Why Are Empirically Supported Treatments for BulimiaNervosa Underutilized and What Can We Do About It?

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Bruce A. ArnowDepartment of Psychiatry & Behavioral SciencesStanford University Medical Center

Empirically supported therapies for bulimia nervosa, as well as for otherdisorders, are rarely utilized. Underutilization is frequently attributed todoubts among psychotherapists about the value of randomized controlledtrials and professional resistance to the perceived constraints of manual-ized therapy. However, controversies about the usefulness of empiricallysupported therapies have been shaped by lack of access to adequatetraining and inexperience in delivering these treatments. A proposal forexpanding training opportunities is presented along with discussion abouthow more intensive training for the practicing therapist would affect cur-rent controversies regarding the value and relevance of empirically sup-ported therapies for bulimia nervosa and other disorders. © 1999 JohnWiley & Sons, Inc. J Clin Psychol 55: 769–779, 1999.

As research studies documenting the efficacy of specific treatments for discrete psycho-logical disorders have proliferated, there is growing concern that such therapy is rarelyprovided for clients. The concern clusters around three themes. First, it has been arguedthat psychotherapists have an ethical (Persons in Persons & Silberschatz, 1998) and poten-tially legal (Barlow, 1996) obligation to offer empirically supported therapy for disordersin cases for which such treatments exist, as opposed to psychotherapy without empiri-cally based support. Second, in an era when containing health care costs is a paramountissue among policy makers, third-party payers—whether government or private—aredemanding evidence of treatment efficacy and cost-effectiveness when evaluating claims.And finally, the practice of psychotherapy is in danger of becoming marginalized againstthe weight of numerous well-financed pharmaceutical studies, however short-term, thatdemonstrate the efficacy of medications for psychological disorders (Barlow, 1996). Thus

I am grateful to W.S. Agras, M.D., for his helpful comments on an earlier draft of this manuscript.Correspondence and requests for reprints should be sent to Bruce Arnow, Ph.D., Department of Psychiatry &Behavioral Sciences, Stanford University Medical Center, 401 Quarry Road, Stanford, CA 94305-5722.

JCLP/In Session: Psychotherapy in Practice, Vol. 55(6), 769–779 (1999)© 1999 John Wiley & Sons, Inc. CCC 0021-9762/99/060769-11

psychotherapists’ willingness to embrace empirically supported therapies, and research-ers’ ability to provide training in, or disseminate, them has become a crucial and contro-versial issue.

Bulimia nervosa is among the disorders for which ample research evidence docu-ments the effectiveness of psychological treatment. The most substantial evidence sup-ports the efficacy of cognitive–behavioral therapy (CBT) for bulimia. This treatment isassociated with 70% to 80% reductions in binge eating and purging, abstinence rates ofaround 40%, reductions in comorbid disorders such as depression, and reasonably goodmaintenance of response (Arnow, 1997; Peterson & Mitchell, this issue). In addition,interpersonal therapy (IPT) adapted from the intervention developed by Klerman andcolleagues for depression, was found in one study to be as effective as CBT for bulimianervosa, with both therapies superior to behavioral treatment (Fairburn, Jones, Peveler,Hope, & O’Connor, 1993). Thus bulimia provides an excellent case example for exam-ining issues involved in the relatively low utilization of empirically supported psycho-therapies.

I will first touch on some of the major objections that have been raised regardingempirically supported therapies. Following that, I discuss issues that have been over-looked in explaining their low utilization, with a focus on bulimia nervosa. Finally, I offera proposal for increasing utilization of empirically supported treatment for bulimia aswell as other disorders, and discuss how this might affect the current controversy abouttheir usefulness.

OBJECTIONS TO EMPIRICALLY-SUPPORTED THERAPIES

As Wilson (1998) observed, CBT for bulimia nervosa is “underutilized.” The same is trueof empirically supported therapy for other disorders (Persons, 1997). In a discussion ofthe relevance of manualized treatment of bulimia to clinical practice, Wilson attributedlow utilization to several factors including: (i) practitioner skepticism about the relevanceof outcome data gathered in randomized controlled trials for clients seen in clinical prac-tice; and (ii) the perception that manualized therapies are too constraining. I will discusseach of these.

