Interesting Practitioners in Training in Empirically
Supported Treatments: Research Reviews Versus
Case Studies
m
Rebecca E. Stewart and Dianne L. Chambless
University of Pennsylvania
It has been repeatedly demonstrated that clinicians rely more on
clinical judgment than on research findings. We hypothesized that
psychologists in practice might be more open to adopting empirically
supported treatments (ESTs) if outcome results were presented with
a case study. Psychologists in private practice (N 5 742) were
randomly assigned to receive a research review of data from
randomized controlled trials of cognitive-behavioral treatment (CBT)
and medication for bulimia, a case study of CBT for a fictional patient
with bulimia, or both. Results indicated that the inclusion of case
examples renders ESTs more compelling and interests clinicians in
gaining training. Despite these participants’ training in statistics, the
inclusion of the statistical information had no influence on attitudes or
training willingness beyond that of the anecdotal case information.
& 2009 Wiley Periodicals, Inc. J Clin Psychol 66: 73–95, 2010.
Keywords: empirically supported treatments; private practitioners;
dissemination; case-based research
Evidence is building that efforts to identify and promote empirically supported
treatments (ESTs) have had minimal impact on the practice of front-line
practitioners (Arnow, 1999; Becker, Zeyfert, & Anderson, 2004; Crowe, Mussell,
Peterson, Knopke, & Mitchell, 2000; Goisman, Warshaw, & Keller, 1999; Haas &
Clopton, 2003; Mussell et al., 2000; von Ranson & Robinson, 2006). It is becoming
increasingly clear that the identification and endorsement of psychotherapies as
empirically supported is not sufficient to achieve successful dissemination (Cook,
Weingardt, Jaszka, & Wiesner, 2008). If ESTs are to be adopted outside of academic
circles, more effective dissemination efforts are required.1
Correspondence concerning this article should be addressed to: Rebecca E. Stewart, Department of
Psychology, University of Pennsylvania, Solomon Labs, 3720 Walnut Street, Philadelphia, PA 19104-6241;
e-mail: [email protected]
1
It is not the purpose of this article to argue for the merits or disadvantages of the EST approach. For a
discussion of these issues, see Chambless and Ollendick (2001) and Norcross, Beutler, and Levant (2006).
JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 66(1), 73--95 (2010)
& 2009 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20630
74
Journal of Clinical Psychology, January 2010
One argument often promulgated in the literature is that clinically relevant
research findings must be presented in a form practicing therapists can easily use.
Researchers tend to write for other researchers, and not clinicians (Beutler, Williams,
Wakefield, & Entwistle, 1995; Goldfried, Borkovec, Clarkin, Johnson, & Parry,
1999; Goldfried & Wolfe, 1996). Although the information and language utilized in
research reports (e.g., end-state functioning, treatment fidelity, effect size) are critical
for researchers communicating with other researchers, they may not be meaningful
to the practicing clinician (Goldfried & Wolfe, 1998) and efforts must be made to
communicate research findings in a manner that is readily understandable and
relevant for the front-line practitioner. Despite extensive discussion of this issue,
there is remarkably little research focusing on the difficult question of just how to
make EST research more influential and compelling to practicing clinicians.
If clinicians are not using EST research to inform practice, from what sources are
they drawing? Stewart and Chambless (2007) surveyed a random sample of members
of APA Division 42 (Psychologists in Private Practice) regarding their approach to
treatment decisions, specifically the use of research on ESTs to inform practice.
Consistent with prior research, clinicians reported that they often but do not usually
use treatment materials informed by EST research findings. They described the most
important influence on their work as their own past clinical experiences. On a 7-point
scale (1 5 Strongly Agree to 7 5 Strongly Disagree), they strongly to moderately
agreed (M 5 1.53, SD 5 0.91) that past clinical experiences affect their treatment
decisions and indicated that they usually use past experiences with patients to
improve therapy skills and effectiveness. That clinicians prefer to rely on clinical
experience rather than EST research to inform treatment decisions is consistent with
prior research in the field (Morrow-Bradley & Elliott, 1986; Raine et al., 2004; von
Ranson & Robinson, 2006). However, it is inconsistent with the thrust of evidencebased practice, which emphasizes the use of research to guide practice, albeit
tempered by the therapist’s clinical expertise (Sackett et al., 2000; Spring, 2007).
How accurate is clinical judgment? The limitations of humans as information
processors suggest that cognitive biases (Dawes, Faust, & Meehl, 1989) may limit the
degree to which clinicians can accurately draw on their own clinical experiences,
much less keep up with new developments in the field after a full day of seeing
patients and paperwork. There is a large body of research on clinicians’ decision
making regarding psychological assessments, much of which suggests clinical
experience does not increase practitioners’ ability to reach valid conclusions if they
rely on clinical experience rather than empirical data to reach these conclusions
(Garb, 1998). In a related fashion, making decisions about how to treat patients is the
result of an assessment process and is likely subject to the same errors in judgment.
Although clinicians value their clinical judgment as a guide to treatment, the available
data suggest that they may not be particularly adept at predicting which treatments
will lead to success or failure for their clients. Three studies are pertinent here.
Kadden, Cooney, Getter, and Litt (1989) asked therapists of inpatients with
alcohol dependence to predict which of two aftercare treatment programs would be
better for their patients. Patients were randomly assigned to one of two treatments,
and the authors found that empirical patient data (e.g., severity of psychopathology)
predicted which treatment would work better for which patients. However,
therapists were no better than chance at predicting which treatments would work
for which of their patients despite their extensive contact and experience with these
patients. Schulte, Kunzel, Pepping, and Schulte-Bahrenberg (1992) randomly
assigned patients with phobias to standardized treatment with exposure or to an
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75
individualized program of cognitive-behavioral therapy of the therapist’s device.
Therapists were significantly more effective when they were constrained to use the
standardized treatment than when they were allowed to devise their own treatment
plan presumably guided by clinical judgment. Hannan et al. (2005) compared the
judgment of clinicians in a college counseling center with a research-derived
algorithm for prediction of treatment failure, and they found that clinicians were
quite poor at predicting outcome, whereas the actuarial method worked very well.
Hannan and colleagues noted that therapists rarely predicted deterioration even
though it occurred in 42 of 550 patients. In contrast, the empirical method identified
all of the patients who would become reliably worse, but it generated numerous
false-positive results. Nevertheless, the false alarms did have poorer outcomes than
those not identified as likely treatment failures. Although more research is clearly
needed, these three studies indicate that reliance primarily on clinical judgment,
although prevalent, may misdirect therapy.
