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Computers in Human Behavior 23 (2007) 850–859
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Does therapist guidance improve uptake,
adherence and outcome from a CD-ROM
based cognitive-behavioral intervention
for the treatment of bulimia nervosa?
Kathryn Murray a, Ulrike Schmidt b,*,
Maria-Guadelupe Pombo-Carril a, Miriam Grover a,
Joana Alenya a, Janet Treasure c, Christopher Williams
d
a
Eating Disorders Unit, Maudsley Hospital, Denmark Hill, London SE5 8AZ, UK
Section of Eating Disorders, Institute of Psychiatry, De Crespigny Park, PO Box 59,
London SE5 8AF, UK
Department of Academic Psychiatry, 5th floor, Thomas Guy House, Guys Hospital, London SE1 9RT, UK
d
Section of Psychological Medicine, Academic Centre, Gartnavel Royal Hospital,
1055 Great Western Road, Glasgow G12 0XH, UK
b
c
Available online 10 December 2004
Abstract
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.
*
Corresponding author. Fax: +44 2078480182.
E-mail address: [email protected] (U. Schmidt).
0747-5632/$ - see front matter 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.chb.2004.11.014
K. Murray et al. / Computers in Human Behavior 23 (2007) 850–859
851
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 cognitivebehavioral 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.
2004 Elsevier Ltd. All rights reserved.
Keywords: Bulimia nervosa; Eating disorder; CD-ROM; Treatment; Self-help; Computerised cognitivebehavior therapy
1. Introduction
Systematic reviews have demonstrated the efficacy of cognitive behavioral therapy (CBT) for the treatment of bulimia nervosa (Hay & Bacaltchuk, 2003a,
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, Kenwright, McDonough, Whittaker, & Mataix-Cols, 2004; Proudfoot et al., 2003a, 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; Murray et al., 2003).
One important question is whether clinician guidance, supporting patientsÕ 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 & Palmer, 2002; Perkins &
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
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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 patientsÕ 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.
2. Method
2.1. Sample
Patients were recruited from two consecutive cohorts of patients newly referred
to the Eating Disorders Unit of the South London and Maudsley NHS Trust
which provides a service to a catchment area population of two million. Patients
with a diagnosis of BN or eating disorder not otherwise specialised (EDNOS) were
eligible for participation. Patients with EDNOS were included, as many of them
closely resemble bulimia nervosa, with severe, distressing and long lasting symptoms, even though they do not meet the precise diagnostic criteria (Fairburn &
Harrison, 2003). We defined EDNOS as any clinically relevant eating disorder
(i.e. with significant impairment of physical health or psychosocial functioning)
where the patient met all the criteria for bulimia nervosa except that the binge eating and/or inappropriate compensatory mechanisms occurred at a frequency of less
than twice a week or for a duration of less than three months. All diagnoses were
assigned by experienced and trained clinicians using a semi-structured clinical interview, devised in our Unit, for DSM-IV diagnoses. The exclusion criteria were:
insufficient knowledge of English, insufficient literacy level, severe learning disability, anorexia nervosa, severe depression or acute suicidality, or alcohol/substance
dependence.
Informed written consent was sought from patients at initial assessment. The
study was approved by the research ethics committee at the Institute of Psychiatry
and South London and Maudsley NHS Trust. Patients who were eligible and consented to participation were offered the CD-ROM treatment as a first step in treatment, with the option of a therapist intervention 6–8 weeks after completion of the
program. The first cohort, described in more detail in a previous paper (Bara-Carril
K. Murray et al. / Computers in Human Behavior 23 (2007) 850–859
853
et al., 2004) completed the package with minimal guidance and the second cohort
received therapist guidance (TG) as detailed below.
2.2. Procedure
After their initial assessment, patients were introduced to the research team, who
were responsible for administering the program and booking appointments. Treatment consisted of eight interactive computerised modules making up the Overcoming Bulimia disc. The program uses a cognitive-behavioral therapy format,
incorporating educational and motivational strategies, with personalised feedback,
homework tasks, accompanying manuals and an audio relaxation tape (Williams
et al., 1998). Patients were required to complete sessions in sequential order and were
encouraged to attend on a weekly basis, though they were able to book appointments at their convenience within working hours. The CD-ROM treatment was conducted in a small self-contained clinic room and patients were left to work through
each session alone at their own pace.
