factors influencing the utilization of empirically supported treatments for eating disorders

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Factors Influencing the Utilization ofEmpirically Supported Treatments forEating DisordersAngela M. Simmons a , Suzanne M. Milnes a & Drew A. Anderson aa Department of Psychology , University at Albany, SUNY , Albany,New York, USAPublished online: 19 Jun 2008.

To cite this article: Angela M. Simmons , Suzanne M. Milnes & Drew A. Anderson (2008) FactorsInfluencing the Utilization of Empirically Supported Treatments for Eating Disorders, Eating Disorders:The Journal of Treatment & Prevention, 16:4, 342-354, DOI: 10.1080/10640260802116017

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Eating Disorders, 16:342–354, 2008Copyright © Taylor & Francis Group, LLCISSN: 1064-0266 print/1532-530X onlineDOI: 10.1080/10640260802116017

UEDI1064-02661532-530XEating Disorders, Vol. 16, No. 4, May 2008: pp. 1–25Eating Disorders

Factors Influencing the Utilization of Empirically Supported Treatments

for Eating Disorders

Utilization of ESTs for Eating DisordersA. M. Simmons et al.

ANGELA M. SIMMONS, SUZANNE M. MILNES, and DREW A. ANDERSON

Department of Psychology, University at Albany, SUNY, Albany, New York, USA

This study expands upon previous research investigating the use ofempirically supported treatments (ESTs) for eating disorders bysurveying a large sample of clinicians who specialize in treatingeating disorders. Surveys developed for this study were sent to 698members of a large, professional, eating disorder organizationwho were listed as treatment providers on the organization’s web-site. Despite clinicians reporting frequently using CBT techniques,most identified something other than CBT or IPT as their primaryapproach to treatment. In contrast with previous research, themajority had received prior training in the use of manual-basedtreatments. However, consistent with previous investigations, mostdenied regular use of such treatments. Although manual-basedCBT and IPT are referred to as “treatments of choice,” professionalclinicians in the field are not consistently using them. Responsessuggest several barriers to the utilization of ESTs in practice.

Eating disorders are associated with significant psychological, psychosocial,and physical consequences (Bulik, 2002; Nielson, 2001; Pomeroy & Mitchell,2002; Striegel-Moore, Silberstein, & Rodin, 1993), and are often challengingto treat. Accordingly, it is essential that individuals with these problems

This article is based on the masters thesis of the first author. Portions of this researchwere presented at the annual conference of the Eating Disorder Research Society in Toronto,Ontario, September, 2005.

Address correspondence to Angela M. Simmons, Department of Psychology, Universityat Albany, State University of New York, 1400 Washington Avenue, Albany, NY 12222.E-mail: [email protected]

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Utilization of ESTs for Eating Disorders 343

receive the best available treatment. Research has demonstrated thatcognitive-behavior therapy for BN (CBT-BN; Fairburn, Marcus & Wilson,1993) and interpersonal therapy for BN (IPT-BN; Fairburn, 1997) are effica-cious in the reduction of eating disorder symptomology (Fairburn, Jones,Peveler, Hope & Doll, 1993; Wilson & Fairburn, 2002).

The importance of selecting therapeutic interventions based onempirical support has gained increased attention since the publication ofguidelines recommending the adoption of empirically supported treat-ments by the American Psychological Association’s (APA) Division 12 TaskForce on Promotion and Dissemination of Psychological Procedures(1995; Chambless & Hollon, 1998). Several lines of reasoning, includingethical obligations as well as pressures from an era of managed care, callfor the necessity of widespread implementation of treatments that havedemonstrated efficacy (Hayes, 1998; McFall, 1991).

Yet, despite advances in treatment outcome research, there has been agrowing concern that clinicians infrequently implement empirically supportedtreatments in clinical practice (e.g., Persons, 1995). These concerns do notappear to be unfounded; research suggests that empirically supported treat-ments for a variety of disorders are infrequently utilized in the clinical setting(Barlow, 1994; Goisman, et al., 1993). Unfortunately, clinicians treatingpatients with eating disorders appear to be no exception. For example, Wil-son (1998) observed that while CBT–BN has been demonstrated to be moreefficacious than any other form of treatment, it is “underutilized” in practice.

