Doing it by the book: What place for guided self-help for bulimic disorders?

European Eating Disorders ReviewEur. Eat. Disorders Rev. 10, 379–385 (2002)Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/erv.494

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Doing It by the Book: What Place for GuidedSelf-Help for Bulimic Disorders?

Helen Birchall1* and Bob Palmer21Leicestershire Partnership NHS Trust, Brandon Mental Health Unit,Leicester General Hospital, Leicester, UK2Leicester Warwick Medical School, Department of Psychiatry, BrandonMental Health Unit, Leicester General Hospital, Leicester, UK

The treatment of bulimic disorders—bulimia nervosa (BN), binge eatingdisorder (BED) and similar atypical states—tends to provoke the classicdivision between optimists and pessimists. The former may rightly pointto the unusual size of the evidence base. For a disorder that found a nameless than a quarter of a century ago, it is remarkable that there are manystudies available to guide practice (Schmidt, 1998). These include anumber of randomized controlled trials of adequate quality. Further-more their conclusions are fairly clear. Many antidepressant drugs havemodest but real benefits provided people are able and willing to takethem (Mayer & Walsh, 1998). They are easy to deliver but rarely lead tosustained remission of symptoms. By contrast, some kinds of briefpsychotherapy—notably manualized cognitive behavioural therapy(CBT)—have been shown repeatedly to lead to full and lasting remissionin many and improvement in most patients (Wilson, Fairburn, & Agras,1997). Interpersonal therapy (IPT) has also been shown to be similarlyefficacious (Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000; Birchall,1999; Fairburn, 1997) and there is also evidence for some other brieftherapies (Lacey, 1983, 1992; Safer, Telch, & Agras, 2001).

So where is the snag? What is the pessimists’ point of view? Thosewho see the bottle as half empty have three main arguments. Firstly, theymay point out that even the best treatments in the best circumstancesleave at least half of bulimic patients still disordered after treatment.Some of these may be improved but a significant minority remainunaffected by the treatment. The current evidence base is largely silentwith regard to how best to help these non-responding patients. New or

European Eating Disorders ReviewCopyright # 2002 John Wiley & Sons, Ltd and Eating Disorders Association. 10(6), 379–385 (2002)

*Correspondence to: Helen Birchall, Brandon Unit, Leicester General Hospital, Leicester LE5 4PW,UK. Tel: 0116 225 6230. Fax: 0116 225 6235. E-mail: [email protected]

modified treatments are needed. Secondly, the presently defined treat-ments of proven efficacy are either not very effective—drugs—ordifficult to deliver in practice—the psychotherapies.

Although CBT and IPT are described as ‘brief’ therapies, they are briefonly by comparison with lengthy therapy in the psychodynamictradition where years of treatment might be not uncommon. Both CBTand IPT typically require around 20 ‘hours’ of skilled therapist time. Soone snag is that this is fairly costly even when appropriately trained andsupervised therapists are available. Further snags are that therapists,training or supervision may each be in short supply. Not uncommonlythey all are. Is it possible to help at least some patients with treatmentsthat are cheaper and easier to provide?

Guided self-help has recently emerged as one possible response tosome of these problems. A number of books have been written for theself-treatment of disorders involving binge eating (Cooper, 1995;Fairburn, 1995; Schmidt & Treasure, 1993). They may be used alonebut there are claims that their use with guidance is more effective. Suchguided self-help (GSH) involves the use of a self-help book or similarprogramme as the chief source of information and instruction for thepatient but with additional encouragement and guidance given bysomeone who may or may not be a trained professional. What is theevidence for GSH in the treatment of bulimic disorders?

Over the past few years there have been a number of studies of the useof GSH for this group of patients. Treasure et al. (1994) randomized 81patients with BN or atypical BN to CBT, a self-help manual or a waitinglist. Full remission was reported in 24 and 22 per cent of the treatmentgroups respectively, and in 11 per cent of the waiting list controls. In afurther study, Treasure et al. (1996) randomized 110 patients with BN oratypical BN to 8 weeks of a self-help manual followed by up to eightsessions of CBT if they were still symptomatic, versus 16 sessions ofCBT. At end of treatment, and at 18 months follow-up, about 30 and40 per cent respectively of both groups were free from all bulimicsymptoms. The median number of CBT sessions used in the self-helpgroup was just three. Cooper, Coker, and Fleming (1996) gave 82patients supervised self-help. Sixty-seven patients completed treatment,and among these there was an 80 per cent reduction in bingeing andvomiting. This improvement was largely maintained at 12-monthfollow-up. Thiels, Schmidt, Treasure, Garthe, and Troop (1998) compa-red 16 sessions of weekly CBT and a self-help manual supplemented byeight biweekly CBT sessions in 62 patients with bulimia nervosa. Atfollow-up, about two-thirds of patients in both groups were free frombingeing and vomiting, and there were also marked improvements indepression and self-esteem. Carter and Fairburn (1998) looked at

