آیا فردگرایی مهم است؟ یک کارآزمایی تصادفی شده از درمان استاندارد شده (متمرکز) در مقابل درمان شناختی رفتاری فردگرایی (گسترده) برای بولیمیا

Does higher level of individualization increase treatment efficacy? Fifty patients with bulimia nervosa were randomized into either manual-based (focused) or more individualized (broader) cognitive behavioral therapy guided by logical functional analysis. Eating disorders Examination and a series of self-report questionnaires were used for assessment at pre-, and post-treatment as well as at follow-up. Both conditions improved significantly at post-treatment, and the results were maintained at the 6 months follow-up. There were no statistically and clinically significant differences between the two conditions at post-treatment with the exception of abstinence from objective bulimic episodes, eating concerns, and body shape dissatisfaction, all favoring the individualized, broader condition. Both groups improved concerning self-esteem, perceived social support from friends, and depression. The improvements were maintained at follow-up. Ten patients (20%) did not respond to the treatment. Notably, a majority of non-responders (80%) were in the manual-based condition. Non-responders showed extreme dominance of rule-governed behavior, and lack of contact with actual contingencies compared to responders. The study provided preliminary support for the superiority of higher level of individualization (i.e. broader CBT) in terms of the response to treatment, and relapses. However, the magnitude of effects was moderate, and independent replications, with blind assessment procedures, and a larger sample sized are needed before more clear cut conclusions can be drawn.

Fairburn's early formulation of a cognitive behavioral approach (Fairburn, 1981) for bulimia nervosa (BN) set the standard for the treatment of BN and binge eating disorder. Cognitive behavior therapy (CBT) for BN is a structured and manual-based treatment that has expanded and evolved (e.g. Fairburn, 1985; Fairburn, Marcus, & Wilson, 1993; Wilson, Fairburn, & Agras, 1997) as a result of further experience and empirical findings from efficacy and effectiveness studies (e.g. Agras et al., 1992; Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000; Carter & Fairburn, 1998; Fairburn et al., 1991; Treasure et al., 1996; Wilfley et al., 1993; Wilson, Eldredge, Smith, & Niles, 1991; Wilson, Vitousek, & Loeb, 2000). As a result of accumulated research, CBT is now suggested to be the treatment of choice for BN (e.g. American Psychiatric Association Work Group on Eating Disorders Washington, 2000; Dingemans, Bruna, & van-Furth, 2002; Mizes & Bonifazi, 2000; National Institute for Clinical Excellence, 2004; Wilson & Fairburn, 2002). Reviews of the CBT outcome literature show an approximate 40%–55% recovery rate (remission) (Anderson & Maloney, 2001; Wilson, 1996b), with broad and durable effects (Wilson, 1996b). However, it is also known that no more than roughly 50% of patients recover after receiving CBT, although some of those who do not cease binge eating and purging show partial improvement. CBT is insufficiently helpful for a significant proportion of patients. Thus, the present study investigated an important question in this context: “would a larger number of patients benefit from CBT if the treatment is more individualized (broader) than what is usually done when using the standardized CBT (i.e. focused on the specific psychopathology of BN)? Debate has ensued regarding the use of manual-based treatments versus the individualized approach typically found in practice (Kendall, Holmbeck, & Verduom, 2004). Many good arguments have been presented in favor of using manuals. Manual-based treatments are often empirically supported, more focused, and more disseminable (Wilson, 1996a). Critics of manual-based treatments suggest that the use of manuals preclude idiographic case formulation, and undermine therapists’ clinical artistry. However, no clear-cut empirical evidence supports the superiority of individualized treatment. As an example, a sophisticated study comparing manual-based treatment, individualized treatment, and yoked control condition (in which each patient receives the therapy individualized for another patient in the individualized condition) showed that the standardized manual-based treatment was superior to the other two treatments (Schulte, Kunzel, Pepping, & Schulte-Bahrenberg, 1992). Similar findings has been reported in other studies (e.g. Emmelkamp, Bouman, & Blaauw, 1994). On the other hand, there are also studies showing superiority of individualized treatment to standardized interventions (e.g. Jacobson, Schmaling, Holtzworth-Munroe, Wood, & Follette, 1989). After summarizing empirical findings, and pointing to the limitations of individual case formulation, Wilson (1996a) argues that standardized treatment is no less effective than individualized therapy. When the first line manual-based treatment fails, the therapist should use other empirically supported treatments, and if they don’t work or are not available, then the therapist