To date, five studies have investigated the types of treatments used inclinical practice with eating disorder patients (Crow, Mussell, Peterson,Knopke, & Mitchell, 1999; Haas & Clopton, 2003; McAlpine, Schroder,Pankratz, & Maurer, 2004; Mussell et al., 2000; von Ranson & Robinson, 2006).The first of these studies used advertisements to recruit 581 women whoreceived prior treatment for bulimia to determine whether they had receivedeither an adequate pharmacological treatment or CBT (Crow et al., 1999).Of the 61.4% of the sample described as having probable BN, only 4.3%reported receiving CBT although 18.1% reported at least one adequatecourse of pharmacotherapy.

A follow–up study by Mussell and colleagues (2000) assessed clinicianuse of ESTs by mailing questionnaires to 500 psychologists in Minnesota.Responses from the 60 psychologists who reported that at least 5% of theirtypical caseload was comprised of patients with eating disorders indicatedthat while the majority reported frequent use of CBT techniques, theyendorsed something other than CBT or IPT as their primary theoreticalapproach for treatment. When asked about training in manual–based CBTor IPT most respondents (78.3% and 73.3%, respectively) reported that theyhad not received training in these treatments and 83.3% of the respondentsreturned a postcard indicating that they would like to receive training inmanual–based CBT or IPT for BN.

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344 A. M. Simmons et al.

In another study, Haas and Clopton (2003) compared treatments foreating disorders used by practitioners with those used in research. Clinicianslisted as providing psychological treatment in a national database for serviceproviders in psychology responded to a survey inquiring about their mostrecent treatment of a patient with an eating disorder. Responses from 126clinicians were then compared to content analysis of 76 published eatingdisorder treatment outcome studies. Clinicians reporteded longer treatementduration and a relative lack of manual–based treatments as compared totreatmetns described in research studies. Almost half of the cliniciansreported not using empirically validated treatments, primarily due to feelingsthat they are inadequate for the types of comorbidity and complexity seenin individuals with eating disorders. Additionally, participant’s responses indi-cated that the utilization of ESTs was significantly positively related to thefrequency with which clinicians reported reading eating disorder journalarticles.

More recently, von Ranson and Robinson (2006) conducted telephoneinterviews to assess the educational and training backgrounds and treatmentpreferences in a community of clinicians from a large, metropolitan areathat treat eating disorders. Of the 52 respondents, the majority had a gradu-ate degree and had received some form of training in the treatment of eatingdisorders, most commonly a workshop or seminar (71%) or self-education(54%). Similar to previous investigations, eclecticism was the most frequentlyreported primary orientation (50%) followed by CBT (33%). The respon-dents reported using CBT techniques such as relapse prevention, cognitiverestructuring, and self-monitoring most frequently (87%). Surprisingly,addictions based approaches were the third highest reported; however,subsequent analyses revealed that theoretical approach was related to edu-cation level, with more highly educated participants endorsing CBT andthose less-educated endorsing an addictions approach. Additionally, while aminority of respondents reported training in the use of manual based CBTor IPT (38.5% and 17.3%, respectively) over three-fourths indicated that theywould like to receive such training.

In contrast, McAlpine and colleagues (2004) surveyed a variety of healthcare providers (e.g., primary care physicians, advanced practice nurses) in anacademic setting to assess treatment recommendations as well as opinionsabout psychological and pharmacological treatments for BN. Respondentsreported dietary counseling as the most frequently recommended treatment(90.8%) followed by antidepressants and CBT (84.2% and 81.4%, respec-tively). CBT was rated as being almost as available as dietary counseling andpharmacotherapy. Additionally, they rated CBT as more effective than theother psychotherapies listed (e.g., psychodynamic therapy).