If evidence does not drive practice, then what is the point of research? An
assumption of this article is that treatment decisions in psychotherapy should be
made whenever possible on the results of empirical evidence. But if evidence is to
drive practice, researchers need to make it more appealing to practicing clinicians. It
has been repeatedly demonstrated that clinicians prefer to rely on clinical judgment
when making treatment decisions. It is a product of our imperfect human cognition
that a fascinating case history with personal details will affect clinical decision
making more than a summary of well-controlled experimental studies. Furthermore,
it would be an enormously difficult (and impractical) task to convince clinicians to
abandon the belief that clinical experience is an excellent source upon which to base
clinical judgment. Training sessions would need to be multifaceted and interactive to
be effective (Davis et al., 1999), and it is not clear whether any changes in thinking
would endure without sustained interventions (Jameson, Stadter, & Poulton, 2007).
How can we use clinical experience to make EST research more influential? It is
conceivable that practitioners reject treatment outcome data because they believe
that although such treatments may work for the average treatment study patient,
they are unlikely to work for the complex patients seen in their practices. It has been
documented that people reject statistical reasoning in favor of anecdotal reasoning
such as clinical experience (Borgida & Nisbett, 1977), an effect known as the
vividness bias (Nisbett & Ross, 1980).
Ubel, Jepson, and Baron (2001) investigated this effect when both statistical
information and anecdotal information are presented. Ubel et al. presented participants
(who were prospective jurors at a county courthouse) with hypothetical statistical
information about the percentage of angina patients who benefited from angioplasty
(50%) and bypass surgery (75%). Participants were also given written testimonials
from patients who had benefited or not benefited from either treatment: These
testimonials were varied to be either proportionate or disproportionate with the
statistical information. For example, those who received proportionate testimonials
received one success and one failure for angioplasty, and three successes and one failure
for bypass surgery. Those who received disproportionate testimonials received the same
testimonials for angioplasty, but only one success and one failure for bypass surgery. In
other words, the disproportionate testimonial success rate for bypass surgery was 50%,
whereas one could expect 75% from the statistical information. Participants were then
asked which of the two treatments they would choose. Because the statistical
information derived from aggregated patient data is more accurate, participants should
have discounted the testimonials and should have chosen their treatment according to
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Journal of Clinical Psychology, January 2010
the presented statistical information. Of those participants who received the
proportionate questionnaire, 44% chose bypass surgery. In contrast, only 30% of
participants receiving the disproportionate questionnaire chose bypass surgery,
suggesting that the anecdotal information significantly influenced treatment choices
when presented in conjunction with statistical information.
There are several reasons why anecdotal information may have an undue influence
on decisions. In the case of the clinician, it may be easier for clinicians to identify with a
specific patient than with a statistically average person. Whereas statistical information
is abstract in nature, anecdotal information is concrete. For these reasons and given
clinicians’ propensity to value clinical experience (their own or others), a vividly
detailed case study with a clear outcome might be more compelling than a summary of
results from randomized controlled trials (RCTs). Stewart and Chambless (2007) found
that providing practitioners with a summary of treatment outcome literature affected
how clinicians said they would treat a specific case of a patient with panic disorder.
Those participants who received a summary of the treatment outcome literature for
panic disorder (recommending CBT or medication) were more likely to recommend
using CBT than were the control participants who did not receive the research
summary following the description of the case patient. The effect was significant but
small, which was expected given the minimal intervention. However, the effect size is
noteworthy given the possibility of a ceiling effect: The majority of therapists in both
experimental and control groups reported that they would use CBT for the case.
Unfortunately, psychologists in the experimental group (who received the research
summary) were no more willing to seek training in the EST than the control group,
thus indicating the limitations of information comprised solely of statistical
information derived from group means. This preliminary research indicates that
providing information can have some effect on treatment decisions.
The primary aim of the present study is to extend and expand upon this finding by
drawing from the judgment and decision-making literature and using a vivid case
study. We hypothesized that clinicians will find EST statistics more compelling and
will be more willing to receive training in ESTs if outcome statistics are presented
with a case study. If clinicians read a case of a complex and comorbid patient who
was treated successfully with a particular EST, they may be more inclined to believe
that EST results can generalize to their patients. We were also interested in whether
statistical information affects attitudes and training willingness above and beyond
the case information alone. Although it is documented that people reject statistical
reasoning in favor of anecdotal reasoning, the vast majority of the sample were
Ph.D.-level psychologists who had, by nature of their degree, received statistical
training. It is possible this sample would pay more attention to the statistical
information than would be expected from the general population. A secondary aim
is to test whether Stewart and Chambless’s (2007) findings are replicated in the
present sample. The final aim is to provide descriptive information on how many
hours and how much money clinicians might be willing to devote for training in CBT
for bulimia and to compare these findings with existing workshops.
Method
Participants
Using mailing labels purchased from American Psychological Association (APA),
we sent a cover letter and survey to a randomly selected sample of 3,200 members of
the APA, who specified themselves as practitioners in private practice. APA
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77
maintains a database of over 19,660 members indicating themselves employed in
private practice. We believed this would provide a more balanced sample of
practitioners across APA than Stewart and Chambless (2007) obtained by selecting
members in a specific division of APA (such as Division 42: Psychologists in
Independent Practice, which has 4,672 members). Front-line clinicians practice in a
number of settings, including, for example, community agencies and hospitals as well
as private practice. To achieve greater sample homogeneity in light of limited
resources, this study was limited to private practitioners. Thirteen envelopes were
returned to the sender due to faulty mailing addresses. Of the 799 respondents, 57
were unusable (i.e., participants returned blank surveys indicating they did not have
time, were not currently in practice, or had retired). We had a total of 742 useable
responses to the mailing, for an effective response rate of 23%.
Measures
A questionnaire was developed comprising 62 self-report items and is presented in
the Appendix. The survey is divided into five sections. Section 1 assessed
practitioners’ demographic information, theoretical orientation, clinical experience,
primary employment setting, and whether continuing education (CE) credits are
required by the participant’s state. In Section 2, all participants read a description of
the fictional case of Tracy, abstracted (with permission) from a published treatment
case in the literature (Oltmanns, Neale, & Davison, 1999). This included excerpts
from Tracy’s history and a description of her symptoms of bulimia nervosa. We
endeavored to select a disorder for which the research evidence indicates a
psychosocial treatment of choice. Bulimia was chosen because ESTs have been
identified for this particular disorder (Chambless & Ollendick, 2001), and the
National Institute for Health and Clinical Excellence (NICE, 2004) guidelines in the
United Kingdom and the Cochrane Collaboration review on psychotherapies for
bulimia (Hay, Bacaltchuk, & Stefano, 2004) designate CBT as the treatment of
choice for bulimia. There is also evidence that ESTs for bulimia are rarely utilized in
clinical practice (Arnow, 1999).
The outcome statistics section comprised Section 3. This comprised data from RCTs
of CBT and of medication for bulimia and provided the response rates to each.
Outcome statistics were presented as percentage reductions in binge eating and purging.
