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Journal of Counseling & Development
April 2013
Volume 91152
2013 by the American Counseling Association. All rights reserved.
Received 08/26/11Revised 10/28/11
Accepted 02/10/12DOI: 10.1002/j.1556-6676.2013.00083.x
Bulimia nervosa is an eating disorder associated with a drive
or thinness or requent episodes o binge eating and harm-
ul compensatory behaviors to avoid an increase in weight
(American Psychiatric Association, 2000). A binge eating
episode involves a lack o control over the intake o substantial
amounts o ood. Compensatory behaviors can include vomit-
ing, laxatives, diuretics, asting, and extreme exercise (Keel &
Haedt, 2008; Shapiro et al., 2007). Characteristics o bulimia
nervosa also include a severe concern with ones body shape
and weight (Steano, Bacaltchuk, Blay, & Hay, 2006) and
perceptual distortion and extreme body dissatisaction (Cash
& Deagle, 1997). Cash and Deagle (1997) ound that 73%o patients with bulimia nervosa perceived their body size to
be larger than it actually was, and their body dissatisaction
attitudes exceeded 87% o the control participants.
Hudson, Hiripi, Pope, and Kessler (2007) estimated that
bulimia nervosa aected 0.5% o males and 1.5% o emales
over their lietime, with prevalence rates increasing in recent
generations. The estimated mean age o onset was 19.7 years,
and the average duration o the disorder was 8.3 years (Hudson
et al., 2007). Hudson and colleagues reported that 94.5% o par-
ticipants with bulimia nervosa had at least one other diagnosed
mental disorder, and most participants had received mental health
assistance or other emotional issues. Seventy-eight percent o
participants reported signifcant role impairments in their home,work, personal, or social lie, and 43.9% reported a severe impair-
ment. However, only 48.3% o individuals with bulimia nervosa
sought treatment or their eating disorder.
Although the ull syndromal incidence o bulimia nervosa
has been stable over time, the report o bulimia nervosa is on the
Bradley T. Erford, Taryn Rchards, Elzabeth Peacock, Karen Voth, Heather McGar, and Brooke Mller, Education SpecialtiesDepartment, Loyola University Maryland; Kelly Dncan, Division o Counseling and Psychology in Education, University o SouthDakota; Catherne Y. Chang, Department o Counseling and Psychological Services, Georgia State University. Correspondenceconcerning this article should be addressed to Bradley T. Erord, School Counseling Program, Education Specialties Department,Loyola University Maryland, Timonium Graduate Center, 2034 Greenspring Drive, Timonium, MD 21093 (e-mail: [email protected]).
Counseling and Guided Self-HelpOutcomes for Clients WithBulimia Nervosa: A Meta-Analysis
of Clinical Trials From 1980 to 2010Bradley T. Erord, Taryn Richards, Elizabeth Peacock,
Karen Voith, Heather McGair, Brooke Muller, Kelly Duncan,
and Catherine Y. Chang
This meta-analysis included 111 clinical trials exploring the eectiveness o counseling/psychotherapy and guided
sel-help approaches in the treatment o bulimia nervosa. In general, single-group studies supported higher efcacy
o counseling/psychotherapy, whereas wait-list, treatment-as-usual, and placebo studies indicated both approaches
were equally eective at termination (posttest) and ollow-up in altering binging, purging, laxative use, and sel-reported
bulimia or body dissatisaction perceptions in nearly all comparisons.
Keywords:meta-analysis, bulimia nervosa, guided sel-help, counseling, psychotherapy
rise. With less than hal o those diagnosed seeking treatment,
it is important to determine the most eective and accessible
treatment modalities available to restore individuals to a healthy
level o unctioning. Common treatment approaches or bulimia
nervosa include counseling/psychotherapy, pharmacotherapy,
and guided sel-help. There is debate over which approach is
most eective. For example, many studies have reported the
efcacy o counseling and psychotherapy in the treatment o
bulimia nervosa (Fettes & Peters, 1992; Ghaderi & Anderson,
1999; Lewandowski, Gebing, Anthony, & OBrien, 1997;
Shapiro et al., 2007; Thompson-Brenner, Glass, & Westen,
2003; Whitbread & Mcgown, 1994; Whittal, Agras, & Gould,1999). Although medication alone produced an initial posi-
tive result, Nakash-Eisikovits, Dierberger, and Westen (2002)
concluded that the eects 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 proessionals working in outpatient or inpatient
acilities, and these treatments can be quite expensive.
At the same time, there have been studies on client-directed
(pure) sel-help and therapist-directed guided sel-help ap-
proaches, and clinical trials have yielded mixed results. Sha-
piro et al. (2007) reported that the guided sel-help approach
yielded smaller eects than psychotherapy, whereas Steanoet al. (2006) recommended the sel-help approach as an e-
ective and less expensive alternative to psychotherapy and
medication or the treatment o bulimia nervosa. Signifcant
advantages o the guided sel-help approach are lower cost,
convenience, and accessibility o services in rural locales.
Earn CE credit.Visit http://learning.counseling.orgto purchase and complete the test online.
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Counseling and Guided Sel-Help Outcomes or Clients With Bulimia Nervosa
Counseling/psychotherapy was the most common treat-
ment approach or clients with eating disorders, and eect
sizes o clinical trials were generally positive (i.e., d> 0).
Simultaneously, recent research also inconsistently supported
the use o guided sel-help, although ar ewer clinical trials
on this approach were reported. Proessional counselors who
treat clients with bulimia nervosa should be interested in theefcacy and staying power o these therapeutic approaches.
Our current meta-analytic study was undertaken to answer
three general questions: (a) Is counseling/psychotherapy an
eective treatment or clients with bulimia nervosa, and i
so, do the results last? (b) Is guided sel-help an eective
treatment or clients with bulimia nervosa, and i so, do the
results last? and (c) Is there a dierence between counseling/
psychotherapy and guided sel-help interventions in the treat-
ment o clients with bulimia nervosa?
The Effectiveness of
Counseling/PsychotherapyMany clinical trials support the eectiveness o counseling
and psychotherapy or the treatment o bulimia nervosa,
with a majority o studies using cognitive behavior therapy
(CBT) as a primary treatment. Many researchers stated that
CBT is the treatment o choice or bulimia nervosa (Ghaderi
& Anderson, 1999; Lewandowski et al., 1997; Shapiro et al.,
2007; Whitbread & Mcgown, 2008; Whittal et al., 1999). Le-
wandowski et al. (1997) attributed the popularity o CBT to
the availability o published, standardized treatment manuals
and CBTs ocus on clients cognitive distortions and negative
attitudes, which are common symptoms reported by clients
with bulimia nervosa.Many CBT studies ound moderate to large eect sizes
in the reduction o bulimic symptoms and body dissatisac-
tion attitudes (e.g., Agras et al., 1994; P. J. Cooper & Steere,
1995; Ghaderi, 2006a; Grifths, Hadzi-Pavlovic, & Channon-
Little, 1994; Nevonen & Broberg, 2006; Tasca et al., 2006;
Wiley & Agras, 1993). Several previous attempts have
been made to synthesize these fndings. Lewandowski et al.
(1997) conducted a fxed-eects model meta-analysis o 25
studies using behavioral outcome measures and 17 studies
using cognitive-attitudinal outcome measures. They reported
average correlations o .69 or behavioral outcomes and .67
or attitude-related outcomes. Lewandowski et al. concluded
that CBT eectively reduced behavioral symptoms and cog-nitive distortions, such as concern with body shape/weight
and depressive symptoms. These researchers ound an eect
size od= 0.27 or ollow-up results over a small number o
studies reporting results at varying lengths o time.