Objections to Psychotherapy Research Findings

Most psychotherapy research findings derive from randomized controlled trials, or effi-cacy studies, which can be distinguished from effectiveness studies. In an efficacy trial,treatments are compared by randomly assigning participants with a specific disorder todifferent conditions [for instance, a presumably active treatment versus a no-treatment(or wait list) condition, or to one or more comparison treatments]. Psychotherapists whoparticipate in these trials are generally provided manuals that guide therapy. In addition,they often receive intensive supervision, which serves two functions: Providing expertconsultation designed to obtain the best possible outcome and monitoring adherence tothe treatment being evaluated. Like other types of investigations, efficacy studies specifycriteria to identify which clients are, and are not, eligible to participate. It is common toexclude clients with certain coexisting psychological or medical conditions (for example,current substance abuse, psychosis). In general, efficacy trials are most appropriate forevaluating a novel treatment.

Effectiveness studies, on the other hand, are designed to determine whether the ben-efit associated with a treatment under rigorously controlled conditions is generalizable.

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For example, an effectiveness trial investigating CBT for bulimia nervosa might be locatedin a community mental health setting as opposed to an academic medical center. Anyonewith bulimic symptoms might be eligible (for instance, a given study might include thosewho binge and purge less than twice weekly—as DSM-IV specifies for a bulimia diag-nosis), and exclusion due to medical or psychological problems might be minimal (forexample, schizophrenia, conditions requiring hospitalization). Therapists would receivesome training and perhaps consultation, but considerably less than would be character-istic of an efficacy trial.

Questions raised about the value of efficacy studies concern their generalizability toclinical practice. The treatment conditions in efficacy trials are unique. Participatingclinicians have access to expert and frequent supervision. Treatment length is specified inadvance, whereas in clinical practice there is more leeway. Clients have to agree to exten-sive assessment, which may select out those who are less motivated. And, it has beenargued, the practice of excluding clients due to coexisting Axis I or II conditions raisequestions about whether participants in such trials are roughly comparable to clients seenin clinical practice (Goldfried & Wolfe, 1996; Persons, 1991).

However, as Wilson (1998) noted, these objections may be overstated. For instance,clients in randomized controlled trials receive free treatment, whereas those in practicesettings commonly pay for treatment; free treatment may reduce motivation, and payingfor treatment may enhance it. In addition, studies that promise free treatment in exchangefor accepting random assignment might attract clients who have lower incomes and morelife stressors than those able to pay for treatment. And finally, criticism that randomizedcontrolled trials incorporate so many exclusions that clients are less complicated thanthose seen in practice may be less apt when applied to more recent investigations. Exclu-sions in some recent bulimia studies have been quite limited resulting in samples notablefor coexisting depression, other Axis I disorders, and personality disorders. Randomizedcontrolled trials also have rigidinclusioncriteria (Jacobson & Christensen, 1996). Forinstance, a person who binges and purges once weekly as opposed to twice weekly wouldbe screened out of a study requiring that participants meet DSM-IV criteria for bulimia.Thus individuals treated in such studies may be more severely disturbed than the averageclient seen in clinical practice.

Objections to Manualized Therapies

Objections to manualized therapies for bulimia (Wilson, 1998), as well as other disorders(Persons, 1991; Seligman, 1995) include: (i) absence of individual case formulation; (ii)inability to self-correct if treatment isn’t proceeding fruitfully; and (iii) absence of guid-ance in dealing with relationship ruptures.