The minimal guidance (MG) group had low-key interaction with a researcher who
introduced them to the program at their first appointment, and logged them onto the
computer and booked subsequent appointments with them. The therapist guidance
(TG) group received three 20-min sessions of therapist guidance after sessions 1, 3
and 8 as has been recommended by the developers of the CD-Rom. The sessions
were delivered by several professionals with different degrees of experience, including
nurse therapists and assistant psychologists. The aims of these sessions were to help
people make the best use of the CD-ROM sessions by looking at how the materials
applied to them, to increase and maintain motivation to complete the program; to
clarify any information on the program that the patient had not understood and
to foster compliance with homework. Thus, the guidance sessions focussed predominantly on issues raised in the CD-ROM modules rather than on any additional topics. If clients raised other topics, they were either told that this would be covered later
on in the program, or where that was not the case that they might wish to discuss this
issue with their therapist when they began face-to-face therapy at a later date. The
therapists giving the guidance received regular clinical supervision of their cases by
one of the authors (US).
2.3. Measures
Demographic information and baseline measurements of eating disorder symptomatology were collected from patients prior to starting the computer program.
The main outcome measure used was the short evaluation of eating disorder
symptoms (SEED), a patient self-rating instrument developed in the context of
a large naturalistic European multi-centre study of eating disorders (Kordy
et al., 1999). This scale gives separate ratings for frequency of bingeing, self-induced
vomiting, laxative/diuretic use, excessive exercise and food restriction. The scale
points are as follows: ‘‘1 = not at all’’, 2 = up to 1 · week’’, 3 = 2/3 · week’’,
‘‘4 = daily’’, ‘‘5 = more than 1 · day’’. Although full validation of the SEED
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has not yet been published, preliminary analyses on data from approximately
180 patients with a range of eating disorder diagnoses for whom ratings made
independently by both the patient and experienced and trained clinicians are
available and indicate excellent inter-rater reliability. The j values for those
symptoms included in this report are all above 0.70. The SEED was completed
by patients at assessment, session 3 and at follow-up (6–8 weeks after completing
the CD-ROM).
2.4. Statistical analysis
The data were analysed using SPSS-11 for Windows, using parametric and
non-parametric tests where appropriate. Symptom remission (defined as being below the DSM-IV frequency threshold of twice-weekly occurrence of a particular
behaviour) was calculated for bingeing, vomiting, laxative abuse, dieting and
excessive exercise pre-treatment, from the SEED scores at week 3 and at follow-up. Change scores from pre-treatment to week 3 and from pre-treatment to
follow-up (6–8 weeks after completing the CD-ROM) were calculated according
to improvement (= 1), no change (= 0) or deterioration (= 1) in terms of whether
a patient stayed the same or moved above/below the DSM threshold frequency
for each symptom. Independent samples Mann–Whitney tests were then carried
out to look for differences between the MG and TG groups at each of these time
points. The week 3 change score was used because we wanted to know whether
there might be differences in the speed of improvement in the two groups and
the follow-up score was used to assess whether there were any more lasting differences. SEED data on 73% of participants were available at week 3 and on 85.5%
of participants at follow-up.
3. Results
3.1. Baseline characteristics
A total of 103 patients were eligible for the study and agreed to participate. Eighty
two of these patients (79 female, 3 male) took up the computer programme (43/53
(81%) of patients in the MG group and 39/50 (78%) of the TG group). Patients
who took up the computer treatment had a diagnosis of BN binge–purge type in
82% of cases; 12% suffered from BN non-purging type and 6% had eating disorder
not otherwise specialised. The age range of participants was between 18 and 62 years,
and the mean duration of the eating disorder was 11 years (SD 9.7). Thirty-two
(39%) of the 82 patients were receiving antidepressant medication at assessment. This
information was missing for 12 patients. There were no significant differences between the two groups on demographic characteristics. Table 1 gives the baseline details of patients who took up the CD-ROM treatment. The only significant baseline
difference in eating symptomatology was that the TG group had a significantly higher
rate of laxative use (p < 0.046).
K. Murray et al. / Computers in Human Behavior 23 (2007) 850–859
855
Table 1
Pre-treatment symptomatology
Mean BMI (SD)
Eating disorder symptoms
(percent below DSM-IV frequency threshold)
Bingeing
Vomiting
Laxative use
Excessive exercise
Food restriction
a
b
Minimal guidance
group (n = 43)
Therapist guidance
group (n = 39)
p
21.4 (8.7)
%
22.2 (4.3)
%
0.59a
20.9
35
80.5
72.5
17.1
13.9
21.6
58.3
52.8
27.8
0.557b
0.217b
0.046b
0.097b
0.284b
Independent samples t-tests.
FisherÕs exact test.
3.2. Session attendance
There were no significant differences between the groups on session attendance
(Table 2). Twenty patients (47%) of the MG group and seventeen patients (44%)
of the TG group completed all eight sessions.
3.3. Symptom change
Table 3 gives the percentages of each group below the DSM-IV frequency
thresholds and the symptom changes at weeks 3 and and at follow-up. There
was a trend for patients in the TG group to improve more rapidly on bingeing,
vomiting and exercise from baseline to week 3 with p-values of 0.118, 0.163 and
0.154, respectively. At follow-up, the only significant difference between the
groups was that the TG group showed significantly more improvement in exercise
(p = 0.006).