Section 4 contained the case treatment section, which included a 2-page description of
Tracy’s treatment with CBT abstracted from the aforementioned case study.
Sections 5 comprised the dependent measures in this study. In Section 5,
participants were asked questions assessing their positive attitudes towards CBT.
The attitude measures were modified from the Treatment Expectancy Scale
(Borkovec & Nau, 1972), a widely used measure of expectancy and credibility
administered to patients participating in randomized controlled psychotherapy
trials. In the current survey this measure was reworded to assess attitudes
practitioners held about CBT. Participants are asked to rate on 10-point Likerttype scales how appropriate CBT seems, how confident they are that CBT would
reduce the severity of bulimia, and how likely they would be to use CBT for a patient
with bulimia. Section 5 also included questions assessing participants’ training
willingness. Participants were asked how likely they would be to complete workshop
and home-study training in CBT for bulimia and another treatment (of their choice)
for bulimia. The latter is included to control for participants’ willingness to seek
training in general and to see if they are more likely to seek training in CBT over
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another treatment for bulimia. Although some research indicates that workshops are
not effective in changing practitioner behavior (Davis et al., 1999), a workshop may
offer an introduction to a treatment and serve as a motivational gateway to gaining
further training. Lastly, Section 5 comprised questions assessing training specifics.
Participants are asked how many hours they would be willing to devote to training in
CBT for bulimia in a workshop or a home-study program and how much they would
be willing to spend for that training.
There were five versions of this questionnaire to satisfy relevant controls. The first
two (case1statistics and statistics1case) versions included all sections of the survey
and counterbalanced the order of the statistics portion (Section 3) and the
description of the case treatment with CBT (Section 4). The third version (statistics
only) omitted the description of Tracy’s treatment with CBT (Section 4). The fourth
version (case only) omitted the statistics section (Section 3). The fifth version served
as the baseline. It omitted the statistics section (Section 3) and Tracy’s treatment
description (Section 4). See Table 1.
Workshop Analysis
Given the hours and money participants indicate they are willing to devote to
training in CBT for bulimia, are there existing workshops and home study programs
that meet their specifications? To determine the average cost and hours of a CE
workshop, we analyzed CE workshop offerings on the APA Web site (www.apa.org/
ce/) as well as the Institute offerings at the Association for Behavioral and Cognitive
Therapies (ABCT) conferences. We also analyzed the List of Independent Study
Table 1
Description of Questionnaire Types and Descriptive Data on Dependent Variables
Questionnaire type
Section
1. Demographics
2. Description of Tracy’s
history and symptoms
3. CBT for bulimia
statistical summary
(statistics)
4. Case study of Tracy’s
treatment with
CBT (case)
5. Dependent measures
Attitudesa
Trainingb
Version 1
Case1
statistics
n 5 117
Version 2
Statistics1
case
n 5 118
Version 3
Statistics
only
n 5 169
Version 4
Case only
n 5 119
Version 5
Baseline
n 5 158
23.38 (5.32)
0.18 (1.69)
23.71 (5.64)
0.30 (1.70)
21.14 (6.23)
0.20 (1.67)
24.08 (4.84)
0.22 (1.43)
19.63 (5.97)
0.20 (1.41)
Note. CBT 5 cognitive-behavioral therapy. Practitioners who reported they already had significant
training in CBT for bulimia were removed (n 5 61). Case1statistics and statistics1case were combined
after analyses indicated no order effect.
a
Higher numbers denote more positive attitudes about CBT (of 30).
b
Scores indicate raw willingness to get training based on difference scores. Higher numbers denote more
willingness to get training in CBT compared to another treatment for bulimia.
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Programs on the APA Web site. These analyses provide descriptive data on existing
and available workshops and home study programs and permit an assessment of fit
between available program and the time and money practitioners report being
willing to spend on training.
Results
Sample Characteristics
Of the practitioners, 64% were female. The mean age of the sample was 56.69 years
(SD 5 9.71, range 5 28–87). In terms of highest professional degree, 80% of the
practitioners had earned a Ph.D., 13% had received a Psy.D., 6% had received
an Ed.D., and 1% reported they had earned an Masters’ degree. Practitioners
had an average of 22.4 years (SD 5 9.45) in practice. They saw patients an average of
24.12 (SD 5 11.28) hours a week. The large majority (96%) of the practitioners worked
in private practice. The two most commonly self-described primary theoretical
orientations were cognitive-behavioral (39.8%) and psychodynamic (28.2%). An
additional 19.3% reported themselves as eclectic, 5.5% of clinicians described
themselves as humanistic/experiential, and 3.9% subscribed to family systems. An
additional 3.4% chose the category other as their primary theoretical orientation.
To evaluate the representativeness of the sample, the above-mentioned characteristics were compared with data on the 19,660 practitioners in APA who report
private practice as their primary employment setting (American Psychological
Association, 2008). The sample collected was virtually identical in terms of age,
professional degree, and number of years in practice. Our sample had a somewhat
larger percentage of women responding than the larger sample (65% versus 56%)
and this is consistent with prior research indicating women are more likely than men
to respond to surveys (Green, 1996). Information on theoretical orientation and
place of employment was not available from the APA.
Power
Power analyses were conducted for the experimental study, specifically for attitudes
about ESTs after participants read EST outcome data with a case versus outcome
data without a case. The experimental manipulation was minimal, and a small effect
size was expected. With a small effect size of f 5 .1, alpha set at .05, and a sample size
of 681 participants (after excluding 61 participants who reported having received
significant training in CBT, see below), the power for the primary analyses (section
below) was estimated at .74.
Positive Attitudes and Willingness to be Trained
There are two primary, dependent variables in this study: the positive attitudes and
willingness to be trained measures. The three attitudes questions (Section 5) are on
the same 1–10 scale. These three items were summed to produce a measure of
positive attitudes for CBT for bulimia, where higher scores indicate more valuing of
CBT for bulimia. Cronbach’s alpha was adequate at .93. The willingness to be
trained in CBT measure is the difference between subjects’ ratings on willingness to
be trained in CBT for bulimia and their willingness to be trained in another
treatment (of their choice) for bulimia. This is to control for participants’ interest in
training in general. We asked subjects about both workshop training and homestudy training in CBT and another treatment for bulimia. The two difference scores
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were highly correlated (r 5 .70) and were summed to produce an overall score in
willingness to be trained in CBT for bulimia. Practitioners who reported that they
had already had significant training in CBT for bulimia were removed (n 5 61).
Means and standard deviations on the dependent variables for all versions of the
questionnaire are reported in Table 1.