Manualized therapies are sometimes accompanied by a generic case formulation asopposed to an idiographic one. The formulation underlying CBT for bulimia nervosasuggests that: (i) low self-esteem and other factors render some individuals more vulner-able to pressure to conform to unrealistic societal norms regarding weight and shape; (ii)extreme concerns about weight and shape lead to overly restrained eating; (iii) for mostindividuals, such restraint is unsustainable and leads to binge eating; (iv) efforts to undothe effects of a binge lead to purging behavior such as self-induced vomiting, laxativeabuse, and so forth (Fairburn, Marcus & Wilson, 1993; Spangler, this issue). The inter-ventions carried out in CBT for bulimia derive from this specific formulation.

Those objecting to generic case formulation observe that although a group of indi-viduals may meet criteria for the same diagnosis, the factors maintaining the disorder

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often differ from person to person (Goldfried & Wolfe, 1996; Persons, 1991). For instance,a bulimic may conform to the above CBT formulation where weight and shape concernsand restrained eating predominate, and/or may incorporate binge-purge behavior as away of regulating affect. In the latter case, manualized CBT for bulimia, which empha-sizes normalizing the eating pattern and altering attitudes toward weight and shape, willbe ineffective, or inadequate. Individualized case formulation, according to this view,would bring about better results.

However, the degrees of freedom in tailoring the formulation to the client’s uniquepresentation varies among different manualized approaches. IPT for bulimia devotes fourfull sessions to information gathering aimed at understanding the symptom-maintainingfactors. The process involves joint therapist-client collaboration and agreement. IPT for-mulation locates the individual’s difficulty in one or possibly more of the following fourareas: (i) grief; (ii) role dispute; (iii) role transition; (iv) interpersonal deficits (Apple, thisissue; Fairburn, 1997). Although delimiting the formulation to these areas may appeardistant from an idiographic approach, the domains are broadly defined, thereby allowingconsiderable latitude. Moreover, as therapy progresses, therapist and client may decide toadd to or alter the formulation. For instance, as the client reduces binge eating and purg-ing, she may come to regret the long-standing preoccupation with these behaviors andgrieve for lost time and opportunities. This would bring about a change or addition to theformulation and treatment focus.

An additional objection to manualized therapy is that the interventions are pre-scribed, often in sequence, and do not allow for self-correction if treatment fails to progress.However, framing the choice between strict adherence to a manual versus individualizedtreatment is unnecessarily dichotomous. IPT allows for considerable therapist discretionin treatment intervention. And as Wilson (1996a) noted, even though a CBT manual forbulimia nervosa that he coauthored (Fairburn et al., 1993) suggests a sequence of eightinterventions, the manual explicitly encourages therapists to abandon an intervention thatis not working. It is understood that the client may be receptive to some, but not all,strategies. The therapist’s responsiveness and artistry will determine which strategies areused, when they are used, and how they are presented.

A further objection to manualized therapies is their relative silence regarding waysto resolve impasses in the client–therapist relationship (Goldfried & Wolfe, 1996; Sil-berschatz in Persons & Silberschatz, 1998). For instance, in a section on the importanceof between-session record keeping in CBT for bulimia, Fairburn et al. (1993) note thatwhen a client fails to monitor eating and purging episodes: “The therapist must try tounderstand why this has happened. Often it is appropriate to react with some surprise,since not monitoring will effectively sabotage treatment. Under these circumstances, therationale for monitoring must be restated, and any misunderstandings and difficultiesresolved” (pp. 371–372). Whereas there is acknowledgment that such difficulties ariseand must be addressed, there are neither clinical examples regarding reasons clientsoften present for not keeping records (for example, shame and fear of therapist judg-ment, feelings of being “controlled” by the therapist, and so forth) nor detailed sugges-tions for addressing them.

It is difficult to disagree with the criticism that relationship factors are underempha-sized in many manualized therapies. The traditional CBT view of the client–therapistrelationship emphasizes its role as a vehicle for delivering symptom-reducing interven-tions (Safran & Segal, 1990), and many empirically supported therapies derive from CBTprinciples. But one can acknowledge relative inattention to relationship factors withoutdismissing the value of other information contained in therapy manuals, denoting spe-

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cific effective interventions for defined client populations. Omissions can be addressed infuture iterations.

