The study utilized data collected in routine care. Consecutively admitted patients in a specialised centre for assessment of an eating disorder between 18 November 2018 (launch date of the intervention) and 8 March 2020 (start date of the first pandemic-related lockdown which forced the intervention to be suspended) were assessed for eligibility and enrolled (n=208). Inclusion criteria were: diagnosis of an eating disorder, based on DSM-5 criteria , and a Body Mass Index (BMI) >16. Exclusion criteria were: severe malnutrition requiring acute care, and non-French-speaking.
Our study was undertaken according to the Declaration of Helsinki and the French Public Health Code (Article L1121-1). It was registered in the national Health Data Hub (health-data-hub.fr) (D20-R048 - J3 Psychotherapies). Each patient was informed of the objectives of the study and data anonymity prior to the signature of an informed consent form that systematically confirmed their participation.
The single-day workshop
The intervention was organized into two main steps held in a single day (Figure 2). The first step consisted of a group workshop (7 h) devoted to the experience-based knowledge of eight psychotherapy approaches tailored to suit subjects presenting eating disorders, and typically used in specialised centres: CBT, including Acceptance and Commitment Therapy (ACT) and Mindfulness-based cognitive therapy (MBCT); Motivational Interviewing; Psychoeducation; Cognitive Remediation Therapy (CRT); Family Therapy; Psychodynamic approach and art therapies. The second step, taking place at the end of the group workshop, comprised an individual interview with a clinical psychologist. Its purpose was to discuss the day's activities, identify the approach that best fitted the participant and outline a tailored-made plan for engaging the user in psychotherapy care (individual/group, hospital/community care, public/private practice…) (Figure 2).
The intervention was conducted by eight senior psychologists, experts in one of the proposed approaches. The duration of each approach-specific exploration activity varied between 45 to 60 minutes. The number of participants was limited to a maximum of ten participants to encourage interaction between participants and with the facilitators. The intervention representing the final step of the patient assessment pathway, it occurred every 2 weeks. Patients attended the session typically within 2 weeks after receiving the diagnosis of an eating disorder.
2.3 Clinical assessment and instruments
Participants were assessed before (T0) and ten days (T1) after the intervention. Socio-demographical and clinical data of the study population were collected from the participants’ medical records.
At T0 and T1, we measured:
Motivation and commitment to take active steps toward change
In order to measure the evolution of participants’ motivation we used the University of Rhode Island Change Assessment Scale (URICA) [49–51], French translation [52, 53]. This 32-item self-report inventory is widely used in psychotherapy research for measuring disorder-specific stages of change . The URICA is based on the stages of change model which is a central construct of the Transtheoretical Model (TTM) by Prochaska and DiClemente. This model refers to a range of aims and behaviours that a person experience when deciding and deploying action in order to solve a problem . Authors originally identified four different stages of change [51, 55, 56]: “precontemplation” (P) stage (no intention to make a change emerges); “contemplation” (C) stage (the problem behaviour may be acknowledged, but there is not yet commitment to change, to doubts about one’s self efficacy, ambivalence about the need for change); “action” (A) stage (active involvement in solving the problem); “maintenance” (M) stage (active efforts to maintain the improvement and prevent relapse). A number of studied adopted the transtheoretical stages of change model in the field of eating disorders, including AN [57–61].
The URICA scale assesses participants’ attitudes on 4 subscales reflecting the 4 levels of change. Each item is rated on a 5-point Likert scale that ranges from “strongly disagree” to “strongly agree”. Sub-scores are averaged, and thus the scores range from 1 to 5. Scores are calculated cumulatively and range from eight to forty for each of the subscales. The URICA provides four discrete stage scores, with higher scores indicating greater endorsement of particular attitudes or behaviours. In the present study, we employed the generic ‘problem’ frame for the items and it does not focus on a speciﬁc behaviour associated with eating disorders. Participants are instructed that ‘for all statements that refer to your “problem”, they have to answer in terms of “eating disorders”.
We further used the “Committed action” (CA) composite score, calculated by subtracting the “Contemplation” raw subscale score, reflexing a measure of ambivalence, from the “Action” subscale raw score. This score, ranging from -32 to +32, is considered appropriate to assess motivation for change in psychotherapy treatment-seeking populations. This is because it does not include the “precontemplation” (no recognition of the problem or intention to change) and “maintenance” (focus on maintaining improvements and preventing relapse) scales that may be less meaningful at early stages of therapy . The CA composite score proved to be a good instrument to assess in particular the level of commitment to take concrete action and engage actively in psychotherapy care, including CBT  and patients who suffer from eating disorders .
Evidence from previous studies suggests that insight is an important aspect of ED psychopathology and a relevant predictor of treatment outcome in patients with EDs. Its impairment may contribute to poor outcome [17, 64, 65]. Participants’ insight before and after treatment was measured using of Schedule for the Assessment of Insight for Eating Disorders (SAI-ED), a validated questionnaire for the disorder speciﬁc assessment of insight in EDs. Improvement in insight after treatment may constitute a meaningful indicator of the treatment eﬃcacy. The SAI-ED is a short, self-reported questionnaire consisting of seven items (Q 1-7), evaluating five dimensions (“awareness of psychological changes”, “recognition of illness”, “awareness of psychosocial consequences”, “awareness of need for psychological treatment”, “relabelling of symptoms”) [64, 66]. We used the French version of this scale (EDI-TCA) . Each item is scored either 0 or 1, the total score ranges from 0 to 7.
Subjective satisfaction and outcomes
Participants’ subjective assessment of the workshop was measured using a satisfaction questionnaire (“Single-day workshop Satisfaction Questionnaire”) including three Likert scales (rating from 0% to 100%). The evaluated dimensions notably included the following: the perceived benefits of the intervention; the relevance of being treated for EDs; the feeling of personal competence to change one’s relationship with the disease. Reliability and validity of the Likert scales was not established.
2.4 Statistical Analysis
Frequencies and descriptive statistics was reported using means and standard deviations. Normal distribution of variables was checked using Kolmogorov–Smirnov test prior to analyses. Student T-tests for paired samples were used to compare URICA scores, including the “Committed Action” composite score, and SAI-ED scores before vs after intervention. Pearson’s correlations were used to evaluate correlations between variables. The significance level was set at p ≤.05.
All analyses were performed with the SPSS® statistical package for social sciences version 17.0 (IBM).