H. Birchall and R. L. Palmer Eur. Eat. Disorders Rev. 10, 379–385 (2002)

Copyright # 2002 John Wiley & Sons, Ltd and Eating Disorders Association. 380

patients with binge eating disorder and compared pure self-help, GSHand waiting list. At 6-month follow-up, almost half of both the treatmentgroups had ceased to binge. There was little change in the waiting listgroup. Loeb, Wilson, Gilbert, and Labouvie (2000) used a CBT self-helpmanual, and compared pure versus guided self-help. Both groupsimproved, but GSH was notably superior in reducing binge eating. Ahigh degree of general psychopathology was a negative prognosticindicator. Palmer, Birchall, McGrain, and Sullivan (2002) compared 121patients randomized to four conditions, three treatment groups whichused a self-help manual and a waiting list comparison group. One grouphad the book alone, one group had the book with four face-to-facesessions of guidance from a therapist and one group had the book andfour telephone guidance sessions. In this study, the book alone was notsignificantly superior to waiting list, but additional guidance deliveredface-to-face, led to improved outcome over 4 months. Telephoneguidance showed some promise, but was less effective than face-to-face contact. Wells, Garvin, Dohm, and Striegal-Moore (1997) hadpreviously explored the use of telephone guidance with encouragingresults.

A number of questions arise about GSH itself. Most of them as yet donot have answers. Firstly, are the available self-help books equallygood? Secondly and more crucially perhaps, it would be good to knowwhat is the optimal form and pattern of guidance. And how much do itscharacteristics affect the outcome? There are presumably two obviouscomparisons to be made. At one extreme, there is comparison with theuse of a book or some similar impersonal source of information andadvice without any form of guidance. The evidence cited above suggeststhat guidance does add something to the effectiveness of the use of thebooks. At the other extreme, there is comparison with full therapy—especially CBT. Here the amount and type of guidance is an obviousvariable. It is not impossible that 20 sessions of GSH might be as good asa similar number of sessions of CBT with a therapist. It is evenconceivable that the effect of ‘doing it oneself’ with encouragementmight even be better than conventional therapy although the collabora-tive style of CBT might make this unlikely. No such comparison hasbeen published as yet. Of course, the more sessions that are used the lessmay be the economic advantage of using GSH over full therapy. And yetthere might still be advantages, sessions of GSH might be shorter thantypical therapy sessions and the clinician involved might be less skilledand might perhaps be paid less. There is little evidence as yet as towhether clinicians with more general experience and training do betterthan those with less. Indeed, do ‘guides’ need to be trained cliniciansat all?

Eur. Eat. Disorders Rev. 10, 379–385 (2002) Bulimic Disorders


Intensively guided self-help might be advantageous especially whereit is not potential clinicians that are lacking but appropriately trainedclinicians. Then, where training and supervision are in short supply,such guided self-help might have another advantage. Giving theguidance might be a powerful learning experience for the ‘guide’.Guided self-help for the patient might come to be combined with guidedself-training for the clinician. There is as yet no evidence for this effectbut people with little special experience or expertise in the treatment ofeating disorders who nevertheless finds themselves needing to providefor people with bulimic disorders, could do worse than to start by doingit by the book in this way. In addition, two of the self-help books aresupported by manuals to aid the administering clinician (Fairburn,Marcus, & Wilson, 1993; Schmidt & Treasure, 1997).