AN OVERLOOKED FACTOR IN UNDERUTILIZATION:LACK OF TRAINING OPPORTUNITIES

Devaluing randomized controlled trials and resistance to manualized therapies in favor oftreatment without empirical support is sometimes discussed as a problem that rests withthe consumer, namely the therapists in the field. However, others have noted that thosewho have developed such treatments bear some responsibility for their lack of accep-tance. Hayes (1998) observed that empirically supported therapies are presented in abland, unappealing fashion. Goldfried and Wolfe (1996) noted that such treatments aredeveloped by academic researchers who rarely present findings in ways that are useful toclinicians. One can read numerous research papers that testify to the efficacy of CBT forbulimia, but typically such papers provide only the briefest description of treatment. Onthe other hand, considerable space is devoted to methodological issues of greatest interestto other researchers. One could read twenty or more such papers and know little abouthow to conduct the therapy.

No doubt all of the foregoing—belief that randomized controlled trials are irrelevant,resistance to the constraints of manualized therapies, absence of guidance about resolv-ing alliance problems, presenting treatments in ways that are not user friendly—play arole in the underutilization of empirically supported therapy for bulimia and other disor-ders. But reluctance to employ such treatment may also derive from practical, as opposedto intellectual, considerations: The therapist in practice has few opportunities to learnhow to apply such treatment.

Therapists are pressured to provide empirically supported therapies but in most casesthey lack the training to do so. It is not surprising that they fall back on what they knowand do best. This may be a wise decision. Research findings that promote the efficacy ofempirically supported therapies have, for the most part, been gathered in settings whereparticipating therapists are well trained and well supervised. It is unlikely that psycho-therapists who have access only to a manual, without specific training or ongoing super-vision in the model, would obtain results comparable to those reported in randomizedcontrolled trials.

Consider the opportunities and scope of postgraduate training available to practition-ers who want to study psychoanalysis or psychoanalytic psychotherapy. In virtually anylarge city in America, there is at least one, and are often several, postgraduate analyticinstitutes that interested psychotherapists can attend. The typical course of study extendsover several years. Candidates are provided didactic experiences as well as extensivecase supervision. Although video and audio taping are generally frowned upon in theanalytic world, supervision often involves process notes that attempt to capture in detailthe client–therapist interaction. And, typically, candidates are required to conduct anddemonstrate proficiency in at least one psychoanalysis under supervision.

Several points stand out about such training. First, treatment is not assumed to besimple; even an experienced clinician would not be expected simply to read a text anddeliver competent treatment. Second, analytic institutes are generally open only to post-graduates, whether Ph.D., M.D., or social workers. It is not assumed that one could learnenough in a graduate program—with all the other demands one faces as a student—topractice competent psychoanalysis. Finally, the candidate’s years of training often enable

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teaching the model to others. In my suburban community, those who attend a psycho-analytic institute often become leaders among those interested in such treatment, teach-ing and disseminating psychoanalytic therapy themselves. They form consultation groupsfor interested therapists who have not been trained at analytic institutes. Sometimes suchgroups meet for many years. It is not surprising that when I am asked about a referral toan analytically inclined therapist I can provide a long list of names. But when asked toprovide the name of a therapist to provide CBT or IPT for bulimia I have difficultycoming up with any names apart from therapists who work, or have been trained, in myown clinic where a series of clinical trials have been conducted.

Why Are There So Few Opportunities to Learn Empirically Supported Therapies?

There are several reasons why few opportunities exist to learn CBT or IPT for bulimia aswell as other empirically supported therapies. First, I believe we have underestimatedtheir complexity. Although manuals focus on delivering specific interventions, in prac-tice, an endless number of other issues arise that must be negotiated successfully if treat-ment is to succeed. Among bulimics, problems may include failure to keep between-session records, breaking appointments due to low motivation or the client’s fear that sheis disappointing the therapist, “cravings” accompanied by binges even after the client hassucceeded in normalizing her eating pattern, weight gain during treatment—and so on. Iapplaud the manuals that have been written. They are extremely helpful, and the recenttrend incorporating client manuals as Apple and Agras (1997) did for bulimics is animportant advance in delivering such treatment competently. But as helpful as thesemanuals are, without accompanying supervision by someone with considerable experi-ence in CBT or IPT for bulimia, it will be difficult for a therapist to approximate thesuccess achieved in randomized controlled trials. Although outstanding one- or two-daycontinuing education workshops on specific treatments are sometimes available, they fallfar short of the training received by therapists who participate in trials.