Using a ixed-eects model, Ghaderi and Anderson
(1999) perormed a meta-analysis on randomized controlled
trials (RCTs) to assess the eectiveness o CBT. Ghaderi
and Anderson reported large mean gain eect sizes (single-
group studies) or binge eating (d= 1.32) and purging (d
= 1.32) and small to medium mean dierence eect sizes
(comparison-group studies) or binge eating (d= 0.47) and
purging (d= 0.58). In general, CBT was superior to other
psychotherapy treatments and pharmacotherapy. However,
these researchers ound little evidence that these gains were
maintained at ollow-up.
Whittal et al. (1999) compared 39 studies o psychotherapyand pharmacology treatments or bulimia nervosa and con-
cluded that CBT was superior to pharmacotherapy. Average
eect sizes or bulimic behaviors, attitudes, and depression
were reportedly 1.22 to 1.35 or CBT and 0.39 to 0.73 or the
medication trials. The efcacy o the combination o psycho-
therapy and pharmacology was explored; however, the small
number o studies led to inconclusive results.
Whitbread and Mcgown (1994) conducted a fxed-eects
meta-analysis using a mean gain ormula (single group)
because many clinical trials lacked a control group. They
reported an average eect size od= 1.72 or CBT trials and
concluded that CBT was superior to behavior therapy (d=
1.05), short-term psychotherapy (d= 1.01), amily therapy
(d= 1.00), and pharmacotherapy (d= 0.98). Whitbread and
Mcgown attributed the success o CBT to participant train-
ing in assertiveness, communication, problem solving, and
social skills. CBT also addressed the cognitive distortions that
aected the body shape attitudes oten expressed by clients
with bulimia nervosa.
Although the majority o clinical trials supported the su-
periority o CBT over all other approaches to counseling and
psychotherapy, Thompson-Brenner et al. (2003) concluded
that behavior therapy was actually more eective than CBT.
Their meta-analytic results indicated that 44% o patients
receiving behavior therapy were ully recovered at the con-clusion o treatment compared with 39.6% o CBT patients.
Mean dierence eect sizes (comparison group) or binge
eating behaviors across three CBT studies averagedd= 0.52
compared with d= 0.83 across three behavior therapy studies.
Mean dierence eect sizes or purging behaviors were d=
0.79 across fve CBT studies compared with d= 0.90 across
fve behavior therapy treatments. Unortunately, no ollow-up
results were reported.
Another issue embedded in the question o treatment
efcacy was the eectiveness o group versus individual
approaches to counseling and psychotherapy. Fettes and
Peters (1992) concluded that group therapy was moderately
eective and was superior to individual therapy alone.Fettes and Peters reported that 25% o group therapy par-
ticipants were in remission rom symptoms at termination
and maintained abstinence at the 1-year ollow-up. Average
group therapy eect sizes were d= 0.89 or 3 to 6 months
o ollow-up andd= 1.17 or 9 to 12 months o ollow-up.
Conversely, using a random-eects model, Thompson-
Brenner et al. (2003) concluded that individual therapy
was more eective than group therapy because 45.6% o
individual therapy patients stopped displaying binging and
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Erord et al.
purging symptoms at treatment conclusion compared with
only 26.7% o group therapy patients. Shapiro et al. (2007)
also concluded that individual psychotherapy resulted in a
greater percentage o participants without bulimic behav-
iors than was true or group therapy participants.
Support or CBT and behavior therapy and individual and
group approaches in the treatment o bulimia nervosa sug-gested the general efcacy o counseling and psychotherapy.
However, with a lack o inormation on the lasting eects,
it is not clear whether these treatments are eective or the
treatment o bulimia nervosa over the long term (Ghaderi &
Anderson, 1999; Lewandowski et al., 1997; Whitbread &
Mcgown, 1994). Prior to 2003, all meta-analyses o bulimia
treatment used the fxed-eects model. The most recent meta-
analyses on the eectiveness o counseling and psychotherapy
or the treatment o bulimia nervosa were published in 2003
(Thompson et al; diverse clinical trials) and 2007 (Shapiro et
al.; RCTs only), both using a random-eects model. In addi-
tion, numerous additional clinical trials have appeared in the
literature over the past decade, many with better ollow-up
procedures, which could shed light on the question o treat-
ment efcacy at both termination and ollow-up.
The Effectiveness of Guided Self-Help
Far ewer clinical trials have studied the efcacy o the guided
sel-help approach or the treatment o bulimia nervosa, and
those that have been conducted have ound mixed results.
No studies ound to date used standardized meta-analytic
procedures to produce eect sizes or sel-help procedures
on behavioral and attitudinal symptoms. Steano et al. (2006)
conducted a systematic review o sel-help RCTs and oundsignifcant reductions in binge eating requency at termina-
tion compared with the wait-list control. Unortunately, these
researchers could not locate adequate inormation about the
lasting eects o sel-help treatments because o the lack o
ollow-up studies. Steano et al. recommended the use o sel-
help or initial treatment o bulimia nervosa but emphasized
the need or additional RCTs to assess the efcacy o sel-help
and ollow-up eects.
Sysko and Walsh (2008) reviewed client-directed sel-help
trials and revealed generally positive results, with an abstinence
rate o 26.8% to 50% or bulimia symptoms. These researchers
ound that sel-help was superior to the wait-list control condi-
tion, with reduction in symptoms ranging rom 25% to 87% or
the sel-help participants compared with 6% to 19% or those
in the no-treatment condition. Sysko and Walsh concluded
that therapist-guided sel-help reduced binging and purging
requency when compared with pure client-initiated sel-help.
Still, sel-help was somewhat benefcial i no other treatment
option was available. Sysko and Walsh ound that reductions
in symptoms were maintained rom ollow-up until 3 to 18
months. However, the lack o sel-help RCTs limits confdence
in pure client-initiated sel-help efcacy.
The Differences Between Counseling/Psychotherapy and Guided Self-Help
Few studies have directly compared counseling/psycho-
therapy with sel-help trials. Steano et al. (2006) reported
no dierence between the remission rates o sel-help and
individual or group CBT, supporting the use o the sel-helpapproach as a more accessible and cost-eective preliminary
treatment. However, this conclusion should be viewed with
caution because it was based on ew trials; small sample
sizes; and diverse treatment lengths (e.g., several sessions to
multiple months o treatment), therapist qualifcations (e.g.,
proessional counselors, psychologists, graduate research
assistants), and outcome measures.
Similarly, Keel and Haedt (2008) reviewed studies that
compared psychotherapy with a CBT-based guided sel-help
program or adolescent patients with bulimia nervosa and
reported no dierences in bulimic behavior abstinence rates.
However, the guided sel-help condition had more patients
demonstrating no binge eating behaviors at termination.
Several additional guided sel-help trials have also been
published in the extant literature over the past decade, and our
current meta-analysis was aimed at answering the question o
the dierential treatment efcacy o traditional counseling/
psychotherapy and guided sel-help approaches. In the current
meta-analysis, we addressed the three main questions noted
earlier by searching the extant literature or published clini-
cal trials that used quasi-experimental or true experimental
designs o interventionsor bulimia nervosa
Method
For this meta-analysis, counselingorpsychotherapy was de-fned as any intervention or treatment perormed by a mental
health practitioner or practitioner-in-training meant to reduce
the symptomatic display o bulimia nervosa. Self-help or
guided self-help was defned as any intervention primarily
perormed by a client with or without guidance rom a mental
health practitioner or practitioner-in-training meant to reduce
the symptomatic display o bulimia nervosa.
Inclusion and Exclusion Criteria
We used nine criteria to acilitate study selection procedures
to obtain a robust set o moderate to high-quality clinical
trials on the treatment o bulimia nervosa:
1. Studies appeared in print between 1980 and 2010.
2. Studies were published in English with no limitation
on the nation or culture o origin.
3. A treatment or intervention was implemented to di-
rectly reduce the symptoms o participants diagnosed
with bulimia nervosa.
4. Treatment involved individual, group, or amily ap-
proaches to counseling or psychotherapy. Drug trials
were excluded.
