Counseling and Guided Self-Help Outcomes for Clients with Bulimia Nervosa: A Meta-Analysis of Clinical Trials from 1980 to 2010

Bulimia nervosa is an eating disorder associated with a drive for thinness or frequent episodes of binge eating and harmful compensatory behaviors to avoid an increase in weight (American Psychiatric Association, 2000). A binge eating episode involves a lack of control over the intake of substantial amounts of food. Compensatory behaviors can include vomiting, laxatives, diuretics, fasting, and extreme exercise (Keel & Haedt, 2008; Shapiro et al., 2007). Characteristics of bulimia nervosa also include a severe concern with one's body shape and weight (Stefano, Bacaltchuk, Blay, & Hay, 2006) and perceptual distortion and extreme body dissatisfaction (Cash & Deagle, 1997). Cash and Deagle (1997) found that 73% of patients with bulimia nervosa perceived their body size to be larger than it actually was, and their body dissatisfaction attitudes exceeded 87% of the control participants. Hudson, Hiripi, Pope, and Kessler (2007) estimated that bulimia nervosa affected 0.5% of males and 1.5% of females over their lifetime, with prevalence rates increasing in recent generations. The estimated mean age of onset was 19.7 years, and the average duration of the disorder was 8.3 years (Hudson et al., 2007). Hudson and colleagues reported that 94.5% of participants with bulimia nervosa had at least one other diagnosed mental disorder, and most participants had received mental health assistance for other emotional issues. Seventy-eight percent of participants reported significant role impairments in their home, work, personal, or social life, and 43.9% reported a severe impairment. However, only 48.3% of individuals with bulimia nervosa sought treatment for their eating disorder. Although the full syndromal incidence of bulimia nervosa has been stable over time, the report of bulimia nervosa is on the rise. With less than half of those diagnosed seeking treatment, it is important to determine the most effective and accessible treatment modalities available to restore individuals to a healthy level of functioning. Common treatment approaches for bulimia nervosa include counseling/psychotherapy, pharmacotherapy, and guided self-help. There is debate over which approach is most effective. For example, many studies have reported the efficacy of counseling and psychotherapy in the treatment of bulimia nervosa (Fettes & Peters, 1992; Ghaderi & Anderson, 1999; Lewandowski, Gebing, Anthony, & O'Brien, 1997; Shapiro et al., 2007; Thompson-Brenner, Glass, & Westen, 2003; Whitbread & Mcgown, 1994; Whittal, Agras, & Gould, 1999). Although medication alone produced an initial positive result, Nakash-Eisikovits, Dierberger, and Westen (2002) concluded that the effects did not last, and better results were obtained when medication was combined with psychotherapy. Counseling/psychotherapy alone, as well as in combination with pharmacotherapy, requires highly trained mental health and/or medical professionals working in outpatient or inpatient facilities, and these treatments can be quite expensive. At the same time, there have been studies on client-directed (pure) self-help and therapist-directed guided self-help approaches, and clinical trials have yielded mixed results. Shapiro et al. (2007) reported that the guided self-help approach yielded smaller effects than psychotherapy, whereas Stefano et al. (2006) recommended the self-help approach as an effective and less expensive alternative to psychotherapy and medication for the treatment of bulimia nervosa. Significant advantages of the guided self-help approach are lower cost, convenience, and accessibility of services in rural locales. Counseling/psychotherapy was the most common treatment approach for clients with eating disorders, and effect sizes of clinical trials were generally positive (i.e., d > 0). Simultaneously, recent research also inconsistently supported the use of guided self-help, although far fewer clinical trials on this approach were reported. …