Second, empirically supported therapies are typically developed in academic set-tings in which few incentives exist to invest time and energy in more extensive trainingprograms. To return to the example of training in psychoanalysis, such treatment is largelyconducted in the private, as opposed to the academic, sector. For those practicing innonacademic settings, forming a training institute or serving as a supervisor in a post-graduate training program confers prestige, provides refreshing variety in one’s work,and can generate new referrals. But for the academic researcher, career advancementoften depends upon carrying out programmatic research. For many, devoting extensivetime to administer and participate in a postgraduate institute would be considered a dis-traction that fails to further the individual’s career goals.

Third, most empirically supported therapies are developed for a specific diagnosticpopulation. Being an expert in CBT for bulimia doesn’t confer expertise in IPT for bulimia,CBT for panic, depression, or obsessive-compulsive disorder. Unlike psychoanalysis,which is not geared to DSM-defined disorders and is considered by its practitioners to beappropriate for clients with a variety of presenting problems, the sheer number of specificempirically supported therapies poses a significant training challenge.

LEARNING EMPIRICALLY SUPPORTED TREATMENT FOR BULIMIA NERVOSA

A potentially fruitful way to disseminate CBT and IPT for bulimia is to establish post-graduate training programs, as the psychoanalytic community has done for decades. But

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numerous issues require resolution before such an enterprise could be undertaken. Theseinclude where such programs might be located, how to deal with the specificity of empir-ically supported therapies, how such programs might be staffed, and specifying trainingexperiences required of candidates.

Several types of locations might serve as training sites for CBT or IPT for bulimia.Settings in which clinical investigations of these therapies have been carried out arepotentially attractive sites. Even if the developer of the treatment(s) declines to be involvedin the training program, those psychotherapists who have participated in trials at the siteare often uniquely well trained, experienced, and fully capable of providing outstandinginstruction and supervision. There are also sites in the private sector at which therapistshave either participated in trials or have had extensive training and experience with thesetherapies. Some have formed relatively large psychotherapy practices with associateswhom they have trained. Such sites would also be desirable.

The diversity and specificity of empirically supported therapies pose formidabledifficulties. Because the incidence of bulimia nervosa is considerably lower than forother disorders for which empirically supported treatment is available (for example, uni-polar depression), it is unlikely that a postgraduate institute devoted specifically to treat-ment for bulimia or eating disorders in general would attract a sufficient number ofcandidates to be viable. Training would have to be offered in empirically supported ther-apies for several disorders. Although this may seem daunting—some groups may havemany qualified therapists in CBT or IPT for bulimia but no one well trained in otherempirically supported therapies—it might be possible to do what is done in multisiterandomized controlled trials, namely creating networks that are not geographically lim-ited. Multisite studies frequently have a local case supervisor, whereas someone fromanother geographical area serves as the overall study consultant, reviewing audio or vid-eotaped case material and offering detailed feedback. The site supervisor may not havethe same level of expertise as the person reviewing the tapes but by working as a team,training can be successful. The staff of an institute in which the greatest strength is inCBT and IPT for bulimia nervosa may be able to provide didactic training in other empir-ically supported therapies (for instance, IPT for depression, CBT for panic disorder, andso forth) whereas those better trained in these treatments in other parts of the countrycould provide case-oriented supervision via audio or videotapes. Over time, such expe-rience might result in all sites having expert supervisors.