These studies have provided insight into the gap between researchand practice in the treatment of eating disorders. However, these studieshave also had methodological limitations, particularly with regard to

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sample size and selection. For example, the majority of these studies werelimited to one geographical region, used relatively small samples (i.e., lessthan 100), and were conducted with clinicians who reported treating aminority of individuals with eating disorders (e.g., 12–15%) in their typicalcaseload. Therefore, these studies do not provide a full understanding ofthe types of treatments individuals presenting with eating disorders aremost likely to receive in a typical clinical practice context. Thus, the pur-pose of the present investigation was to replicate and expand upon previ-ous findings by surveying a large, national sample of members of aprofessional organization for eating disorders who reported providingtreatment for individuals with eating disorders. The study was designed toassess the types and frequency of treatments used as well as specific thera-peutic techniques.

More specifically, based on prior research linking level of educationwith use of ESTs, we expected clinicians who are members of a profes-sional organization devoted to eating disorders and specialize in providingtreatments for these disorders to be more likely to follow the research andunderstand the importance of using ESTs with their clients than clinicianssurveyed in previous studies. Additionally, these individuals should havehigher caseloads of eating disorder clients and thus provide a more accuratereflection of the types of treatments these individuals are likely to encoun-ter. We also anticipated that these individuals would report more training inresearch supported therapeutic techniques.

METHOD

Participants

Potential participants were obtained from the Academy for Eating Disordersonline membership directory (Academy for Eating Disorders, 2005). The Acad-emy for Eating Disorders is a professional organization that aims to promoteresearch, treatment and prevention of eating disorders (www.aedweb.org).Members who reported providing outpatient treatment services for individu-als with eating disorders were recruited for participation. Using these criteria,698 names were obtained.

Measures

A brief questionnaire, similar to that used by Mussell and colleagues (2000),was created to assess the types of treatments and therapeutic techniquesprofessionals use in clinical practice for the treatment of eating disorders.Because it is important to distinguish between theory and technique, thequestionnaire was divided into four parts: demographic information, typesand frequencies of various theoretical approaches to treatment, the use of

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manual-based empirically supported treatments, and information on the useof specific therapeutic techniques.

Procedure

After obtaining names and addresses of potential participants, copies of thesurvey were sent out along with a cover letter explaining the purposes ofthe study. A postage-paid business reply envelope was enclosed for partici-pants to return completed surveys. Approximately two months after the initialmailing, a follow-up letter was sent to those who had not yet responded.Another copy of the survey and postage-paid return envelope was included.They were advised to contact the author if there were any questions oranother replacement was needed.

RESULTS

Demographics

A total of 698 individuals met the criteria listed above and were mailedquestionnaires. Of these 698, five were returned due to an incomplete orincorrect address and 16 respondents reported that they were retired or nolonger treating clients with eating disorders. Thus, 677 surveys were sentout that could be returned as valid. Overall, 19 respondents declined toparticipate, 14 because they did not engage in psychotherapy but workedwith eating disorder participants in some other professional capacity (e.g.,physician, dietician) and 5 returned blank surveys without specifying areason. A total of 268 (40%) completed surveys were returned.

Respondents ranged in age from 24 to 91 years, with a mean age of47 years. The majority (86.2%) were female. Education included Ph.D. levelcounseling psychologists (43.3%), followed by masters’ level practitioners(25%), medical doctors (17.2%), Ph.D. level clinical psychologists (6.7%), andother professionals (7.1%). Most (28.7%) reported they had been practicingmore than 20 years; 19.4% reported practicing between 15 and 20 years andbetween 10 and 15 years, 20.1% between 5 and 10 years, and 10.8% lessthan 5 years. Of those currently practicing, eating disorder patients made upan average of 61.68% of their typical caseload (range of 5 to 100%).

Theoretical Approach to Treating Eating Disorders

Respondents most frequently reported CBT as their primary theoreticalapproach to the treatment of eating disorders (36.6%) followed by eclecti-cism (21.6%), psychodynamic (7.5%), interpersonal (2.2%), family systems(1.5%), and nutritional counseling (1.5%). Additionally, almost 10% listed

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CBT in addition to another form of treatment (e.g., CBT and IPT, 2.6%)making a total of 44.8% endorsing CBT as a primary approach for thetreatment of eating disorders. Respondents reported using their primarytheoretical approach an average of 85% of the time.

