor his help in the data collection and technical support.The authors would like to thank the family members thathave taken part in the workshops without those help thisstudy would not have been possible.

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Documents

Feasibility and acceptability of DVD and telephone coaching-based skills training for carers of people with an eating disorder