Even though I think postgraduate analytic institutes provide a useful model for con-ceptualizing the dissemination of empirically supported therapy for bulimia and otherdisorders, I do not imply that the training experiences need be as lengthy as for psycho-analysis. For bulimia nervosa, didactic training might focus on issues such as incidenceand prevalence of the disorder, diagnostic criteria, clinical features, and outcomes asso-ciated with different treatments, as well as available information regarding predictors andmediators of outcome, controversies in the field (for example, competing explanationsregarding the equivalence of CBT and IPT), and, finally, the models underlying eachtreatment and their relationship to intervention. A therapist would have to show profi-ciency in a prespecified number of bulimia nervosa cases (for instance, two) according tothe treatment model in a satisfactory manner. Case supervision would include focus ongeneric skills (such as forming a good working alliance, addressing problems such asfailure to complete between-session tasks, and dealing with ruptures in the therapeuticrelationship) as well as training in the specific treatment procedures.

It is speculative to estimate how long such a course of training would be. This woulddepend upon the number of empirically supported therapies for which training isoffered—as well as other unknown factors. But such institutes could also offer ongoing

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supervision to candidates who have successfully completed training, as well as seminarsfocused on new research findings and their implications for clinical practice.

How Training in Empirically Supported Therapies Might Changethe Debate About Their Usefulness

The debate about the utility of empirically supported therapies has been colored by lackof access to training and an absence of experience delivering such treatment. For instance,in my experience, thecharacteristicsof clients (such as comorbidity or motivation) seenin trials versus practice are not noticeably different from one another. What is different isthe nature of the therapeutic contract and the consequent client–therapist relationship.

In efficacy studies focused on bulimia as well as other disorders, participants areassigned randomly to different treatment groups to determine whether one treatment isassociated with better outcomes than another, or sometimes to identify specific interven-tions in a “treatment package” that are most responsible for its benefits. Those of us whobecome involved in such research studies generally communicate hope that each partici-pant will benefit. Nevertheless, at times we must remind participants that the chief goalof our working together is to learn more about a scientific question. We appeal explicitlyto their altruism in the consent form, and sometimes in the course of therapy (particularlywhen they do not respond to treatment), noting that their willingness to partake in thestudy even if they fail to benefit contributes to our knowledge. But our primary commit-ment, apart from their safety, is to answer the questions posed by the study. Thus the quidpro quo is specific to this context. Treatment is free. In exchange, the participant agreesto accept random assignment, fill out numerous questionnaires, submit to various inter-views, and try faithfully to participate in the protocol regardless of the benefit or lackthereof.

The quid pro quo in a practice setting is entirely different. The client pays for treat-ment. In exchange she receives the best treatment that the therapist can deliver for thepresenting problem. If there are multiple problems, they can be addressed within thetherapist’s scope of expertise. Thus, if the client is bulimic, and also has posttraumaticstress disorder, both may be addressed (although the therapist may choose to do so sequen-tially). If the therapist is committed to an evidence-based approach, the bulimic clientwill likely be engaged in CBT. If she fails to benefit, the therapist may switch to IPT,and/or consider adding medication (Wilson, 1996b). But whatever the therapist’s orien-tation, the primary goal is that the client benefit from treatment.

The difference in the treatment contract substantially influences the client–therapistinteraction. Consider a bulimic client assigned to CBT in a randomized controlled trialwho arrives for the fifth session saying that she had a major argument with a friend anddoesn’t want to discuss her problem with bulimia today. Instead, she prefers to focus onthe problem with her friend. The therapist does not believe that this particular relation-ship or the client’s way of dealing with it is significantly related to the bulimic symptoms(for example, the conflict didn’t serve as a trigger for a binge-purge episode, had noimpact on the client’s restrained eating habits, preoccupation with weight and shape, andso forth). And, after some probing, the therapist does not believe that the proposed shiftin focus derives from a hidden motive related to treatment (for instance, the client feelsshe let the therapist down by failing to progress and seeks to avoid disappointing thelatter by bringing up the friend). With a research protocol, the therapist may remind theclient that they have a prescribed and brief period of time to try to resolve the bulimicsymptoms. Although the therapist can sympathize with the client’s strong feelings about

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the matter, in order to carry out the aims of the study the two of them must work togetheron the bulimic symptoms using the methods suggested by the study protocol. In myexperience conducting therapy within the context of a research program, such an expla-nation is often sufficient and serves to maintain the therapeutic focus without compro-mising the alliance. Alternatively, one can try to incorporate the client’s concern into thesession in a way that doesn’t compromise adherence (for instance, considering the argu-ment as a trigger for binge-purge episodes).