We have two a priori hypotheses and conducted contrast analyses to address our two
focused predictions, in addition to a third contrast to test whether our study replicated
prior research by Stewart and Chambless (2007). Prior to hypothesis testing, we tested
for an order effect for the case treatment section and statistical information as
demonstrated by differences between Versions 1 and 2 of the questionnaire. Contrast
analyses indicated that there was no significant order effect between Versions 1 and 2 of
the questionnaire for either dependent variable. Accordingly, the data from these two
versions were combined for the remainder of the analyses.
The primary hypothesis in this study is that clinicians provided with the case
treatment section will find statistical information about ESTs more compelling, and
they will be more likely than those clinicians who did not receive the case treatment
section to hold positive attitudes towards CBT for bulimia and to be willing to
receive training. As predicted, participants who received Versions 1 or 2 (now
collapsed) had more positive attitudes toward CBT for bulimia and were more
willing to seek out training than those participants who received only the statistical
information (Version 3). (See Table 2.) The third planned comparison was to
determine whether statistical information had any impact. Results indicated that
contrary to our hypothesis that psychologists would pay attention to statistics by
nature of doctoral training, the statistical information did not add to the effects of
the case treatment section: Participants who received statistics plus the case
treatment section (Versions 1 and 2) did not differ from participants who received
only the case treatment section (Version 4) in their positive attitudes for CBT for
bulimia and willingness to be trained. (See Table 2.)
A secondary hypothesis of the current study is that statistical information (in the
form of a summary of the treatment outcome literature) has influence above and
beyond receiving no information at all (baseline), a replication of Stewart and
Chambless’s (2007) finding. A contrast analysis indicated that participants who
Table 2
Planned Contrasts for Positive Attitudes and Willingness to be Trained in CBT
Contrast and dependent variable
Case1stats (V1) versus stats1case (V2)
Positive attitudes
Training willingness
Case1stats (V1&2) versus stats only (V3)
Positive attitudes
Training willingness
Case1stats (V1&2) versus case only (V4)
Positive attitudes
Training willingness
Stats only (V3) versus baseline (V5)
Positive attitudes
Training willingness
df
F
d
p
733
658
0.24
0.37
0.04
0.05
.62
.54
734
658
15.6
6.06
0.30
0.19
o.001
.04
732
658
0.78
0.04
0.06
0.02
.38
.84
735
659
6.17
0.00002
0.18
0.001
.01
.99
CBT 5 cognitive-behavioral therapy.
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received the statistical information (Version 3) had more positive attitudes about
CBT for bulimia than participants who received no information beyond the
description of the patient (Version 5). However, the statistical summary did not
increase willingness to be trained in CBT for bulimia. (See Table 2.)
Theoretical orientation, pro-research attitudes, years out from graduate school,
and the impact of statistical data. Overall, we found that statistical information had
no influence above and beyond the case information. However, it is possible that the
predicted relationship obtains, but for only part of the sample. Accordingly, we
investigated how three moderators may have affected the results: theoretical
orientation, pro-research attitudes, and years since completion of the degree.
Subjects who reported having extensive training in CBT for bulimia (n 5 61) were
excluded.
Do the statistical data have a differential effect on practitioners of different
theoretical orientations? This question was tested with two contrasts utilizing
questionnaire type (case, case1statistics) and theoretical orientation (CBT, other) as
the independent variables, and positive attitudes and willingness to be trained as the
dependent variables. The analyses indicated significant and large main effects for
orientation for both positive attitudes (F(1, 372) 5 17.79, d 5 .44, po.0001) and
willingness to obtain training in CBT (F(1, 326) 5 23.13, d 5 .53, po.0001),
indicating that CBT practitioners held more positive attitudes and were more likely
to be interested in training in CBT for bulimia than practitioners of other
orientations. Consistent with our previous results, there was no main effect for the
experimental condition for either dependent variable (attitudes: F(1, 372) 5 .02,
d 5 .01, p 5 .89; training: F(1, 326) 5 .56, d 5 .08, p 5 .45). There were no significant
interaction effects for either dependent variable (both Fs 5 .00), suggesting that
statistical data did not have a differential impact on practitioners of different
theoretical orientations.
We were next interested in whether the statistical information had influence on
those practitioners who had graduate training that emphasized research outcome
findings. We created a dichotomous research training variable by utilizing a median
split on the 1–7 graduate training variable (Mdn 5 4.5).2 We employed two contrasts
utilizing experimental condition (case, case1statistics) and graduate research
training (high, low) as the independent variables, and positive attitudes and
willingness to be trained as the dependent variables. The analyses indicated
significant and small main effects for graduate training in research (F(1, 388) 5 5.45,
d 5 0.24, po.05) for CBT, suggesting that practitioners who reported more graduate
training in research held more positive attitudes about CBT for bulimia than those
who reported less research training in graduate school. However, there was no main
effect for research emphasis in graduate school and willingness to gain training in
CBT for bulimia (F(1, 340) 5 0.71, d 5 0.09, p 5 .40). Consistent with previous overall
results, there was no main effect for the experimental condition for either dependent
variable (attitudes: F(1, 388) 5 1.10, d 5 0.10, p 5 .29; training: F(1, 340) 5 .004,
d 5 0.007, p 5 .95). There were no significant interaction effects (both Fs 5 0.00)
indicating that regardless of graduate training that emphasized research, the statistical
information had no impact above and beyond the case.
2
This question was also tested with a regression analysis using research training in graduate school as a
continuous independent variable. No significant interaction was observed (b 5 .08, t(387) 5 0.237,
p 5 .81). Contrast analyses are reported due to the increase in power afforded by this technique.
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Third, we investigated whether statistical information had an impact on those
practitioners who more recently emerged from graduate school. It is plausible that
more recently trained practitioners are more amenable to interpreting statistical
results than more seasoned practitioners who are many years out from their
academic training. This hypothesis was tested with two contrasts utilizing
experimental condition (case, case1statistics) and years out of graduate school
(high, low; Mdn 5 25) as the independent variables, and positive attitudes and
willingness to be trained as the dependent variables.3 There was no main effect for
years out of graduate school for either dependent variable (attitudes, F(1, 382) 5
0.11, d 5 0.03, p 5 .74; training, F(1, 335) 5 0.03, d 5 0.02, p 5 .98). Additionally,
there was no main effect for the experimental condition for either dependent variable
(attitudes: F(1, 382) 5 1.08, d 5 0.11, p 5 .30; training: F(1, 335) 5 0.002, d 5 0.004,
p 5 .97). There were also no significant interaction effects (both Fs 5 0.00); newer
practitioners were no more likely to be influenced by the statistical information
above and beyond the case than were more seasoned clinicians.
Effect of the case and CE requirements on training specifics: hours and money
Excluding subjects who reported having extensive training in CBT for bulimia
(n 5 61), practitioners who received the case (n 5 394, hereafter the target group)
reported they would be willing to devote a median of 5.5 hours (lower quartile 0,
upper quartile 8) for workshop training and 2 hours (lower quartile 0, upper quartile
6) for home study training in CBT for bulimia. Clinicians reported they would be
willing to spend a median of $100 (lower quartile 0, upper quartile 175) on training.