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Counseling and Guided Sel-Help Outcomes or Clients With Bulimia Nervosa
5. Symptoms o bulimia nervosa were assessed by at
least one standardized measurement procedure (e.g.,
sel-report rating scale, requency count).
6. Output data (means and standard deviations) were
available or computation o mean gain eect sizes
or mean dierence eect sizes.
7. Participants were adolescents (age 13 years and older)or adults.
8. Studies had a minimum sample size o six participants.
9. Studies included quasi-experimental or true ex-
perimental clinical trial designs using either a single
group or some control or comparison condition (i.e.,
wait-list, placebo, or treatment as usual [TAU]).
Nonexperimental or preexperimental designs were
excluded.
I multiple studies were published using results rom the
same sample, redundant studies were eliminated to preserve
the independence o results.
Search Strategies
Candidate studies were identifed through redundant com-
puterized searches, review o reerence lists rom previous
meta-analyses and clinical trials, and hand searches o the
journals most likely to publish clinical trials on the treat-
ment o bulimia nervosa. We conducted computerized
searches o PsycINFO, Academic Search Premier, and
MEDLINE rom 1980 to 2010 using key words related to
intervention (e.g., counseling, psychotherapy, self-help)
and condition (e.g., bulimia, binging, purging). Search
parameters were limited to English, age (adolescents 13
years and older and adults), peer review, and clinical tri-als.Next,reerence lists o previously published synthesis
articles and clinical trials were searched or additional
candidate art icles. Finally,journals with high requencies
o candidate studies were searched (i.e.,International Jour-
nal of Eating Disorders, Behavior Research and Therapy,
European Eating Disorders Review, Journal of Consulting
and Clinical Psychology, American Journal of Psychiatry,
andArchives of General Psychiatry).Dissertation abstracts
were not searched because we assumed that moderate- to
high-quality dissertation candidates would have been sub-
mitted to a peer-reviewed journal or publication.
The third and ourth authors provided independent
judgments while applying inclusion/exclusion criteria toinormation garnered rom the title, abstract, and ull text
(when available) o each candidate study.Disagreements
were resolved by consensus-building processes, and the frst
author adjudicated fnal selection decisions.
Coding Procedures
Coding o 25 participant (e.g., sample size, age, sex, ethnic-
ity), design (e.g., randomization, recruitment method, setting
o treatment, type o treatment, type o comparison group),
and method (e.g., blind assessment, treatment manual, in-
dividual or group method, number o sessions, duration o
sessions) characteristics was completed to acilitate later
moderator or mediator analysis should sets o eect sizes
lack homogeneity. Each article was independently coded by
two authors (rom among the second to sixth author, with di-
erent authors coding dierent articles), each o whom was agraduate counseling student who excelled in research and as-
sessment course work, completed a training session conducted
by the frst author, and underwent rigorous supervision during
the coding process. Full text versions o each selected article
were obtained, and the frst author reereed any discrepancies
among coder ratings. Peer review o selected clinical trials,
all o which used true or quasi-experimental designs, served
as a proxy or study quality.
Outcome Measures
Outcome measures were required to be direct assessments o
one o the fve dependent variables: binging, purging, laxative
usage, bulimia rating (specifc subscales rom sel-report in-
struments), and body dissatisaction. Within the 111 selected
articles, nearly all outcome measures used were standardized
sel-report measures. The Eating Disorders Inventory (Garner,
Olmstead, & Polivy, 1983) was used in 30% o the trials,
the Eating Attitudes Test (Garner & Garfnkel, 1979) was
used in 8% o the trials, the Body Shape Questionnaire (P. J.
Cooper, Taylor, Cooper, & Fairburn, 1987) was used in 7%
o the trials, and the Bulimic Investigatory Test, Edinburgh
(Henderson & Freeman, 1987) was used in 8% o the trials.
The Eating Disorder Examination (Z. Cooper & Fairburn,
1987) was a clinician-administered interview that was used
in 30% o the trials.
Statistical Methods
As per Erord, Savin-Murphy, and Butler (2010), eect sizes
(i.e., mean dierence or mean gain eect size) rom similar
study designs (i.e., all wait-list, all placebo, all TAU, or all
single-group designs separately) were combined. All eect
sizes were independent.We analyzed posttreatment eects by
combining eect sizes generated immediately ater the buli-
mia treatment. Follow-up eects were analyzed by advancing
the last (i.e., most conservative) ollow-up eect size. Cohens
dwith pooled variance was used to compute standardized
mean dierence eect sizes or comparison-group studies;
positive eect sizes indicated a positive eect o treatment.Computation o standardized mean gain eect sizes or
single-group samples (dsg
) ollowed a ormula suggested
by Lipsey and Wilson (2001) and used a deault reliability
estimate o .80 in cases where sample reliabilities were not
reported. All eect size estimates (d) were then corrected or
sample bias (Erord et al., 2010), and then these unbiased
estimates (d) were again corrected using an inverse weight-
ing procedure (Erord et al., 2010; Lipsey & Wilson, 2001),
producing the corrected eect size (d+). Finally, eect size
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estimates rom similar study designs and dependent variables
were combined and averaged or hypothesis and homogeneity
testing (Cochrans Q andI2; see Erord et al., 2010) using a
random-eects model (Hedges & Olkin, 1985). Within homo-
geneity studies, ip < .05 or the Q statistic, the null hypothesis
o homogeneity could be rejected and potential mediation or
moderation explored.Likewise, Higgins, Thompson, Deeks,and Altman (2003) recommendedI2 interpretations o 0%
indicating total homogeneity, 25% low, 50% moderate, 75%
high, and 100% total heterogeneity. II2 > 50%, exploration
o mediator or moderator variables may be warranted.
Finally, hypothesis testing o d+ > 0 was acilitated by
the computation o 95% confdence intervals (CIs; Erord et
al., 2010; Lipsey & Wilson, 2001). Thus, i the entire 95%
CI range was greater than zero, the null hypothesis could
be rejected. Power is a major consideration in any empirical
study using samples o data. Ordinarily, meta-analytic sum-
mary statistics based on k> 20 studies have sufcient power
(Cornwell, 1993; Cornwell & Ladd, 1993), reducing the
probability o Type II errors. In this meta-analysis o bulimia
treatment outcome research, nearly all comparison-groupd+
analyses were underpowered (k< 20). In contrast, most o
the single-group, posttest, and ollow-up d+ analyses hadk
> 20, thus demonstrating sufcient power.
Publication Bias
Unpublished manuscripts were not included in the current
meta-analysis, which may have resulted in some publication
bias. Funnel plot analysis and Rosenthals (1979) ail-saeN
procedure were conducted on each set o eect sizes to assess
or publication bias. The ail-saeNprocedure provides inor-
mation about the stability o a meta-analysis by calculatingthe number o studies needed to bring a signifcantp level to
a nonsignifcant level o .01. Few outliers were noted, because
the eect sizes basically conormed to expected graphical
confgurations, and these ew outliers tended to reect both
high and low estimates in equal proportion. As a result,
these ew outliers were retained in the analyses rather than
removed or trimmed. Fail-saeNestimates or each analysis
are included in the tables.
Results
The decision-making ow process or article selection is
outlined in Figure 1. Electronic search procedures identifed1,441 candidate articles, whereas hand searching o reer-
ence lists and target journal tables o contents identifed 65
more articles, or a total o 1,506 candidate articles. O these
candidate articles, 1,346 were excluded or violation o at
least one o the inclusion criteria on cursory inspection, and
an additional 49 were excluded ater closer scrutiny through
a ull-text review (e.g., no direct outcome measurement,
no appropriate data to compute d, duplicate study).Judges
agreed on 97.0% (= .93) o independent selection decisions
and reached consensus on the rest. Landis and Koch (1977)
provided the ollowing interpretations or kappas: .41 to .60
were moderate and sufcient or research purposes, .61 to .80were substantial, and .81 to 1.00 were almost perect. In the
reerence list, a single asterisk preceding an article indicates
the article was advanced into the meta-analysis.