Use of Empirically Supported Psychotherapies

Of those who replied, most reported that they had received training in theuse of manual-based CBT or IPT for the treatment of eating disorders (57.1%compared to 34.0% who had not), although roughly half (50.7%) deniedusing manual-based therapies. Of those who had received prior training,66% desired even more training while 34% did not. Similarly, 62% with noprevious training reported wanting training compared to 38% who did not.

The most frequently cited reason for not using manual-based treat-ments was that they are too rigid or constraining and not a good fit for mostclients seen in a clinical setting (54.6%). Other reasons included the feelingthat manuals are not useful (15.7%), a lack of training in manual-basedtreatments (12.0%), and that such treatments are inconsistent with theirtheoretical orientation (10.2%). Additionally, of those who had receivedprior training, 33% reported not using these treatments because they are tooconstraining.

Of those who reported using manual-based treatments (38.1%), theCBT manual by Fairburn (Fairburn, Marcus, et al., 1993) was the mostfrequent response. The Dialetical Behavior Therapy Skills manual forborderline personality disorder (Linehan, 1993) and the client workbookOvercoming Eating Disorders (Apple & Agras, 1997) were listed as well (seeTable 1). Additionally, Fairburn’s CBT manual and the Maudsley model(Lock, Le Grange, Agras, & Dare, 2001) were rated as being highly effective,although few (n = 9) reported using the Maudsley model (see Table 1).

Treatment Techniques

Table 2 presents the eight most frequently used treatment techniques (i.e.,those with a mean rating of a 4 or above on a 5-point Likert scale) from a

TABLE 1 Percentage of Specific Manuals used and Mean Ratings ofEffectiveness by those who Report Using Manual-Based Treatments

Name of manual % use manual (n) Mean effectiveness rating

Fairburn 56.4% (n = 62) 4.0DBT 9.1% (n = 10) 3.8Maudsley 8.2% (n = 9) 4.0Apple & Agras 4.5% (n = 5) 3.8

Note. N = 102

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list of 27. Cognitive restructuring, goal setting, problem solving techniques,relapse prevention, and self-monitoring were the most frequently reportedas “always” or “almost always” used. Other techniques that were frequentlyreported as “always” or “almost always” used included nutritional counsel-ing, stress management, and homework assignments (see Table 2).

Secondary Analyses

While no specific differences with regard to practice or training werepredicted a priori between those who reported using manual-based treat-ments (n = 102) and those who reported not using manuals (n = 135), posthoc analyses between the two groups revealed several statistically signifi-cant differences. Unsurprisingly, those who reported using manual-basedtreatments were more likely to have received prior training in their use;however, they were also more interested in receiving additional training inthese treatments than those who reported not using them. Also, those whoreported using manual-based treatments were less likely than those whodo not use manuals to be clinical psychologists or medical doctors, havespent fewer years in practice, and report treating more eating disorderpatients in their typical caseload (see Table 3). There were no differencesbetween groups in use of manual-based IPT. Regardless of whether aclinician reported regularly using manual-based ESTs or not, theprimary reason for not using these treatments was the belief that they aretoo rigid or constraining for the types of clients seen. However, there weresome differences in use of specific treatment techniques; those who usemanual-based treatments were more likely to report assigning homework,t(232) = −3.42, p < 0.01, and using exposure and response prevention, t(228) =−3.03, p < 0.01, goal setting, t(232) = −2.75, p < 0.01, cognitive restructuring,t(234) = −2.03, p < 0.05, food records, t(230) = −4.91, p < 0.001, operantconditioning techniques, t(220) = −3.33, p < 0.01 and meal planning, t(229) =−3.41, p < 0.01.