To determine whether CE requirements affected the time and money people were
willing to devote to training in CBT for bulimia, a Mann-Whitney U test was carried
out between participants who did and did not have state CE requirements on the
training specifics variables. The test showed there was no significant differences
between participants with and without CE requirements on the number of resources
participants were willing to devote to workshop (hours, z 5 0.32, p 5 .75; dollars,
z 5 0.30, p 5 .76) or home-study (hours, z 5 0.23, p 5 .82; dollars, z 5 0.64,
p 5 .52) programs.
Existing CE workshops and home-study programs on ESTs. Given the time and
money clinicians are willing to devote to receiving training in CBT for bulimia, and
ostensibly other workshops on ESTs, are there existing workshops to meet their
specifications? To determine the average cost and hours of a CE workshop, we
analyzed 6 months (August 2008–January 2009) of CE workshop offerings on the
APA Web site (www.apa.org/ce/). Of the 851 offerings, 86 (10%) were treatmentrelated workshops, and 38 were EST workshops (44% of treatment workshop
offerings, 4% overall). Excluding one basic training program in EMDR that was 40
hours and a clear outlier, these workshops averaged a mean of 6.69 hours
(SD 5 3.15) and $211.77 (SD 5 121.04) in price. We also examined the Institute
offerings at the Association for Behavioral and Cognitive Therapies (ABCT)
conferences. Practitioners can attend workshops given by experts in the field,
without registering or paying for the conference. In 2007 and 2008, 12 of the 15
offered workshops were treatment related (80%) and 9 of the 15 (60%) workshops
3
The question was tested with a regression analysis using years out as a continuous variable. The
interaction term was not significant (b 5 .05, t(381) 5 0.721, p 5 .47).
Journal of Clinical Psychology
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involved training in ESTs. For both years, a 5-hour workshop had a fee of $140 and
a 7-hour workshop cost $175 for non-members.
To determine the average cost and hours of a home-study program for an EST, we
analyzed the List of Independent Study Programs on the APA Web site. Of the 94
offerings (as of September 18, 2008), 27 (29%) were treatment related and 11 (12%)
related to ESTs. The average home study program required 7.18 hours (SD 5 3.15)
and had a fee of $107.04 (SD 5 42.44).
Discussion
How can we make EST statistics more compelling to the average practitioner? The
results of the present study indicate that practitioners who received the case
treatment example held more positive attitudes toward the EST described and were
more willing to get trained in CBT for bulimia than those who did not receive the
description of Tracy’s treatment with CBT. Unfortunately for the evidence-based
practice movement, despite psychologists’ statistical training, the inclusion of
statistical information had no influence on attitudes and training willingness beyond
that of the anecdotal case treatment information, consistent with prior research
indicating that lay people ignore statistical reasoning in favor of anecdotal/
testimonial reasoning (Ubel et al., 2001). Nonetheless, by encouraging clinicians to
rely on, trust, and value empirical evidence by (paradoxically) using anecdotal
information in the form of clinical experience, we may foster their openness to ESTs.
Our results replicated the prior research of Stewart and Chambless (2007) in that
providing statistical information affected clinicians’ attitudes towards the EST.
Clinicians who received only the treatment summary (recommending CBT or
medication) were more likely to have positive attitudes towards CBT for panic
disorder than those who did not receive any information at all, suggesting that
statistical information unaccompanied by case treatment information enhances
attitudes. Nonetheless, as Stewart and Chambless (2007) found, the present results
indicated that the statistical information did not increase willingness to get training
in CBT for bulimia, lending further support for the importance of the addition of
case studies for willingness to get trained.
Articles on RCTs of psychotherapy typically do not include case studies of
the treated patients. One major implication of this study is that editors of journals
that publish RCTs providing data supportive of the efficacy of an EST should
be encouraged to include space for a case study of a particular patient in the
trial who was treated successfully. This is not a novel idea. The discrepancy between
academic research reporting and clinical application has been noted repeatedly in the
literature (Beutler et al., 1995; Chambless & Hollon, 1998; Goldfried & Wolfe, 1996).
Bilsbury and Richman (2002) noted that a limitation of statistical reporting (such as
reported in the RCT literature) is that the properties of individual cases cannot be
deduced from the overall population, and yet this is the information practitioners
want and need to know. For example, an RCT may show practitioners that a
treatment helps 40% of clients in the population tested, and yet it does not tell
practitioners if the client walking into their office is one of them (Edwards, Dattilio,
& Bromley, 2004). Moreover, research using complex experimental and statistical
methods yields results in the form of descriptive and inferential statistics, which may
be difficult to comprehend and assimilate despite statistical training. By engaging the
reader, case studies have an immediate appeal to clinicians, especially when the
intervention is presented in a narrative format that allows them to see how a
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treatment actually works. As a result, clinicians may more quickly integrate the
information into their frameworks of clinical knowledge (Dattilio, 2006).
The results of the present study provide initial evidence that case studies may be
able to deliver RCT results in a way that is meaningful and influential to clinicians.
Not only are case studies possibly influential as a dissemination method from
researcher to clinician, several authors have championed the significance of casebased research in the process of building clinical knowledge (Edwards et al., 2004;
Jones, 1993). Barlow (1981) argued persuasively that encouraging clinicians to
conduct case-based research might benefit both clinician and researcher by creating a
meaningful role for clinicians in the research process and providing researchers with
rich and detailed information from real clinical practice. In sum, a greater respect for
and appreciation of case-based research could go a long way towards bridging the
science-practice gap (Jones, 1993).
We tested several moderators in our analyses to see if they affected our overall
finding that statistical information had no impact above and beyond the case
information. None of the moderator interaction effects were significant. The
statistical information had no differential impact regardless of theoretical orientation, graduate training in psychotherapy outcome findings, or years out of graduate
school. In other words, despite training or influences that may engender more
statistical literacy or interest, the overall finding that the statistical information had
no influence above and beyond the case information was robust. It is unclear why
ostensibly more empirically based clinicians are equally unaffected by data, and
more research is needed on this point. However, these results are consistent with the
vividness effect and speak to the influential power of case studies and the need for
case material to be integrated into the treatment outcome literature.
Our results indicate that CE requirements do not influence the amount of training
or money practitioners are willing to spend on an EST workshop. There is some
indication in the literature that licensed psychologists tend not to attend CE
programs just for the sake of earning needed credits and report attending CE
programs even when they do not need credits (Sharkin & Plageman, 2003). This is a
promising finding suggesting that clinicians are motivated to learn and are not
simply interested in accumulating credits towards continuing education. However,
because CE requirements do not stipulate types of training (aside from ethics) that
are required, it is unknown whether a CE requirement specifically for evidence-based
practice would change our results.