Study Characteristics
O the 111 articles advanced to the coding process, 82 were
single-group pretestposttest designs, and 29 used random-
ized samples with a comparison-group design (15 wait-list,
8 placebo, and 6 TAU).The total number o participants was
FiGuRE 1
Flow Chart of inclded Stdes
Note. k= number o studies.
Potentially relevantarticles identifed throughcomputerized search oPsycINFO and MEDLINE19902008 (k= 1,441)
Potentially relevant additionalarticles identifed throughsearch o article reerencelists and hand search oprominent journals (k= 65)
Total number o relevantarticles identifed andscreened or inclusion(k= 1,506)
Articles excluded ater titleand abstract review orailure to meet all inclusioncriteria (k= 1,346)
Articles potentiallyappropriate to be includedin the review and procuredin ull text (k= 160)
Excluded articles (k= 49),
including:
No direct measure ofbulimia outcomes (k= 12)
Treatment not counseling/psychotherapy (k= 3)
Appropriate effect sizedata not available (k= 28)
Duplicate study/sample(k= 6)
Articles fnally included in the meta-analysis with usableinormation (k= 111; n= 4,926; 142 posttest comparisons;75 ollow-up comparisons), including:
Single-study groups (k= 82; n= 3,272; 102 posttest
comparisons; 65 ollow-up comparisons) Wait-list control groups (k= 15; n= 852; 23 posttestcomparisons; 2 ollow-up comparisons)
Placebo study groups (k= 8; n= 394; 11 posttestcomparisons; 7 ollow-up comparisons)
Treatment-as-usual comparison groups (k= 6; n= 408;6 posttest comparisons; 1 ollow-up comparison)
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Counseling and Guided Sel-Help Outcomes or Clients With Bulimia Nervosa
4,926. Across all 25 coded characteristics, intercoder agree-
ment ranged rom 73% to 100%, with a median percentage
agreement o 97%. Related kappas ranged rom .47 to 1.00,
with a median kappa o .93. Erord et al. (2011) pointed out
that eect sizes vary depending on the comparison condi-
tion. For example, single-group mean gain eect sizes are
usually higher, on average, than comparison-group eectsizes. Among comparison-group eect sizes, wait-list results
are usually more positive, on average, than TAU or placebo
comparisons because the latter two control methods provide
an active comparison as opposed to a no-treatment, wait-list
comparison. Thus, dierent study conditions may yield vary-
ing results on the same outcome variable (Thompson, 2002,
2006). Caution is thereore warranted in the interpretation o
eect size magnitudes, because each must be interpreted as
embedded in the appropriate context o condition, outcome
variable, number o studies, and sample sizes. Finally, or
interpretation o eect sizes, Cohen (1988) suggested d=
0.20 (small), d= 0.50 (medium), andd= 0.80 (large). Be-
cause d+ can be converted to a percentile rank using the z
transormation, an eect size o 1.00 means that the average
treatment group participant scored at the 84th percentile o the
comparison-group distribution (or mean dierences), or or
single-group studies (mean gain), the average posttest score
alls at the 84th percentile o the pretest score distribution.
Is Counseling/Psychotherapy Eective or the
Treatment o Clients With Bulimia Nervosa?
And I So, Do the Results Last?
The results o the current meta-analysis o the eectiveness
o counseling/psychotherapy on the treatment o bulimia
nervosa were analyzed by condition (single group, wait-list,placebo, and TAU) across fve relevant bulimia outcome vari-
ables (requency o binging, requency o purging [vomiting],
requency o use o laxatives, sel-reported bulimia charac-
teristics, and sel-reported body dissatisaction). The second
part o the question involves the assessment o lasting eects
o bulimia treatments. Unortunately, only slightly more than
hal o all identifed clinical trials conducted ollow-up stud-
ies to determine the staying power o treatments or bulimia
nervosa ater the conclusion o treatment. Furthermore,
these ollow-up studies varied markedly in the time ater
termination that the ollow-up measurement was assessed.
When ollow-up eect sizes were reported or studies with
multiple ollow-up measurements, the eects were reportedat the point most distant rom termination, thus giving the
most conservative estimate o the lasting eects. We present
the results by outcome variable across comparison conditions,
where kindicates number o studies andi indicates the number
o eect sizes derived.
Frequency of binging for counseling/psychotherapy.Table
1 presents summary results at the end o treatment (posttest)
or binging behaviors across the comparison conditions.
Eect size averages across all conditions were positive,
meaning that the treatments had positive average treatment
results, except in the placebo condition. A portion o the TAU
condition 95% CI range (d+ = 0.28; 95% CI [0.18, 0.74])
was not above zero, thus the null hypothesis o no dierence
could not be rejected. This was probably due to the small
number o studies and sample size in the TAU condition (i =
3, n = 168), because the placebo condition had virtually thesame d+ (0.26), but with i = 8 andn = 282, the 95% CI [0.01,
0.51] had sufcient control o standard error to reject the null.
Still, both o these d+ analyses displayed small magnitudes.
The single-group d+ was 0.71 (medium to large eect size;
i = 70, n = 2,322), and, surprisingly, the wait-list condition
was still larger, at d+ = 0.99 (large eect; i = 14, n = 475),
indicating robust, eective treatment results. All analyses dis-
played homogeneous eect size groupings, so no moderator
or mediator analyses were conducted. Also, the ail-sae Ns
were quite robust. For example, the TAU condition with only
three studies andd+ o 0.28 still would require the location
o an additional 83 unpublished, unlocated TAU studies with
eect sizes o zero to reduce the observed eect size to a
nonsignifcant d+ o 0.01.
Regarding the staying power o the treatment or reduction
o binging behaviors (see Table 1), both single-group (d+ =
0.75; medium to large eect; i = 49, n = 1,193) and placebo
(d+ = 0.77; medium to large eect; i = 6, n = 223) conditions
yielded average eect sizes greater than zero. Wait-list (d+
= 0.56; medium eect; i = 2, n = 117) and TAU (d+ = 0.11;
small eect; i = 1, n = 71) conditions did not, but again, these
analyses involved only two and one located studies, respec-
tively. It is important to note that a ew additional ollow-up
studies with similar results would have provided enough
power or the wait-list condition (d+ = 0.56) to reject the nullhypothesis o no dierence rom zero. All group eect size
estimates were homogeneous.
Frequency of purging for counseling/psychotherapy. Ac-
cording to Table 2, the d+ was 0.63 (medium eect; i = 63, n
= 1,961) or the single-group condition, 0.98 (large eect; i =
16, n = 491) or the wait-list condition, 0.57 (medium eect;
i = 3, n = 168) or TAU, and 0.36 (small to medium eect;
i = 6, n = 235) or placebo studies. All o these conditions
displayed average eect sizes greater than zero, and all eect
size groupings were homogeneous.
Follow-up or single-group studies resulted in a signifcant
positive result (d+ = 0.71; medium to large eect; i = 36, n =
885), but the wait-list (d+ = 0.66; medium eect; i = 2, n =117), TAU (d+ = 0.18; small eect; i = 1, n = 71), and placebo
(d+ = 0.31; small eect; i = 4, n = 135) conditions were not
greater than zero, again probably because o the small number
o studies reporting ollow-up results. All eect size group-
ings were homogeneous.
Frequency of laxative use for counseling/psychotherapy.
