Background
We recently demonstrated the efficacy and feasibility of a novel CD-ROM based cognitive-behavioral multi-media self-help intervention for the treatment of bulimia nervosa. What is not known in CD-ROM treatments is how to best to deliver and support such packages in clinical practice. In particular, it is of great importance to identify to what extent such packages can be offered stand alone, and to what extent additional support from a practitioner is required.
Objective
The aim of the present study was to examine whether the addition of therapist support to the CD-ROM intervention would improve treatment uptake, adherence and outcome.
Method
Two cohorts of patients with full or partial bulimia nervosa referred to a catchment area based eating disorder service were offered an eight session CD-ROM-based cognitive-behavioral self-help treatment (“Overcoming Bulimia”). The first cohort received minimal guidance only and the second cohort were offered three brief focused support sessions with a therapist. The two cohorts were compared on treatment uptake, adherence and outcome.
Results
Patients in both groups improved significantly. There were no significant differences between the two groups in terms of treatment uptake, adherence or outcome, except that the therapist guidance group more often achieved remission from excessive exercise at follow-up.
Discussion
These findings provide further support for the acceptability and efficacy of the CD-ROM intervention for bulimia nervosa. Brief focused therapist guidance did not confer any significant additional benefits. This result has important implications for the widespread adoption of such approaches.
Systematic reviews have demonstrated the efficacy of cognitive behavioral therapy (CBT) for the treatment of bulimia nervosa (Hay and Bacaltchuk, 2003a and Hay and Bacaltchuk, 2003b), and recently published clinical guidelines for the treatment of eating disorders recommend that CBT should be offered to most people with this disorder (National Collaborating Centre for Mental Health, 2004). However, CBT is expensive and trained therapists are in limited supply. Consequently, alternative methods of delivery of CBT need to be developed to make this intervention more accessible. Computerised CBT (CCBT) programs have previously been shown to be acceptable and effective in the treatment of many psychological disorders such as depression, anxiety disorders, and obsessive-compulsive disorder (e.g. Kaltenthaler et al., 2002, Marks et al., 2004, Proudfoot et al., 2003a and Proudfoot et al., 2003b). We recently piloted the use of a multi-media cognitive-behavioral CD-ROM intervention (Overcoming Bulimia; Williams, Aubin, Cottrell, & Harkin, 1998) in adults with BN in an open study. Patients accessed the CD-ROM in the clinic, but had only minimal guidance from a practitioner who showed them how to operate the program. High levels of patient satisfaction and significantly reduced bingeing and vomiting were found (Bara-Carril et al., 2004 and Murray et al., 2003).
One important question is whether clinician guidance, supporting patients’ in their use of the program, might improve the efficacy of the CD-ROM intervention. Previous research into manual-based cognitive-behavioral self-help for bulimia nervosa has shown that the efficacy of such interventions can be significantly increased if delivered with therapist guidance (for review see Birchall and Palmer, 2002 and Perkins and Schmidt, 2004, in press). This question is of great importance because at present access to cognitive-behavior therapy for BN is often focused within specialised eating services. If wider access to CBT for BN is to occur, information on how much practitioner support is required for effective use is essential.
During our first pilot study, many bulimic patients requested therapist guidance with the computer program. A qualitative analysis of patients’ initial attitudes and expectations towards the CD-ROM program for BN showed that some people who did not engage with the computer treatment saw it as an inferior replacement of therapist-led treatment, rather than the first step in a treatment plan, which could go on to therapist-led help if required (Murray et al., 2003). These people stated their preference for a therapist because they saw human interaction as more flexible and sensitive to their individual needs, and they placed importance on the support, empathy and opportunity for expression of problems offered within a therapeutic relationship.
We hypothesised that analogous to previous research into manual-based self-help in BN the addition of therapist guidance to the CD-ROM treatment program might improve treatment uptake, adherence and outcome. The aim of the present paper was to test this hypothesis
The present study provides further preliminary support for the acceptability and efficacy of a CD-ROM based intervention for bulimia nervosa. If offered in a structured clinical environment minimal low-key support seems to be sufficient and the addition of formal therapist guidance sessions does not seem to be necessary. However, it is not known what the acceptability or efficacy of the same program would be if delivered entirely without support, e.g. in the patient’s home or other public settings such as libraries or via the internet. Further research is needed to elucidate these questions.