But dealing with such an issue in the context of routine clinical practice is considerablydifferent. Despite the therapist’s judgment that the conflict with the friend is not germaneto the bulimic symptoms, the client is preoccupied with the problem and genuinely wantsto discuss it. Moreover, the client is paying for treatment and expects to strongly influencewhat is discussed. Whereas the therapist may be committed to maintaining a focus on thepresenting symptoms, from the client’s perspective, feeling heard and having the therapistrespond to her emergent needs may be equally important. Thus the therapist experiencesthe same interaction differently depending upon the treatment context. In clinical practice,the “pull” to depart from the presenting complaint and the evidence-based proceduresdesigned to address that complaint is considerably more compelling.

At the same time, the decision to depart from the focus on bulimia is not a trivialmatter. By doing so, one imparts a message about how treatment will be conducted. Theclient may feel satisfied with the discussion about the friend, and two weeks later bringup another equally tangential issue. The treatment begins to lose focus, the client growsless committed to the procedures and therapy devolves into dealing with what Barlow(personal communication, May, 1998) called the “issue du jour.” The client may be sat-isfied in the short term, but after devoting several sessions to unrelated issues she beginsto question the therapy’s value. After all, there has been no change in her symptoms.

No manual can address all of the issues that arise in translating therapy developed inthe context of clinical trials to therapy conducted in the world of practice. Similarly, it isimpossible to amass research findings on all the permutations with which therapists con-tend. For the therapist learning to apply empirically supported therapy, issues such as theone raised above are best discussed with an experienced supervisor. One may decide togently bring the client described above back to symptom-focused treatment by sayingsomething like: “I know you have a lot of energy around this issue and that it is really onyour mind today. But my experience is that, while maintaining a focus on the problemyou first presented to me is hard for both of us, we get better results when we do. Will thatbe OK?” On the other hand, one makes judgments based on the nature of the issuepresented and on the client’s response. The therapist may decide that the problem issufficiently important that it merits departure from the symptom-focused treatment.

The notion that manualized therapies are too constraining may have been shaped in partby lack of experience administering them in clinical settings. Once training became avail-able to large number of therapists, it might become clear that manuals are not as confiningas some have characterized them. Differences in the treatment context, therapeutic con-tract, and therapeutic relationship between a trial and clinical practice will likely make clearthat considerable flexibility is needed to successfully practice manualized therapy.

The above assertion is not data based. Certainly I could be proven wrong. As Jacob-son and Christensen (1996) pointed out, randomized controlled trials can be designed tohelp answer such questions as the advantages and disadvantages of flexibility in deliver-ing manualized treatment. But such studies will take considerable time to be completedand published. Funding may be limited. Results may be equivocal or may differ from onetreatment to another, or may differ from one context to another. We do not have the luxury

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of waiting for this question to be thoroughly investigated if we want to provide moretraining opportunities in empirically supported therapies for interested practitioners.

Disseminating CBT and IPT for bulimia as well as other empirically supported ther-apies will inevitably bring about changes and modifications. Each therapist who incor-porates a therapy into his or her repertoire does so in a unique way. Once a therapy iswidely used, modifications are incorporated and passed from therapist to therapist. Sucha process should lead to further productive investigations. Innovation comes from clini-cal experience, not randomized controlled trials. No currently available psychotherapy is100% effective. CBT for bulimia is associated with cessation rates of about 40%. We willnot improve outcomes by having a small group of therapists rigidly adhere to a treatmentwith a 40% remission rate.