Few articles reported on requency o laxative use, but o
those that did, all showed a signifcant eect o treatment (see
Table 3). The d+ was 0.45 (small eect; i = 17, n = 654) or
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158
TABLE1
SmmaryStatstcsfo
rtheFreqencyofBngngOtcomeVarable
ComparsonGrop
Singlegroup
Singlegroup
Wait-list
Wait-list
TAUTAUPlacebo
Placebo
Singlegroup
Singlegroup
Wait-list
Wait-list
TAUTAUPlacebo
Placebo
Posttest
Posttest
Posttest
Posttest
Posttest
Posttest
Posttest
Posttest
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Note.Bingingisthedependent
variable.
k=numberofstudies;i=
num
berofeffectsizesderived;d+=meaneffectsizeestimate;95%
CI=95%
confidenceinterval;>0
=thed+wasgreaterthan0;SigDiff=significantdifferencebetween
thecounseling/psychotherapyandguidedself-helpconditions(Yes=significantdifference;No=no
significantdifferences);Q(df)
=thehomogeneityindexforthegivend
egreesoffreedom;I2=ahomogeneity
indexpresentedasapercentage;YesintheHomogeneous
columnmeansthed+compris
esahomogeneousgroupingofeffectsizes.Posttest=themeasurementwastak
enattheterminationoftreatment;TAU=
treatment-as-usual
condition;Follow-up=themeasurementwastakenatthelongestposttreatmentfollow-upavailable.
Tm
e
Treatment
k
i
n
d+
95%C
i
>0
SgDffFal-SafeN
Q(df)
I2
Homogeneos
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
54
15
9
4
3
0
5
1
34
9
2
0
1
0
3
1
70
17
14
6
3
8
1
49
11
2
1
6
1
2,322
472
475
263
168
282
39
1,193
337
117
71
223
39
0.71
0.62
0.99
0.70
0.28
0.26
0.50
0.75
0.67
0.56
0.11
0.77
0.13
[0.63,0.79]
[0.38,0.85]
[0.76,1.20]
[0.47,0.98]
[0.18,0.74]
[0.01,0.51]
[0.15,1.15]
[0.66,0.85]
[0.34,1.00]
[0.40,1.52]
[0.37,0.59]
[0.03,1.50]
[0.51,0.73]
YesYesYesYesNo
YesNoYesYesNo
No
YesNo
Yes
Yes
No N
oNo
4,956
1,046
1,385
421
83
206
50
3,690
737
111
11
461
13
76.99(69)
23.71(16)
11.73(13)
3.52(5)
2.02(2)
5.96(7)
46.97(48)
15.72(10)
2.35(1)
4.65(5)
10.4
32.5
0.0
0.0
1.0
0.0
0.0
36.4
0.0
0.0
YesYesYesYesYes
Yes
YesYesYes
Yes
-
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159
TABLE2
SmmaryStatstcsforthe
FreqencyofPrgng(Vomtng)OtcomeVarable
ComparsonGrop
Singlegroup
Singlegroup
Wait-list
Wait-list
TAUTAUPlacebo
Placebo
Singlegroup
Singlegroup
Wait-list
Wait-list
TAUTAUPlacebo
Placebo
Posttest
Posttest
Posttest
Posttest
Posttest
Posttest
Posttest
Posttest
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Note.Purgingisthedependentvariable.
k=numberofstudies;i=
num
berofeffectsizesderived;d+=meaneffectsizeestimate;95%
CI=95%
confidenceinterval;>0
=thed+wasgreaterthan0;SigDiff=significantdifferencebetween
thecounseling/psychotherapyandguidedself-helpconditions(Yes=significantdifference;No=no
significantdifferences);Q(df)
=thehomogeneityindexforthegivend
egreesoffreedom;I2=ahomogeneity
indexpresentedasapercentage;YesintheHomogeneous
columnmeansthed+compris
esahomogeneousgroupingofeffectsizes.Posttest=themeasurementwastak
enattheterminationoftreatment;TAU=
treatment-as-usual
condition;Follow-up=themeasurementwastakenatthelongestposttreatmentfollow-upavailable.
Tm
e
Treatment
k
i
n
d+
95%C
i
>0
SgDffFal-SafeN
Q(df)
I2
Homogeneos
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
41
15
9
3
3
0
4
1
24
9
2
0
1
0
2
1
63
17
16
3
3
6
1
36
11
2
1
4
1
1,961
482
491
151
168
235
39
885
337
117
71
135
39
0.63
0.50
0.98
1.37
0.57
0.36
0.48
0.71
0.65
0.66
0.18
0.31
0.17
[0.55,0.71]
[0.28,0.71]
[0.59,1.38]
[0.36,2.37]
[0.26,0.89]
[0.09,0.63]
[0.17,1.13]
[0.61,0.80]
[0.35,0.96]
[0.00,1.31]
[0.30,0.66]
[0.05,0.68]
[0.49,0.83]
YesYesYesYesYes
YesNoYesYesNo
No
NoNo
Yes
No
No N
oNo
3,938
845
1,574
410
172
214
48
2,538
718
131
18
124
17
64.22(62)
19.75(16)
14.37(15)
1.61(2)
0.65(2)
2.72(5)
37.78(35)
13.97(10)
1.00(1)
2.38(3)
3.5
19.0
0.0
0.0
0.0
0.0
7.4
28.4
0.0
0.0
YesYesYesYesYes
Yes
YesYesYes
Yes
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160
TABLE3
SmmaryStatstcsforthe
FreqencyofuseofLaxatves
OtcomeVarable
ComparsonGrop
Singlegroup
Singlegroup
Wait-list
Wait-list
TAUTAUPlacebo
Placebo
Singlegroup
Singlegroup
Wait-list
Wait-list
TAUTAUPlacebo
Placebo
Posttest
Posttest
Posttest
Posttest
Posttest
Posttest
Posttest
Posttest
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Note.Useoflaxativesisthedependentvariable.
k=numberofstudies;i=
numberofeffectsizesderived;d+=meaneffectsizeestimate;95%
CI=95%
confidenceinterval;
>0=thed+wasgreaterthan
0;SigDiff=significantdifferencebetweenthecounseling/psychotherapyandg
uidedself-helpconditions(Yes=significantdifference;No=
nosignificantdifferences);Q(df)=thehomogeneityindexforthegiven
degreesoffreedom;I2=ahomogeneityindexpresentedasapercentage;YesintheHomogeneous
columnmeansthed+compris
esahomogeneousgroupingofeffectsizes.Posttest=themeasurementwastakenattheterminationoftreatment;TAU=treatment-as-usual
condition;Follow-up=themeasurementwastakenatthelongestposttreatmentfollow-upavailable.
Tm
e
Treatment
k
i
n
d+
95%C
i
>0
SgDffFal-SafeN
Q(df)
I2
Homogeneos
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
9
7
1
0
0
0
1
0
4
4
0
0
0
0
0
0
17
9
3
1
5
6
654
217
112
50
154
163
0.45
0.26
0.68
0.58
0.24
0.54
[0.32,0.59]
[0.14,0.37]
[0.18,1.18]
[0.00,1.16]
[0.01,0.49]
[0.08,1.00]
YesYesYes
Yes
NoYes
Yes
Yes
770
230
205
58
121
324
14.43(16)
3.47(8)
0.82(2)
4.12(4)
4.57(5)
0.0
0.0
0.0
2.9
0.0
YesYesYes
YesYes
-
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Journal of Counseling & Development
April 2013
Volume 91 161
Counseling and Guided Sel-Help Outcomes or Clients With Bulimia Nervosa
the single-group condition, 0.68 (medium to large eect; i =
3, n = 112) or the wait-list condition, and 0.58 (medium to
large eect; i = 1, n = 50) or the placebo condition. No TAU
studies assessing or laxative use were identifed. Again, no
heterogeneity was detected.
Follow-up or treatment o bulimia with laxative use as
the outcome measure did not result in a signifcant positiveeect or single-group studies (d+ = 0.24; small eect; i =
5, n = 154). This eect size grouping was homogeneous.
Unortunately, no ollow-up studies were located and selected
on laxative use or the wait-list, TAU, or placebo conditions.