Table 2
Number of CD-ROM sessions attended
Number of sessions attended
GROUP minimal guidance group
Therapist guidance group
Total
1
2
3
4
5
6
8
3
6
5
7
1
1
20
2
6
3
6
3
2
17
5
12
8
13
4
3
37
Total
43
(7%)
(14%)
(12%)
(16%)
(2%)
(2%)
(47%)
39
(5%)
(15%)
(8%)
(15%)
(8%)
(5%)
(44%)
82
(6%)
(15%)
(9%)
(16%)
(5%)
(4%)
(45%)
856
Week 3
Bingeing
Vomiting
Dieting
Exercise
Laxative
Minimal guidance group
a
Mann–Whitney U test.
p
Mean ranks of symptom
changes baseline to week 3
% Below DSM threshold
Mean ranks of symptom
changes baseline to week 3
23.1
50.0
32.0
76.0
91.7
25.2
24.8
24.7
26.7
22
42.1
66.7
47.8
87.0
60.0
20
20
24.3
21.2
20.9
Follow-up (6–8 weeks
after the end
of the CD-ROM treatment)
Bingeing
Vomiting
Dieting
Exercise
Laxative
Therapist guidance group
% Below DSM threshold
Mean rank symptom
changes baseline to
follow-up
31.6
71.1
29.7
80.6
91.7
37.5
34.7
34.8
37.9
34.2
0.118a
0.163a
0.816a
0.154a
0.359a
Mean rank symptom
changes baseline to
follow-up
41.2
57.6
48.5
82.4
75.0
33.2
33.2
33
28.8
30.6
0.335a
0.811a
0.688a
0.006a
0.315a
K. Murray et al. / Computers in Human Behavior 23 (2007) 850–859
Table 3
Percentages below DSM-IV threshold and symptom changes
K. Murray et al. / Computers in Human Behavior 23 (2007) 850–859
857
4. Discussion and conclusions
Patients in both groups showed significant improvements in frequency of bingeing
and a range of reversing behaviours. The only significant difference in terms of eating
disorder-related outcomes between the groups was that a larger proportion of people
were in remission from excessive exercise in the therapist-guidance group at followup. This is interesting, but on its own is probably not enough to justify the addition
of therapist guidance sessions.
Contrary to our hypothesis the addition of limited therapist guidance did not seem
to confer any additional benefit in terms of improving treatment uptake, retention in
treatment or outcome from the CD-ROM program. One possibility is that the failure
to find any differences between the two groups is simply due to the relatively small
sample size. Alternatively, it must be considered that the therapist guidance was
not intensive enough to make a significant difference. However, part of the attractiveness of computerised delivery of treatment is that this can reduce therapist time and
we therefore wanted to keep the time investment quite low. The rather rigid timing of
the guidance sessions may have been less helpful than a more flexible access to guidance sessions if and when needed. In a recent open evaluation of computer-aided CBT
for anxiety and depression, patients were able to access six brief scheduled telephone
or face-to-face contacts for advice as needed, provided it was within office hours
(Marks et al., 2003). Over 12 weeks of computer-aided treatment the average time taken for support was just 1 h, but patients reported high levels of satisfaction with this
form of therapist support. In our study, the minimal guidance group had some (albeit
very limited) contact with the research workers in the clinic and the need to come to
the clinic to schedule appointments to access the computer together with a friendly
face may have been enough Ôto keep most people goingÕ. Overall the findings of the
study provide further support for the acceptability and preliminary efficacy of the
CD-ROM program.
5. Limitations
The study has a number of limitations. First, this is not a randomised controlled
trial and it is possible that the groups differed systematically on variables other than
eating disorder symptoms and that this may have obscured any treatment differences. Moreover, we did not tape-record the guidance sessions and check the quality
of the guidance and clinicianÕs adherence to their task. Thirdly, outcomes were measured by self-report rather than through an interview-based measure, such as the eating disorders examination. Finally, the follow-up period was relatively brief.
6. Conclusions and implications
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
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K. Murray et al. / Computers in Human Behavior 23 (2007) 850–859
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 patientÕs home or other
public settings such as libraries or via the internet. Further research is needed to elucidate these questions.
Conflict of interest
Dr. C. Williams holds IPR in the Calipso Overcoming Bulimia package.
Acknowledgements
K.M. was supported by the Psychiatry Research Trust and the South Thames
Specialist Audit Programme. M.G.P.-C. was supported by the Psychiatry Research
Trust. J.A. was supported by the South Thames Specialist Audit Programme. We
thank Dr. Sabine Landau for statistical advice.
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