Where the overall number of clinicians is the issue, the question ofhow many guidance sessions is optimal, becomes more pressing. Whatshould be their distribution in time? And what should be their style andcontent? Again there is little evidence but conventional wisdom suggestthat packing the sessions into the earlier days and weeks of thetreatment is best and that the guidance should mainly take the form ofencouragement to use the book. If the guide becomes an alternativesource of expertise it may detract somewhat from the patient’s faith inthe book which needs to provide the main thrust of the treatmentprogramme. However, the guide may appropriately suggest anemphasis on certain passages that are especially relevant to theparticular patient. The treatment may be ‘off the peg’ but a little tuckhere and there may help the fit. Another issue concerns whether or notthe guidance needs to be given face-to-face. Here there is some evidencesuggesting that although telephone guidance may be helpful, all otherthings being equal, guidance given face-to-face is better. However, allother things may not be equal. Geography may get in the way and, insome circumstances, GSH with guidance given at a distance may havereal advantages. Then, use of the telephone or the internet orvideoconferencing might provide practical help where otherwise therecould be little or nothing available.

GSH may well have some place in secondary and specialist servicesbut it could also be used in primary care. Indeed, that is where theadvantage might be greatest. Bulimia nervosa, binge eating disorderand variants thereof are common conditions. Most sufferers probably donot come to the attention of professionals at all and only a minoritymake it through the filters on the pathway to secondary care. GSHwould be a rational and evidence-based response that in principle couldbe delivered by general practitioners or other members of the primarycare team. This could be the first step in a stepped care approach that



reserved more elaborate and demanding therapies such as CBT or IPTfor those who had failed to respond (Fairburn & Peveler, 1990). Ideally,of course, it would be possible for the general practitioner to predictwhich patients would do well with GSH and which might be betterreferred on for specialist treatment. However, there is little evidence toinform this judgement with special reference to GSH. In practice, all thatcan be said is that normal rules probably apply, in that those with moresevere purging and those with personality disorders are likely to do lesswell, but this applies to other therapies as well. Likewise, those withsevere physical complications, such as uncontrolled diabetes orworryingly deranged electrolytes, or indeed those with severe psychia-tric comorbidity such as major depression with suicidal risk shouldperhaps be referred on to a setting where these issues can be managed.With these things in mind, GSH in primary care is probably a sensiblefirst choice for most sufferers and it will be enough for many.

Specialists in eating disorders need to think how they may bestpromote and support the delivery of such treatment in primary care.This is a real question since a general practitioner with perhaps 2000patients will not come across bulimic disorder that often. How may heor she be best informed and equipped to firstly think of and then deliverGSH? It is undoubtedly within their competence, but how maydelivering GSH be made sufficiently straightforward so that it can bereadily and effectively wheeled out the necessary once or twice eachyear. Perhaps, jumping on to computer-based treatment might be a wayforward. With CD ROM or even internet treatment, giving support andguidance might demand less familiarity of the ‘guide’ with the material.There is a need for effectiveness studies of GSH in general practice.

GSH has the advantages of being cheap, readily accessible andrequiring less specialist skill to deliver. However, it is not a panacea or auniversal answer to the perennial problem of limited resource andwaiting lists. Some patients take to it like the proverbial duck to water,and feel very validated reading about themselves and their condition ina book. Others quickly feel hopeless and disillusioned. This is where anempathetic therapist may be able to apply the right amount of ‘welly’ tothe posterior to help the patient shift and move on. However, somepeople are unable to work in this kind of way, and it may rapidlybecome apparent that despite their efforts they are getting nowhere. It isthen important to avoid blaming the patient, and to come in with othertreatment options, perhaps fast tracking the individual up the ‘steppedcare’ ladder.

GSH has promise as a cheap and somewhat effective first interventionfor bulimia nervosa, binge eating disorder and similar conditions. Inprinciple, it is easy to deliver. However, as with most things that look



straightforward, there are more outstanding questions than may beinitially evident. These treatments need to be developed further andpromoted with care if their promise is to be fully realized.

REFERENCES

Agras, W. S., Walsh, B. T., Fairburn, C. G., Wilson, G. T., & Kraemer, H. C.(2000). A multicenter comparison of cognitive-behavioural therapyand interpersonal psychotherapy for bulimia nervosa. Archives ofGeneral Psychiatry, 57, 459–466.

Birchall, H. (1999). Interpersonal psychotherapy in the treatment of eatingdisorders. European Eating Disorders Review, 7, 315–320.

Carter, J. C., & Fairburn, C. G. (1998). Cognitive-behavioral self-help for bingeeating disorder: a controlled effectiveness study. Journal of Consultingand Clinical Psychology, 66, 616–623.

Cooper, P. (1995). Bulimia nervosa and binge eating: A guide to recovery. London:Robinson Publishing.