Self-report bulimia ratings for counseling/psychotherapy.
Table 4 provides summary statistics or sel-report bulimia
ratings. Again, all conditions were signifcantly higher than
zero, even though several o the analyses had ew studies and
small sample sizes. The d+ was 0.81 (large eect; i = 44, n =
1,151) or the single-group condition, 0.99 (large eect; i =
5, n = 143) or the wait-list condition, 0.93 (large eect; i =
3, n = 112) or the TAU condition, and 0.62 (medium to large
eect; i = 4, n = 158) or the placebo condition. All conditions
yielded homogeneous eect size estimates.
Follow-up or bulimia sel-ratings on single-group studies
resulted in a signifcant positive result (d+ = 0.88; large e-
ect; i = 29, n = 709), but not or the placebo condition (d+ =
0.38; small eect; i = 4, n = 158). Both eect size groupings
were homogeneous. No TAU or wait-list ollow-up studies
were located.
Self-reported body dissatisfaction for counseling/psychotherapy.
Table 5 provides summary statistics or client sel-report o
body dissatisaction. No placebo studies were located, but
all other conditions resulted in d+ greater than zero, and all
conditions displayed homogeneous eect size groupings.The d+ was 0.50 (medium eect; i = 41, n = 1,424) or the
single-group condition, 0.66 (medium eect; i = 5, n = 143)
or the wait-list condition, and 0.60 (medium eect; i = 4, n
= 218) or the TAU condition.
Follow-up or body dissatisaction sel-ratings was sig-
nifcantly greater than zero or both the single-group (d+ =
0.56; medium eect; i = 24, n = 768) and TAU (d+ = 0.58;
small eect; i = 1, n = 71) conditions, with both eect size
groupings displaying homogeneity. No wait-list or placebo
ollow-up trials were located.
Is Guided Sel-Help Eective or the Treatment
o Clients With Bulimia Nervosa?And I So, Do the Results Last?
Far ewer articles were located evaluating the eectiveness o
sel-help interventions or the treatment o clients with buli-
mia nervosa compared with counseling and psychotherapy,
and some o these trials described guided help procedures that
involved minimal interventions and educational support by
mental health or medical proessionals. These were combined
or convenience in the ollowing analyses and reerred to as
guided sel-help. The same procedures and variables were
examined to determine the eectiveness o guided sel-help
interventions with clients with bulimia nervosa, including
posttreatment and ollow-up assessment at the most distant
ollow-up point.
Frequency of binging for guided self-help. According to
Table 1, the d+ was 0.62 (medium eect; i = 17, n = 472) or
the single-group guided sel-help condition and 0.70 (mediumto large eect; i = 6, n = 263) or the wait-list condition.
Both were signifcantly higher than zero, meaning the null
hypothesis could be rejected and a conclusion made that the
treatment was eective. Homogeneity was displayed within
both eect size groupings. No TAU trials were located, and a
nonsignifcant d+ o 0.50 (medium eect; i = 1, n = 39) was
derived or the single placebo trial.
For the guided sel-help treatment, ollow-up studies us-
ing a single-group analysis resulted in a signifcant positive
result (d+ = 0.67; medium to large eect; i = 11, n = 337),
but the single placebo study (d+ = 0.13; small eect; i = 1, n
= 39) was not dierent rom zero. No TAU or wait-list guided
sel-help ollow-up trials were located. The distribution o
eect sizes or the single-group analysis was homogeneous.
Frequency of purging for guided self-help.Purging behav-
ior results or the guided sel-help condition are presented in
Table 2. The d+ was 0.50 (medium eect; i = 17, n = 482) or
the single-group guided sel-help condition and 1.37 (large
eect; i = 3, n = 151) or the wait-list condition. Both were
signifcantly higher than zero and displayed homogeneity
within both eect size groupings. No TAU trials were located,
and a nonsignifcant d+ o 0.48 (medium eect; i = 1, n = 39)
was derived or the single-placebo trial.
For the guided sel-help treatment, ollow-up studies using
single-group methodology resulted in a signifcant positiveresult (d+ = 0.65; medium to large eect; i = 11, n = 337), but
the single-placebo study (d+ = 0.17; small eect; i = 1, n =
39) was not dierent rom zero. No TAU or wait-list guided
sel-help ollow-up trials were located. The distribution o
eect sizes or the single-group analysis was homogeneous.
Frequency of laxative use for guided self-help.No wait-list,
TAU, or placebo trials were located or the posttreatment or
the ollow-up conditions or laxative use. According to Table
3, the d+ or the single-group guided sel-help condition was
0.26 (small eect; i = 9, n = 217), which was signifcantly
higher than zero and represented a homogeneous grouping o
eect sizes. On ollow-up, the single-group set o studies also
yielded a homogeneous set o eect sizes and a signifcantd+ o 0.54 (medium eect; i = 6, n = 163), indicating that
participants actually used laxatives less on ollow-up than at
the conclusion o treatment.
Bulimia self-ratings for guided self-help.No placebo trials
were located, but Table 4 indicates that the other three conditions
were signifcantly higher than zero or the bulimia sel-rating
outcome variable analysis. The d+ was 0.58 (medium eect; i =
7, n = 220) or the single-group guided sel-helpcondition, 1.25
or the wait-list condition (large eect; i = 3, n = 192), and 0.61
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162
TABLE4
SmmaryStatstcsf
ortheSelf-ReportBlmaOtc
omeVarable
ComparsonGrop
Singlegroup
Singlegroup
Wait-list
Wait-list
TAUTAUPlacebo
Placebo
Singlegroup
Singlegroup
Wait-list
Wait-list
TAUTAUPlacebo
Placebo
Posttest
Posttest
Posttest
Posttest
Posttest
Posttest
Posttest
Posttest
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Note.Self-reportbulimiaisthed
ependentvariable.k=numberofstudies;i=numberofeffectsizesderived;d+=meaneffectsizeestimate;95%CI=95%
confidenceinterval;
>0=thed+wasgreaterthan
0;SigDiff=significantdifferencebetwe
enthecounseling/psychotherapyandg
uidedself-helpconditions(Yes=signific
antdifference;No=
nosignificantdifferences);Q(df)=thehomogeneityindexforthegiven
degreesoffreedom;I2=ahomogeneityindexpresentedasapercentage;YesintheHomogeneous
columnmeansthed+compris
esahomogeneousgroupingofeffectsizes.Posttest=themeasurementwastak
enattheterminationoftreatment;TAU=
treatment-as-usual
condition;Follow-up=themeasurementwastakenatthelongestposttreatmentfollow-upavailable.
Tm
e
Treatment
k
i
n
d+
95%C
i
>0
SgDffFal-SafeN
Q(df)
I2
Homogeneos
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
32
7
3
3
3
2
2
0
20
5
0
0
0
1
2
0
44
7
5
3
3
2
4
29
5
1
4
1,151
220
143
192
112
125
158
709
157
109
158
0.81
0.58
0.99
1.25
0.93
0.61
0.62
0.88
0.69
0.53
0.38
[0.67,0.95]
[0.42,0.75]
[0.34,1.64]
[0.86,1.64]
[0.45,1.40]
[0.23,0.99]
[0.28,0.97]
[0.76,1.01]
[0.45,0.93
[0.14,0.92]
[0.11,0.87]
YesYesYesYesYesYesYes
YesYes
YesNo
Yes
No
No
Yes
3,551
409
496
374
278
122
249
1,764
344
53
153
22.41(43)
6.18(6)
4.01(4)
2.08(2)
1.81(2)
0.04(1)
2.47(3)
27.72(28)
3.82(4)
3.21(3)
0.0
2.9
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
YesYesYesYesYesYesYes
YesYes
Yes
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163
TABLE5
SmmaryStatstcsfo
rtheBodyDssatsfactonOtcomeVarable
ComparsonGrop
Singlegroup
Singlegroup
Wait-list
Wait-list
TAUTAUPlacebo
Placebo
Singlegroup
Singlegroup
Wait-list
Wait-list
TAUTAUPlacebo
Placebo
Posttest
Posttest
Posttest
Posttest
Posttest
Posttest
Posttest
Posttest
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Follow-up
Note.Bodydissatisfactionisthedependentvariable.