Clinicians who received the case reported they would be willing to devote a median
of 5.5 hours and $100 for workshop training. Our analysis of available workshops on
the APA Web site indicated that workshops averaged 6.7 hours and were priced at
$211.77. A 5-hour workshop cost $150 and a 7-hour workshop cost $175 at ABCT.
This suggests that although clinicians are generally willing to devote the time needed
for workshops, available workshops may be priced at somewhat above what they are
willing to pay. Some proportion, however, were willing to allocate sufficient
resources. Of the target group, 33 clinicians (8%) were willing to devote the time and
money needed (or more) for an available workshop from APA, 115 (29%) were
willing to devote the resources for the 5-hour workshop at ABCT, and 46 (12%) for
the 7-hour workshop. Where home-study training in CBT for bulimia was
concerned, practitioners were willing to devote a median of 2 hours and $100,
whereas available home-study programs on the APA Web site required an average of
7.18 hours and $107.04. Thus, although clinicians can afford home-study training,
overall they may not be willing to dedicate the time for some programs. However,
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some are. Of the target group, 58 clinicians (15%) were willing to get training at the
average cost and time found for home-study programs. It is unknown from our
results what deters clinicians from being willing to devote more time or money to
continuing education, and more research is needed on clinicians’ willingness to
gaining training in ESTs. Nonetheless, it is promising that some clinicians are willing
to allocate resources for training given the available offerings, and our results
indicate that workshops within their parameters may be available.
More problematic is the availability of these workshops. Although EST
workshops comprised 60% of offerings at the 2007 ABCT conference, this is not
surprising given this organization’s focus on behavioral and cognitive therapies,
which appear prominently among the EST lists for many disorders (Chambless &
Ollendick, 2001). By contrast, EST workshops comprised only 4% of available
workshop offerings on the APA Web site and 12% of home-study offerings. This
suggests that although CE/EST offerings are available, they are not common and
may be difficult to access for practitioners in many regions in the country. Lack of
access to training has been commonly cited as a reason for the low utilization of
ESTs for many disorders (Arnow, 1999), and more research is needed on the
availability of EST training to the average practitioner.
One limitation of this study is that the sample may not be representative of
practicing psychologists. It is possible that psychologists who join APA are not
representative of psychologists in practice. Moreover, Ph.D. psychologists are only
part of the mental health practice community, which includes Masters’ level
psychologists, social workers, and counselors of various sorts. Moreover, because
only 23% of the sample responded, there is no way of knowing if the responses can
be generalized to describe the initial sample. Although our sample had slightly more
female participants, it was otherwise virtually identical to the larger sample drawn
from APA. Nonetheless, clinicians who respond to a survey describing an EST may
be more sympathetic to EST research than non-responders. Our response rate (23%)
is commensurate with surveys of our page length with no compensation, preliminary
notifications, duplicate mailings, or follow-ups (Yammarino, Skinner, & Childers,
1991). It is possible that survey participation would have been higher had funding
restrictions not limited further mailings and participant payments.
A second limitation of the present study is our use of bulimia nervosa. Bulimia was the
disorder chosen for the case example because of our efforts to select a disorder for which
the research and policy guidelines (NICE, Cochrane) clearly converge on a treatment of
choice. The majority (57%) of practitioners surveyed reported that they saw bulimic
patients; however, a substantial percentage (43%) did not. Clinicians who saw bulimic
patients reported these patients made up 5.28% (SD 5 33.23) of their practices. Although
we asked clinicians to assume they saw bulimic patients for the remainder of the
questionnaire, it is possible that participants did not heed this instruction and, therefore,
did not give legitimate responses to training willingness.4 It is also plausible that even
clinicians who did see bulimic patients were not willing to devote resources for training in
treatment of a disorder that does not make up a large part of their practice. It is possible
that training willingness to spend time and money to obtain would have increased had we
used an example of a highly prevalent disorder, such as depression.
A third limitation is our use of willingness to attend workshops in CBT as the
operational definition of overall training willingness. There is evidence that
4
No differences were found between those who reported seeing bulimics and those who did not. The results
from the analyses of both samples indicated the same pattern of results as in the overall sample.
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workshop training does not influence practitioner behaviors’ or outcomes (Davis
et al., 1999; Morgenstern, Blanchard, Morgan, Labouvie, & Hayaki, 2001).
Although there are some data suggesting a 2-day workshop can increase clinicians’
knowledge, observational ratings indicated only modest changes in practice behavior
and no meaningful impact on client behaviors (Miller & Mount, 2001). Moreover, it
is important to note that a CE workshop in an EST is hardly sufficient to train
therapists in a new treatment, and supervision is necessary beyond didactics in order
to ensure minimum levels of competence (Morgenstern, Morgan, McCrady, Keller,
& Carroll, 2001; Sholomskas et al., 2005). Our survey measures willingness to attend
one particular workshop, and it may not be measuring practitioners’ willingness to
submit themselves to the amount of training that is required when learning a new
EST. Nonetheless, a workshop in CBT may serve as a beginning to more intensive
and advanced training.
Conclusions and Future Directions
The present research suggests that providing clinicians with case studies of ESTs may
have some impact on their attitudes, and it would be desirable to test the effects of
more elaborate case studies than were used here. In addition, further research
designed to elucidate in more detail how clinicians decide to approach further
training is needed. More research is also needed on the barriers to seeking training in
ESTs and the availability of EST training to the average practitioner.
Appendix
Clinicians’ Survey: Treatment of Bulimia Nervosa
(Section 1)
1. What is your age? _____
2. What is your gender?
Female
Male
3. Do you consider yourself to be Hispanic or Latino?
Hispanic or Latino
Not Hispanic or Latino
4. What race do you consider yourself to be?
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African A merican
White
Other
5. What is your highest degree received?
Masters
Ph.D.
Psy.D.
Ed.D.
Other
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6. In what year did you earn this degree? _____
7. To what extent did your training and education in graduate school emphasize the
research literature on psychotherapy outcome? Please pick ONE.
1
2
3
4
5
6
7
Never
Barely
A little bit
Somewhat Frequently
Regularly
Always
8. What theoretical orientation do you most adhere to in your practice? Please pick ONE.
Humanistic/Experiential
Cognitive/Behavioral
Family Systems
Psychodynamic
Eclectic (Please use only if there is no dominant orientation)
Other ____________
9. Please indicate clinical experience in years of practice (post acquisition of highest degree)
_____
10. Please indicate the average number of hours per week you spend doing psychotherapy
_____
11. Please indicate your primary employment setting – Please pick ONE.
Private Practice
Academic
Hospital
Clinic/Community Mental Health Center
Other, please be specific _________
12. In what state is your practice? ___________
13. Does your state require CE credits?
Yes No
14. If yes, how many CE credits are you required to obtain a year? ________
(Section 2)
Case Study of Tracy: Selected History and Description of Problem:5
Tracy, a 22-year old woman, had suffered from Bulimia Nervosa for 5 years by the
time she came for treatment. Her primary treatment goal was to stop binging and
purging. Her secondary goals were to feel better and to learn to trust in relationships.