should resort to the problem solving (hypothesis testing) approach that characterizes CBT (Wilson, 1996b). However, more concrete ways of following such an approach are needed, and there are no empirical studies comparing the efficacy of manual-based CBT compared to a more individualized CBT for BN (i.e. focused vs broader CBT). Behaviorally trained therapist use functional analysis as a way of identifying the core processes and variables maintaining problems and pathologies that bring the clients to treatment. Higher level of individualization when using treatment manuals might be more appealing to the therapists, and it might produce better outcomes. However, its efficacy remains an empirical question. The manual-based cognitive behavioral treatment of BN provides a very useful approach that focuses on variables presented by most of the clients suffering from BN in clinical settings. Treatment manuals should not be used rigidly without any adjustment to the needs of the individual patient. Current CBT manuals for BN provide and encourage flexibility in applying the techniques and methods. Finally, this manual-based treatment has been evolved and refined (Fairburn, Cooper, & Shafran, 2003a) by focusing on four additional variables maintaining BN (i.e. interpersonal difficulties, clinical perfectionism, core low self-esteem and mood intolerance) which were not stressed as much in previous versions of the treatment protocol. In addition to the flexibility of the manual for BN, more clear strategies are needed for further individualization of the treatment. The clinician is usually left to his/her professional and theoretical skills to increase the level of individualization of the treatment beyond what is self-evident. Given the assumption that the origin of this treatment, and the subsequent manual, is a result of years of experience and scientific knowledge on behavioral and cognitive methods and thinking, the core of CBT for BN could be seen as a product of applying functional analysis and cognitive case formulation that has been refined through empirical investigations and clinical experience. Consequently, choosing functional analysis as a method of individualization is in line with the origins of this treatment and in line with behavioral thinking. Although the cognitive case formulation approach by Persons and Tompkins (1997) could constitute an alternative, the mere nature of functional analysis focusing on the function of each behavior in its context instead of reliance on an underlying theory (i.e. Beck's cognitive theory) is assumed to provide a broader basis for individualization. However, comparative empirical studies are needed to test this assumption. On the other hand, individual case formulations and functional analysis have some considerable shortcomings. Both approaches can be seen as a particular instance of clinical judgment (Wilson, 1996a). Rules for selecting techniques that are appropriate are poorly spelled out and much of the knowledge needed comes from clinicians’ personal and clinical experience. As Wilson (1996a) summarizes, a large number of studies show that experienced clinicians are no less immune to cognitive biases in drawing inferences about behavior and making judgments about people than non-professional. Furthermore, the commonly used forms of functional analysis failed to progress as a system for treatment guidance primarily because of lack of replicability, cost-ineffectiveness, ignorance of verbal behavior, and unclear rules about how it should be conducted (e.g. Follette, Naugle, & Linneroth, 1999). Functional analysis needs to be replicable, and useful for treatment planning. These criteria seem to be met by logical functional analysis (Hayes & Follette, 1992). It is an approach where the assessment and conceptual analysis components of functional analysis are specified beforehand in a decision tree with four branches: (1) inadequate (weak, strong or inappropriate) antecedent stimulus control; (2) inadequate (weak, strong or inappropriate) consequential control; (3) inadequate (weak, strong or inappropriate) motivational conditions (establishing operations), and (4) restricted concomitant repertoire of behaviors. Thus the assessment process, regardless of the type of the problem presented, would be organized along these four lines, which facilitates the application of cognitive and behavioral principles. Because of its functional and structural properties (formalized), the logical functional analysis might be replicated more reliably. In summary, an assumption in the present study is that integrating logical functional analysis as a means of individualization into empirically supported, manual-based treatment would enhance the efficacy of the treatment. The aim of the present study was to compare the efficacy of manual-based CBT and a more individualized, broader CBT for BN. It was hypothesized that individualized CBT would result in fewer dropt-outs from the study due to its sensitivity to the client's needs, it would produce better outcome, and it would result in fewer relapses at follow-up.