k=numberofstudies;i=
numberofeffectsizesderived;d+=meaneffectsizeestimate;95%C
I=95%
confidence
interval;>0=thed+wasgre
aterthan0;SigDiff=significantdiffere
ncebetweenthecounseling/psychotherapyandguidedself-helpconditions(Yes=significantdiffer-
ence;No=nosignificantdiffe
rences);Q(df)=thehomogeneityindex
forthegivendegreesoffreedom;I2=
ahomogeneityindexpresentedasape
rcentage;Yesinthe
Homogeneouscolumnmeans
thed+comprisesahomogeneousgroupingofeffectsizes.Posttest=themea
surementwastakenatthetermination
oftreatment;TAU=
treatment-as-usualcondition;Follow-up=themeasurementwastaken
atthelongestposttreatmentfollow-upavailable.
Tm
e
Treatment
k
i
n
d+
95%C
i
>0
SgDffFal-SafeN
Q(df)
I2
Homogeneos
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
Counseling
Self-help
28
11
3
3
4
1
0
0
17
8
0
0
1
1
0
0
41
11
5
4
4
1
24
8
1
1
1,424
384
143
222
218
112
768
268
71
109
0.50
0.38
0.66
0.71
0.60
0.42
0.56
0.54
0.58
0.51
[0.40,0.59]
[0.23,0.54]
[0.29,1.03]
[0.26,1.15]
[0.33,0.88]
[0.04,0.80]
[0.46,0.66]
[0.34,0.74]
[0.10,1.06]
[0.12,0.90]
YesYesYesYesYesYes
YesYes
YesYes
Yes
No
No N
oNo
2,034
420
143
282
241
42
1,349
429
58
51
35.65(40)
8.47(10)
3.00(4)
2.70(3)
0.52(3)
21.80(23)
8.22(7)
0.0
0.0
0.0
0.0
0.0
0.0
14.8
YesYesYesYesYes
YesYes
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(medium to large eect; i = 2, n = 125) or the TAU condition.
Homogeneity was demonstrated in all conditions.
For the guided sel-help treatment, no placebo or wait-list
ollow-up trials were located. Follow-up studies using a single
group resulted in a signifcant positive result (d+ = 0.69; me-
dium to large eect; i = 5, n = 157), as did the single TAU study
(d+ = 0.53; medium eect; i = 1, n = 109). The distribution oeect sizes or the single-group analysis was homogeneous.
Body dissatisfaction self-ratings for guided self-help. Ac-
cording to Table 5, the d+ was 0.38 (small to medium eect; i
= 11, n = 384) or the single-group guided sel-help condition,
0.71 (medium to large eect; i = 4, n = 222) or the wait-list
condition, and 0.42 (small to medium eect; i = 1, n = 112)
or the TAU condition. All three conditions were signifcantly
higher than zero, and homogeneity was displayed within each
eect size grouping. No placebo trials were located.
For the guided sel-help treatment, ollow-up studies using
a single-group design (d+ = 0.54; medium eect; i = 8, n =
268) and a single TAU study (d+ = 0.51; medium eect; i = 1,
n = 109) resulted in signifcant positive results. No placebo or
wait-list sel-help ollow-up trials were located. The distribution
o eect sizes or the single-group analysis was homogeneous.
Is There a Dierence Between Counseling/
Psychotherapy and Guided Sel-Help Interventionsin the Treatment o Clients With Bulimia Nervosa?
Dierences between combined eect sizes or counseling/
psychotherapy and guided sel-help conditions were deter-
mined by comparing the d+ o the guided sel-help condition
with the 95% CI range associated with the counseling/psycho-
therapy d+. We reasoned that the higher number o studies and
samples sizes accompanying the counseling/psychotherapy d+made that range more stable than the range associated with
the guided sel-help studies. This comparison is similar to the
null testing procedure used earlier; that is, i the d+ or the
guided sel-help condition alls outside o the 95% CI range
or the counseling/psychotherapy d+, the null hypothesis o no
dierence can be rejected and the possibility o a signifcant
dierence between mean eect sizes o the two conditions can
be considered. The summary decision or each comparison is
designated in the Sig Di column o Tables 1 to 5. I the
designation is yes, then a signifcant dierence does exist; i
the designation is no, the null hypothesis was retained.
Binging. According to the results reported in Table 1,
counseling/psychotherapy was signifcantly more eectivethan guided sel-help at treatment termination or both the
single-group (counseling/psychotherapy d+ = 0.71, i = 70;
guided sel-help d+ = 0.62, i = 17) and wait-list (counseling/
psychotherapy d+ = 0.99, i = 14; guided sel-help d+ = 0.70,
i = 6) comparisons. No dierence was noted in the placebo
comparison (counseling/psychotherapy d+ = 0.26, i = 8;
guided sel-help d+ = 0.50, i = 1). At ollow-up, there was no
signifcant dierence or either the single-group (counseling/
psychotherapy d+ = 0.75, i = 49; guided sel-help d+ = 0.67,
i = 11) or the placebo (counseling/psychotherapy d+ = 0.77,
i = 6; guided sel-help d+ = 0.13, i = 1) conditions.
Purging. The results in Table 2 indicate that counseling/
psychotherapy yielded signifcantly better results than guided
sel-help or the single-group condition (counseling/psychotherapy
d+ = 0.63, i = 63; guided sel-help d+ = 0.50, i = 17) but not
or the wait-list (counseling/psychotherapy d+ = 0.98, i = 16;guided sel-help d+ = 1.37, i = 3) or placebo (counseling/
psychotherapy d+ = 0.36, i = 6; guided sel-help d+ = 0.48,
i = 1) conditions. No dierence was noted at ollow-up or
either the single-group (counseling/psychotherapy d+ = 0.71,
i = 36; guided sel-help d+ = 0.65, i = 11) or the placebo
(counseling/psychotherapy d+ = 0.31, i = 4; guided sel-help
d+ = 0.17, i = 1) conditions.
Laxatives.The results in Table 3 indicate that counseling/
psychotherapy was signifcantly better at reducing the use o
laxatives than guided sel-help in single-group trials (counsel-
ing/psychotherapy d+ = 0.45, i = 17; guided sel-help d+ =
0.26, i = 9), but at ollow-up, guided sel-help was superior
to counseling/psychotherapy (counseling/psychotherapy d+
= 0.24, i = 5; guided sel-help d+ = 0.54, i = 6). No wait-list,
placebo, or TAU comparisons were available.
Self-report bulimia scales.As seen in Table 4, counseling/
psychotherapy produced signifcantly better sel-report bulimia
scale outcomes or the single-group comparison (counseling/
psychotherapy d+ = 0.81, i = 44; guided sel-help d+ = 0.58, i
= 7) but no signifcant dierences or the wait-list (counseling/
psychotherapy d+ = 0.99, i = 5; guided sel-help d+ = 1.25, i =
3) or TAU (counseling/psychotherapy d+ = 0.93, i = 3; guided
sel-help d+ = 0.61, i = 2) conditions. On ollow-up, the supe-
riority o counseling/psychotherapy over guided sel-help was
maintained (counseling/psychotherapy d+ = 0.88, i = 29; guidedsel-help d+ = 0.69, i = 5). No wait-list, TAU, or placebo ollow-
up comparisons were available or sel-report bulimia scales.