Tracy’s parents divorced when she was 2 years old, at which point her father was
awarded custody because her mother had substance abuse problems and had
abandoned the family. Tracy’s father worked long hours, and Tracy was primarily
raised by a housekeeper whom Tracy described as aloof. When Tracy was 13, her
mother reappeared and wanted to have a relationship with Tracy. Tracy described
her mother as beautiful, thin, and exquisitely dressed. As Tracy and her mom got to
know each other better, Tracy’s mother became more intrusive and critical of
Tracy’s behavior and appearance. She began to tell Tracy it wouldn’t hurt to lose a
few pounds and recommended a series of diets to Tracy, none of which worked for
5
Abstracted with permission from Oltmanns, Neale, and Davison (1998). Case studies in Abnormal
Psychology (5th ed.), New York, Wiley.
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very long. Her father wasn’t interested in these issues, but was very intrusive when it
came to Tracy’s courses, grades, and career path.
Tracy’s notion of an appropriate diet bordered on starvation. She tried not to eat
all day long and would return to her apartment starving. She would usually drink a
bottle of wine to relax, and this would be followed by a binge that often lasted
2–3 hours. Tracy felt helpless and out of control during these binges. At times she felt
as if she were outside of her body, watching the process unfold. It always seemed to
Tracy that it was somehow okay to keep eating because she knew that she would
throw up, expelling those calories she had ravenously consumed. After purging, her
mood would go from bad to worse. She felt disgusted and deeply ashamed of her
inability to control her binge eating. Tracy was depressed and increasingly socially
isolated. Her drinking intensified and complicated her eating disorder, and many of
Tracy’s friends had begun to comment on her drinking behavior. She often drank
quite heavily when she went out socially with other people, and sometimes engaged
in casual sexual relations that contributed to her already ample feelings of guilt,
confusion, and lack of control.
(Section 4)
Treatment Details:
The following describes a cognitive-behavioral treatment program for Tracy, led
by a clinical psychologist who specialized in treatment for eating disorders. Tracy
met with her therapist once a week for 20 weeks.
Weeks 1 & 2: Self-Monitoring
The first step was self-monitoring. Tracy was asked to keep a careful daily record
of everything she ate or drank. The record included information about binge eating
and purging, which would serve as a baseline against which subsequent progress
would be measured. It would also be used to identify possible triggers to binges and
the function that binges might serve. Tracy reported that she did want to stop binge
eating and purging but insisted she needed to lose 5 lbs. before she would be happy
with her body.
Weeks 3 & 4: Cues and Consequences
Tracy and her psychologist reviewed her self-monitoring records from the
preceding weeks, and discussed patterns such as situations and foods that regularly
triggered binges. Tracy was encouraged to replace binges with a pattern of regular
eating throughout the day, including breakfast, lunch, and dinner as well as a snack
every 2-3 hours after each meal. Tracy expressed serious reservations, stating, ‘‘If I
eat in the morning, I’ll be eating all day’’ and that she would think more about food
because she would be eating more frequently.
Weeks 5 & 6: Thoughts, Feelings and Behaviors
These sessions focused on distorted patterns of thinking. The goal of these sessions
was to help Tracy learn to control the consequences of stressful events by
interrupting the chain that led to distorted, self-deprecating thoughts, to negative
feelings, and then to binging and purging. Tracy learned that her intense feelings of
sadness, anger, and fear often triggered binge episodes, and that she often used
binges to blunt or control these feelings. The psychologist recommended that Tracy
generate a list of other activities that could be used to replace binges.
Weeks 7 & 8: Perfectionism and All-or-Nothing Thinking
By this point, Tracy was discouraged. She continued to binge and purge and had
given up self-monitoring. Sessions during these weeks were devoted to a further
discussion of personality traits and distorted thinking patterns that are often
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associated with binge eating. Examples are, ‘‘I need to be thin in order to be liked
and successful,’’ and ‘‘if I eat regular meals, I will turn into a blimp.’’ Tracy learned
how to confront and challenge these maladaptive cognitions and develop more
adaptive attitudes towards her weight and body shape.
Weeks 9 & 10: Assertive Behavior
Tracy reported a crisis in which she had eaten an entire birthday cake meant for a
neighboring child’s party. Thus confronted with her behavior, Tracy resolved to
return to self-monitoring and did so consistently thereafter. She gave up wine when
she came home in the evening and stopped binging and purging. These weeks’
sessions were a logical extension of the preceding discussions of emotional triggers
for binge eating. For some people, anger can be a stimulus for uncontrolled eating.
By training Tracy to behave more assertively, the therapist hoped that she would be
able to solve interpersonal problems, such as criticism from her mother about her
appearance, more effectively and minimize emotional distress.
Week 11 & 12: Body Image
These sessions were devoted to a discussion of Tracy’s image of her own body.
Tracy had already made it clear that her life was, in many ways, dominated by
concerns about her appearance and her weight. Tracy said that she believed that
unless she found a way to keep herself thin, she would be depressed and lonely for
the rest of her life. The therapist explained that Tracy would have to learn to accept
her own body if she was going to recover from bulimia. In an effort to help Tracy to
identify and challenge her negative feelings about her body, the therapist reviewed a
number of facts about physiology (e.g., women need a certain amount of body fat to
enable reproduction, dieting suppresses metabolism). Tracy was asked to write down
five things about her body that she liked. The difficulty that she had in constructing
this list helped her to realize the extent of the distorted and imbalanced views that she
had come to hold about her own body.
Weeks 13 & 14: Dieting and Other Causal Factors
Tracy and the therapist discussed the relation between different types of eating
and the onset of binge eating. In particular, they focused on the role of dietary
restraint in most cases of bulimia. Tracy was asked to gradually introduce small
amounts of forbidden foods into her planned meals and snacks. This process was
designed to diminish the probability of further binges by eliminating extreme forms
of dietary restraint. The next session was devoted to a review of the complex social,
psychological and biological pathways to bulimia. Specific topics included the
popular media, gender, social class, and age.
Weeks 15 & 16: Problem Solving and Stress Reduction
Tracy’s self-monitoring records had indicated clearly that her binge episodes did
not occur at random, but were much more likely to occur during moments of
increased stress. The next two sessions focused on the development of problemsolving skills that might then serve to decrease the frequency of binge eating.