TABLE 2 Percentage of Treatment Providers Reporting Frequencies with which they useSpecific Techniques

Therapeutic Techniques Always Almost Always Sometimes Almost Never Never

Cognitive restructuring 37.3 40.7 11.6 1.1 1.5Goal setting 45.1 30.6 13.4 1.5 1.1Problem solving techniques 41.0 32.8 13.1 2.2 1.1Relapse prevention 43.7 30.2 16.0 0.4 1.1Self-monitoring 35.8 36.9 18.3 1.1 0.0Nutritional counseling 40.3 27.2 17.2 4.9 3.0Stress management 29.1 38.1 19.8 2.6 1.1Homework assignments 32.8 29.5 22.4 6.0 1.1

Note. N = 268

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DISCUSSION

This survey found that of the ESTs for eating disorders, CBT is the mostwidely endorsed by practitioners from a variety of training backgrounds. Itis still only reportedely used regularly by about one-third of what may beconsidered the most highly trained group of practitioners in this field, how-ever. This finding is somewhat surprising, as it is similar to previous investi-gations conducted with practitioners who reported seeing eating disorderedpatients only a minority of the time (e.g., Mussell et al., 2000). Also consis-tent with previous research was the finding that while only a minority ofrespondents reported CBT to be their primary theoretical approach, CBTtechniques were frequently used in treatment. This may indicate that certainaspects of empirically supported treatments are being integrated into gen-eral clinical practice (Mussell et al., 2000), and may also indicate a growingdegree of eclecticism in clinical practice (Garfield & Bergin, 1994). Thesedata support the need to distinguish between a given psychological theory(e.g., CBT) and specific treatment techniques (e.g., thought monitoring) instudies of this nature. These data show that treatment techniques can be

TABLE 3 Differences between Those Who Do and Do Not Use Manual-Based ESTs

Use (n = 102) Don’t use (n = 135) Significance test

Level of training N NMasters 19 37 X2 = 2.36a

Ph.D. Counseling 48 60 X2 = 0.22Ph.D. Clinical 3 14 X2 = 4.73*

M.D. 23 16 X2 = 4.99*

Other 9 8

Average years practicing X2 = 11.84*b

Less than 5 14 10Between 5 and 10 27 19Between 10 and 15 21 30Between 15 and 20 13 32More than 20 26 45

Use CBT 83 (81%) 104 (77%) Fishers exact test, nsc

Use IPT 48 (47%) 54 (40%) X2 = 0.03Previous Training 84 (82%) 62 (46%) X2 = 33.44**

Interested in Training 72 (71%) 71 (53%) X2 = 6.07*

Typical caseload eating disorders

70.1 (30.0) 58.4 (29.1) t(235) = −3.00**

Note. * = p < 0.05, ** = p < 0.01. aAll chi-square tests have 1 degree of freedom. bOmnibus chi-square.cFishers exact test was used to examine differences in use of CBT because there were less than 5 casesin those who reported using manual-based treatments but did not report using CBT (ns = non-significant,p = 0.13).

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adopted by individuals who do not align themselves with the theoreticalperspective that developed or popularized those techniques. Additionally,these data lend further support to idea that IPT is implemented in clinicalpractice much less frequently than approaches without empirical support(Mussell et al. 2000).

Despite these similarities, we observed several differences from previ-ous investigations. Of particular concern was that although the majority ofrespondents reported prior training in manual-based IPT or CBT, mostdenied using such treatments. The primary reason for not using these treat-ments was the belief that they are too rigid for the types of clients seen ortoo constraining. And while it may be related to the fact that a majorityrespondents in this study reportied receiving previous training in ESTs forBN, considerably fewer individuals reported being interested in receivingtraining in IPT or CBT manual-based treatments as compared to previousinvestigations (e.g. Haas & Clopton, 2003; Mussell et al., 2000; von Ranson& Robinson, 2006).

Secondary analyses between practitioners who use and do not usemanual-based treatments revealed several differences. Most interestingamong the differences between the two groups were the results indicatingthat those who use manual-based treatments have been practicing a shorterduration and typically treat more eating disordered patients. This suggeststhat the use of manual-based treatments may be receiving more attention ingraduate training programs. Results also found that those who use manual-based ESTs were also more likely to report using several CBT techniquessuch as food records and cognitive restructuring, suggesting that thoseindividuals were implementing the treatment according to the manual.Additionally, those who use manual-based treatments were more interestedin receiving training than those who do not. However, it is important tonote that these differences should be interpreted cautiously due to theirpost hoc nature.