CONCLUSIONS

I have argued that the controversy regarding the usefulness of manualized therapies hasbeen shaped by their underutilization in clinical practice. I have also proposed that post-graduate institutes might provide an infrastructure for training interested therapists inempirically supported therapies for bulimia. Furthermore, I believe such opportunitieswould influence the debate regarding the usefulness of such treatment and lead to inno-vations in their delivery.

I do not imply that randomized controlled trials focused on outcomes for discreteDSM disorders provide all the information required to improve practice. Process research,which focuses on specific therapist–client interactions that bring about change, yieldsvaluable information that cannot be provided by outcome research. Process researchershave contended that the overall strategy characterizing outcome studies—which focus ondiscrete DSM disorders and designing different approaches for each—is flawed (Gold-fried & Wolfe, 1996). This is a serious criticism, because outcome research has led to animposing number of specific empirically supported therapies, which will be difficult, ifnot impossible, for any one therapist to master. But there is an urgent need to providemore extensive and adequate training in available empirically supported treatments. Thesetherapies are the only evidence-based vehicles for delivering psychosocial treatment thatare currently available.

Psychotherapy must compete with pharmacologic treatment in demonstrating ben-efit. Clearly, the capacity of pharmaceutical companies to fund studies far outstrips theresources available to NIMH and other agencies to fund psychotherapy research. Fur-thermore, pharmaceutical companies view demonstrating efficacy as only one step inthe process of delivering treatment. They expand enormous resources on dissemination.The full-page newspaper ads addressed to consumers highlighting the effectiveness ofvarious medications are an obvious attempt to disseminate treatment. Less obvious tothe non-physician psychotherapist is the role of drug company representatives in pro-moting medications developed by their respective employers. Drug representatives reg-ularly call on physicians (including psychiatrists), present copies of published papers onthe effectiveness of the medication being promoted, discuss the findings, indicationsand contraindications for use, management of side effects, and appropriate dosages.They also provide free samples. Pharmaceutical companies are extremely sophisticatedin the art of dissemination. Failure to provide training to psychotherapists in empiricallysupported therapies and failure to increase their utilization where appropriate may notresult in the extinction of psychotherapy, but will drastically affect the level of its ac-ceptance in the future.

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SELECT REFERENCES/RECOMMENDED READINGS

Agras, W.S., Rossiter, E.M., Arnow, B., Schneider, J.A., Telch, C.F., Raeburn, S.D., Bruce, B., Perl,M., & Koran, L.M. (1992). Pharmacologic and cognitive–behavioral treatment for bulimianervosa: A controlled comparison. American Journal of Psychiatry, 149, 82–87.

Apple, R.F., & Agras, W.S. (1997). Overcoming eating disorders: Client workbook. San Antonio,Texas: Psychological Corporation.

Arnow, B.A. (1997). Psychotherapy of anorexia and bulimia nervosa. In D. Jimmerson & W. Kaye(Eds.), Bailliere’s clinical psychiatry: Eating disorders (pp. 235–257). London: W.B. Saun-ders.

Barlow, D. (1996). Health care policy, psychotherapy research, and the future of psychotherapy.American Psychologist, 51, 1050–1058.

Fairburn, C.G. (1997). Interpersonal psychotherapy for bulimia nervosa. In D.M. Garner & P.E.Garfinkel (Eds.), Handbook of treatment for eating disorders (2nd ed., pp. 278–294). NewYork: Guilford Press.

Fairburn, C.G., Jones, R., Peveler, R.C., Hope, R.A., & O’Connor, M. (1993). Psychotherapy andbulimia nervosa: The longer-term effects of interpersonal psychotherapy, behaviour therapyand cognitive-behavioural therapy. Archives of General Psychiatry, 50, 419–428.

Fairburn, C.G., Marcus, M.D., & Wilson, G.T. (1993). Cognitive behaviour therapy for bingeeating and bulimia nervosa: A comprehensive treatment manual. In C.G. Fairburn & G.T.Wilson (Eds.), Binge eating: Nature, assessment and treatment (pp. 361–404). New York:Guilford Press.

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