Warning signs included the onset of negative mood states (particularly sadness or
anger) as well as particular situations such as being alone with nothing to do or being
drunk. The therapist worked with Tracy on ways to generate a large number of
potential solutions to problems, as well as potential obstacles to action.
Weeks 17 & 18: Healthy Exercise and Relapse Prevention
The psychologist and Tracy worked on ways to help Tracy maintain progress once
treatment was completed. First, Tracy and the therapist talked about the damaging
effects of compulsive exercise as well as the benefits of healthy exercise, such as stress
reduction, mood elevation, social interaction with friends, and the regulation of
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metabolism. The next session was devoted to the prevention of relapse. Minor
setbacks are virtually inevitable in this type of program, and it may be unrealistic for
Tracy to assume that she will never overeat again. Tracy was encouraged to
distinguish between temporary lapses and full-blown relapses, and to address any
problems right away by reinstating those aspects of the program that had been most
successful initially.
Weeks 19 & 20: Coping with Future Events
The final session was devoted to a review of earlier steps and a discussion of the
ways that Tracy could reduce her vulnerability to future binge eating. One crucial
consideration was obviously the continuation of regular meals and avoiding all
forms of dieting. Tracy and her therapist discussed methods Tracy had learned to use
when coping with stressful events, negative emotions, and self-defeating thoughts.
Termination:
By the time therapy was terminated, Tracy had made significant improvements with
regards to her eating problems. Despite initial resistance and skepticism, she had eaten
regular meals on a daily basis for 5 weeks. She had not binged or purged during this time,
and she had stopped taking diet pills and laxatives. Somewhat to her surprise, her weight
had remained fairly steady for the first couple of weeks, and then leveled off at five pounds
less than it had been before she had entered therapy. Her mood was much improved, but
she still experienced periods of marked sadness and loneliness. Her concerns with drinking
as well as difficulties in relationships with boyfriends and her parents had not been
resolved. She decided to continue to work on these issues in further therapy.
(Section 3)
Treatment:
The psychotherapeutic treatment that has received the most research attention and
empirical support for bulimia nervosa is cognitive-behavioral therapy (CBT). CBT for
bulimia has consistently been shown to be superior to waiting-list control groups, which
show no improvement across a range of measures. CBT has also proven more effective at
reducing binge eating and purging than all other psychotherapeutic treatments with
which it has been compared (i.e., behavior therapy, supportive-expressive psychotherapy,
psychodynamic psychotherapy) with the exception of interpersonal therapy (IPT).6
Comparisons of CBT and IPT suggest that although CBT works more quickly to reduce
symptoms, patients who receive IPT continue to improve so that the outcomes are
equivalent at 1-year follow-up. Thus, both CBT and IPT are considered evidence-based
treatments for bulimia nervosa although there is less evidence available for IPT than for
CBT, and CBT’s results come sooner than IPT’s.
Where pharmacotherapy is concerned, numerous controlled studies have indicated
that both tricyclic antidepressants and the SSRI antidepressant fluoxetine are more
effective than a pill placebo in reducing binge eating and purging at the end of
treatment. Studies have indicated that CBT is more effective than treatment with a
6
The questionnaire was mailed as presented in this appendix. We subsequently became aware that our
statement was partially incorrect, in that there is some evidence that CBT is not consistently superior to a
form of short-term focal psychotherapy used by Fairburn, Kirk, O’Connor, and Cooper (1986)—at least
where binge eating and purging are concerned. Fairburn et al. (1986) found that both treatments
significantly reduced the frequency of bulimic episodes and self-induced vomiting, but did not differ
consistently from one another, with the exception of the 8-month follow-up at which point patients in the
CBT group reported significantly greater reduction in frequency of vomiting. However, CBT was superior
to short-term focal psychotherapy in reduction of general psychopathology (including depression) and
improvement in social adjustment throughout the follow-up period.
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single anti-depressant drug and that long-term maintenance of change is better with
CBT than with anti-depressant drugs. Moreover, the weight gain often associated
with these drugs is objectionable to many clients. Lastly, research indicates that
adding CBT to antidepressant medication increases the rate of recovery.
Controlled studies of the efficacy of CBT for bulimia find that on average, roughly
50% of patients completely stop binge eating and purging. The percentage reduction
in binge eating and purging across all patients treated with CBT is typically 80% or
more. These therapeutic changes are maintained at 1 year following treatment.
Longer-term follow-up data are as yet unavailable.
(Section 5)
12. Do you see bulimic patients in your practice? Yes No
13. If yes, what percentage of your patients are bulimic? ________
Regardless of your answer to #12, please assume that you see bulimic patients for the
remainder of this questionnaire. Please use the following rating scales to give your
impressions of how helpful CBT for bulimia would be in your practice. Please circle your
responses.
14. How appropriate does CBT for bulimia seem to you?
1
2
3
4
5
6
7
Not at all
Moderately
appropriate
appropriate
8
9
10
Extremely
appropriate
15. How confident are you that CBT would reduce the severity of bulimia nervosa in your
patients?
1
2
3
4
5
6
7
8
9
10
Not at all
Moderately
Extremely
confident
confident
confident
16. How likely would you be to use CBT (assuming you had adequate training) for a patient
with bulimia nervosa?
1
2
3
4
5
6
7
8
9
10
Not at all
Moderately
Extremely
likely
likely
likely
17. Would you refer bulimic patients to a physician for medication? Please pick one.
Yes, as the sole treatment
Yes, combined with psychotherapy
No
18. Is there another psychotherapeutic approach you would be likely to use for bulimic
patients?
Yes No
19. If yes, what is it? _________
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20. How likely would you be to seek out and complete workshop training in CBT for
bulimia? Assume this workshop is either in your community or at a conference you are
attending.
N/A – I have already had extensive training in CBT for bulimia
1
2
Not at all
Likely
3
4
5
6
Moderately
likely
7
8
9
10
Extremely
likely
21. How likely would you be to seek out and complete workshop training in some other
treatment for bulimia? Assume this workshop is either in your community or at a
conference you are attending.
1
2
Not at all
likely
3
4
5
6
Moderately
likely
7
8
9
10
Extremely
likely
22. How likely would you be to seek out and complete home-study (books, tapes or webbased training) in CBT for bulimia?
N/A – I have already had extensive training in CBT for bulimia
1
2
Not at all
likely
3
4
5
6
Moderately
likely
7
8
9
10
Extremely
likely
23. How likely would you be to seek out and complete home-study (books, tapes or webbased training) in some other treatment for bulimia?
1
2
Not at all
likely
3
4
5
6
Moderately
likely
7
8
9
10
Extremely
likely
24. How many hours would you be willing to devote for training in CBT for bulimia in a
workshop? _____
25. How many hours would you be willing to devote for training in CBT for bulimia in a
home-study program? _____
26. How much money would you be willing to spend for training in CBT for bulimia?
______
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