While it was encouraging to find that practitioners with less experienceand higher eating disorder caseloads are more likely to use manual-basedESTs, overall these data suggest that, despite considerable evidence attest-ing to the efficacy of CBT and IPT in the treatment of eating disorders,relatively few patients presenting with eating disorders are receiving thesetreatments. Furthermore, these data lend further support to the position thatwithin the field of eating disorders few clinicians are employing empiricallysupported standardized methods even among those likely to be the mostscientifically minded, who have received prior training, and report treatingindividuals with eating disorders a majority of the time.

In light of previous research, it appears that two factors may accountfor the lack of utilization of empirically supported manual-based treatments.The first is that current training methods are inadequate. The primary reasongiven for not using manual-based ESTs in this investigation, even by those

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who reported using them occasionally, was the belief that they are too rigidfor clients encountered in a clinical setting. It has been suggested that thebelief that manuals are too rigid results from a lack of experience adminis-tering them in clinical settings (Arnow, 1999). Prior research suggests thatclinicians primarily receive training in ESTs through workshops and semi-nars or through self-education (von Ranson & Robinson, 2006). While suchmethods may be adequate for clinicians with prior training in theseapproaches who are interested in continuing education or staying abreast ofthe field, they may not provide enough depth for those without any previ-ous exposure to them.

The second factor appears to be the perceived value or importance ofmanual-based treatments. This investigation found that while the majorityhad received training in these treatments, only a minority reported usingthem. The second most frequent reason for not using manual-based treat-ments was the belief that they are not useful. While it remains unknownwhether this perception reflects current approaches to treatment in trainingprograms or is indicative of wider values endorsed by the field as a whole,the APA has recently been criticized for their less than encouraging stanceon the importance of evidence-based practice (Kot, 2005).

While this investigation expanded upon previous research on the useof ESTs with patients with eating disorders, there were several limitations.For example, we failed to inquire about specific types of training receivedto determine whether it could be perceived as adequate. Future researchseeking to understand factors that contribute to the use of manual-basedtreatments would benefit from a more detailed assessment of the trainingexperiences individuals have had.

Additionally, the generalizability of these results may be limited by themoderate (40%) response rate, although it is comparable to previous inves-tigations (e.g. Mussell et al., 2000). Moreover, the inclusion of individualsfrom various professions (e.g. physicians, dieticians) resulted in some ambi-guity in examining the use of manual-based psychotherapy. However,because individuals with eating disorders may be treated by a variety ofpractitioners, this inclusion provided insight into the actual types of treat-ment, psychotherapy or otherwise, these individuals are receiving. Similarly,the lack of specificity regarding client age and diagnosis presents a degreeof uncertainty. Other limitations include the use of self-report and a briefquestionnaire, which may limit the accuracy and fullness of the data as wellas encourage demand characteristics.

With the advent of managed care, the last few years have witnessedan increased demand for the translation of research findings into effectivetreatments for patients encountered in non-research settings. Yet, theresults of this study provide further support for the concern that evidencefrom psychotherapy research is not being translated into practice, even bythose who are well-informed and have received training in empirically

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supported treatments. While the present study did not investigate specificfactors that would increase the use of manual-based treatments, these datasuggest that issues of training and the belief that manuals are not effectiveor useful for clinical practice are the primary barriers to more widespreadimplementation.

Previous researchers have asserted that current training in such treat-ment methods is less than optimal (Arnow, 1999). Future research is neededto identify how much training is necessary to use manual-based IPT andCBT in addition to the types of training opportunities that are desirable andfeasible for practitioners with varying levels of training and backgrounds. Arecent study reported improved client outcome following a transition to theuse of manualized ESTs in a graduate training program (Cukrowicz et al.,2005); providing evidence that manualized treatments can be effectivelyapplied in a clinical setting even by those with little clinical experiencewhen offered in conjunction with regular supervision. Also, because manypractitioners without a cognitive-behavioral orientation report using CBTtechniques in treatment, research should be conducted to determinewhether utilization of these techniques is effective when clinicians do notsubscribe to the broader theory on which they are based. This investigationchallenges researchers, training programs, and larger organizations to high-light the importance of using treatment modalities with empirical supportwhen such modalities exist.

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factors influencing the utilization of empirically supported treatments for eating disorders

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