Cooper, P. J., Coker, S., & Fleming, C. (1996). An evaluation of the efficacy ofsupervised cognitive behavioural self-help for bulimia nervosa. Journalof Psychosomatic Research, 40, 281–287.

Fairburn, C. G. (1995). Overcoming binge eating. New York: Guilford Press.Fairburn, C. G. (1997). Interpersonal psychotherapy for bulimia nervosa.

In D. M. Garner, & P. E. Garfinkel (Eds.), Handbook of treatment for eatingdisorders (2nd ed.). London: Guilford Press.

Fairburn, C. G., Marcus, M. D., & Wilson, G. T. (1993). Cognitive-behaviouraltherapy for binge eating and bulimia nervosa: a comprehensivetreatment manual. In C. G. Fairburn, & G. T. Wilson (Eds.), Bingeeating: Nature, assessment & treatment. New York: Guilford Press.

Fairburn, C. G., & Peveler, R. C. (1990). Bulimia nervosa and a stepped careapproach to management. Gut, 31, 1220–1222.

Lacey, J. H. (1983). Bulimia nervosa, binge eating and psychogenic vomiting: acontrolled treatment study and long term outcome. British MedicalJournal, 286, 1609–1613.

Lacey, J. H. (1992). Long-term follow-up of bulimic patients treated inintegrated behavioural and psychodynamic treatment programmes.In W. Herzog, H.-C. Deter, & W. Vanderycken (Eds.), The course ofeating disorders: Long-term follow-up studies of anorexia and bulimianervosa. Berlin: Springer-Verlag.

Loeb, K. L., Wilson, G. T., Gilbert, J. S., & Labouvie, E. (2000). Guided andunguided self-help for binge eating. Behaviour Research and Therapy, 38,259–272.

Mayer, L. E. S., & Walsh, B. T. (1998). Pharmacotherapy of eating disorders. InH. W. Hoek, J. L. Treasure, & M. A. Katzman (Eds.), Neurobiology in thetreatment of eating disorders. Chichester, New York: John Wiley & Sons.



Palmer, R. L., Birchall, H., McGrain, L., & Sullivan, V. (2002). Guided self-helpfor bulimic disorders: a randomised controlled trial comparingminimal guidance with face-to-face or telephone guidance. BritishJournal of Psychiatry, 181, 230–235.

Safer, D. L., Telch, C. F., & Agras, W. S. (2001). Dialectical behaviour therapy forbulimia nervosa. American Journal of Psychiatry, 158, 632–634.

Schmidt, U. (1998). Treatment of bulimia nervosa. In H. W. Hoek, J. L. Treasure,& M. A. Katzman (Eds.), Neurobiology in the treatment of eating disorders.Chichester, New York: John Wiley & Sons.

Schmidt, U., & Treasure, J. (1993). Getting better bit(e) by bit(e). London:Lawrence Erlbaum Associates.

Schmidt, U., & Treasure, J. (1997). Clinician’s guide: Getting better bit(e) by bit(e).London: Lawrence Erlbaum Associates.

Thiels, C., Schmidt, U., Treasure, J., Garthe, R., & Troop, N. (1998). Guided self-change for bulimia nervosa incorporating use of a self-care manual.American Journal of Psychiatry, 155, 947–953.

Treasure, J., Schmidt, U., Troop, N., Tiller, J., Todd, G., Keilen, M., & Dodge, E.(1994). First step in managing bulimia nervosa incorporating a self-caremanual. British Medical Journal, 308, 686–689.

Treasure, J., Schmidt, U., Troop, N., Tiller, J., Todd, G., & Turnbull, S. (1996).Sequential treatment for bulimia nervosa incorporating a self-caremanual. British Journal of Psychiatry, 168, 94–98.

Wells, A. M., Garvin, V., Dohm, F., & Striegal-Moore, R. H. (1997). Telephone-based guided self-help for binge eating disorder: a feasibility study.International Journal of Eating Disorders, 21, 341–346.

Wilson, G. T., Fairburn, C. G., & Agras, W. S. (1997). Cognitive-behavioraltherapy for bulimia nervosa. In D. M. Garner, & P. E. Garfinkel (Eds.),Handbook of treatment for eating disorders (2nd ed.). London: GuilfordPress.



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Doing it by the book: What place for guided self-help for bulimic disorders?