Body dissatisfaction.Table 5 results indicate that counseling/
psychotherapy was superior to guided sel-help interventions
in single-group studies (counseling/psychotherapy d+ = 0.50,
i = 41; guided sel-help d+ = 0.38, i = 11) but not wait-list
(counseling/psychotherapy d+ = 0.66, i = 5; guided sel-help
d+ = 0.71, i = 4) or TAU (counseling/psychotherapy d+ = 0.60,
i = 4; guided sel-help d+ = 0.42, i = 1) comparison studies.
There were no dierences between counseling/psychotherapy
and guided sel-help on ollow-up or either single-group
(counseling/psychotherapy d+ = 0.56, i = 24; guided sel-
help d+ = 0.54, i = 8) or TAU (counseling/psychotherapy d+= 0.58, i = 1; guided sel-help d+ = 0.51, i = 1) conditions.
Discussion
Is Counseling/Psychotherapy Eective or the
Treatment o Clients With Bulimia Nervosa?
And I So, Do the Results Last?
Counseling/psychotherapy is quite eective in the treatment
o clients with bulimia nervosa. In nearly all the observed
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Counseling and Guided Sel-Help Outcomes or Clients With Bulimia Nervosa
comparisons in our meta-analysis, counseling and psycho-
therapy resulted in positive average weighted eect sizes
(d+) o at least small to medium eects that were signif-
cantly higher than zero at termination o treatment (17 o 18
comparisons; 94%) across all our conditions (single group,
wait-list, TAU, and placebo) and all fve outcome measures
(binging, purging, laxative use, bulimia sel-ratings, andbody dissatisaction sel-ratings). However, only about hal
o all ollow-up study comparisons (six o 13 comparisons;
46%) across all conditions and outcome variables resulted in
eect size averages signifcantly greater than zero, although
these eects were also primarily medium in size. All tests o
homogeneity (Cochrans Q andI2) indicated signifcant homo-
geneity and no eects o moderating or mediating variables.
So counseling/psychotherapy is eective in producing
short-term positive therapeutic changes in clients with symp-
toms o bulimia but is inconsistently long-lasting and resistant
to relapse. The results o the current meta-analysis are similar
to previous meta-analyses o bulimia treatment (Ghaderi &
Anderson, 1999; Lewandoski et al., 1997; Thompson-Brenner
et al., 2003; Whitbread & Mcgown, 1994; Whittal et al.,
1999), but our meta-analysis includes ar more clinical trials
o recent publication, with more diverse study designs, and
with disaggregated outcome variables. It is also the frst to
use a random-eects model on a large sample o theoretically
diverse approaches, which tends to result in more conservative
eect size estimates.
The absence o mediator or moderator variables means
that no dierences were detected among various approaches
to counseling/psychotherapy. This means that no theoretical
approach seemed superior to any other and that individual,
group, and systemic approaches appeared to be equivalent.Both o these fndings may help clariy previous contrary
conclusions. For example, Thompson-Brenner et al. (2003)
concluded in a random-eects meta-analysis that strict behav-
ior therapy (with no cognitive component) was more eective
than CBT in reducing purging behaviors, although these
results were based on a handul o trials in each condition.
Likewise, the study o dierential eectiveness o individual
versus group interventions in bulimia treatment led Fettes and
Peters (1992) to conclude that group therapy was superior,
whereas Thompson-Brenner et al. (2003) and Shapiro et al.
(2007) reached the opposite conclusion. As the number o
clinical trials o treatment o bulimia nervosa continues to
accumulate, the power o such analyses also increases (Corn-well, 1993; Cornwell & Ladd, 1993). Thereore, as evidence
continues to accumulate, these previous conclusions will be
reexamined and refned in the aggregated context provided
by meta-analyses.
A continuing concern is the lack o substantive evidence
o the lasting eects o counseling/psychotherapy in the
treatment o clients with bulimia nervosa. Hal o the com-
parisons in the current meta-analysis indicate lasting eects
at ollow-up, whereas the other hal do not. Perhaps this is
due to the observation that ewer than hal o all clinical tri-
als conducted ollow-up components. Fewer studies reduce
the power o analyses, and some optimism can be gained
by inspecting the ollow-up categories in Tables 1 to 5 and
learning that many o these average eect sizes are medium
in magnitude despite the act that they are composed o ewer
than fve studies.
Is Guided Sel-Help Eective or the Treatmento Clients With Bulimia Nervosa?
And I So, Do the Results Last?
A number o studies have been published recently explor-
ing the efcacy o sel-help and guided-help interventions.
Similar to the results or counseling/psychotherapy, in nearly
all observed instances, sel-help or guided sel-help resulted
in positive average weighted eect sizes (d+) o medium e-
ects that were signifcantly higher than zero at termination o
treatment (11 o 13 comparisons; 85%) across all our condi-
tions (single group, wait-list, TAU, and placebo) and all fve
outcome measures (binging, purging, laxative use, bulimia
sel-ratings, and body dissatisaction sel-ratings). But the
ollow-up study comparisons were a bit more positive than
or counseling/psychotherapy, because seven o nine com-
parisons (78%) resulted in eect size averages signifcantly
greater than zero. These eects were also primarily medium
in size. More important, all tests o homogeneity (Cochrans
Q andI2) indicated signifcant homogeneity and no eects
o moderating or mediating variables.
Thereore, as with counseling/psychotherapy, guided sel-
help is also eective in producing short-term positive changes
in clients with symptoms o bulimia nervosa and appears
to yield more substantial lasting results that display greaterresistance to relapse than does counseling/psychotherapy.
This is not so surprising when one considers that guided
sel-help interventions rely on client motivation or success.
Although this selection actor is potentially problematic in
all experimental research, it may be particularly problematic
when researchers recruit participants specifcally or a sel-
help study; that is, participants who are not sel-motivated
may remove themselves rom the study at higher rates than
highly motivated participants. Also, only 29 guided sel-help
articles were selected into this meta-analysis, ar ewer than
the 82 articles exploring the eectiveness o counseling/
psychotherapy, so the results o the current meta-analysis
must be viewed with caution.
Is There a Dierence Between Counseling/
Psychotherapy and Guided Sel-Help Interventions
in the Treatment o Clients With Bulimia Nervosa?
Few head-to-head studies pitting counseling/psychotherapy
against guided sel-help were available, so the comparisons
between these two broad approaches to the treatment o clients
with bulimia nervosa were based on studies contained in 111
dierent articles conducted by a multitude o researchers
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Erord et al.
around the world and summarized in this meta-analysis. In
single-group study comparisons, which had the largest num-
ber o trials by ar, counseling/psychotherapy was superior
to guided sel-help interventions across all fve outcome
variables o binging, purging, use o laxatives, sel-report
bulimia ratings, and body dissatisaction. However, this
advantage was only maintained at ollow-up on the outcomemeasures o laxative use and sel-report bulimia ratings. In
all other conditions (i.e., wait-list, TAU, and placebo) and or
all other outcome variables (i.e., binging, purging, and body
dissatisaction), guided sel-help interventions were just as
eective as counseling/psychotherapy at both termination and
ollow-up. O course, ar ewer studies using wait-list, TAU,
and placebo comparison conditions are currently available in
the literature than studies using single-group designs.
The results o any meta-analysis must be interpreted with
caution because o methodological limitations. Overall,
however, these results provide positive indications or the
eectiveness o both counseling/psychotherapy and guided
sel-help or the treatment o clients with bulimia nervosa.
The results also suggest the need or head-to-head RCTs o
these two increasingly common approaches.
In addition, although cost analyses were not available, it
stands to reason that the guided sel-help approach may be
available to clients at a lower cost compared with counseling/
psychotherapy. This consideration, coupled with the impor-
tance o sel-motivation in any guided sel-help procedures,
may make sel-help or guided sel-help an efcacious frst
line o deense in helping clients with bulimia nervosa. Fur-
ther research should certainly explore the cost-eectiveness,
time-eectiveness, and overall treatment efcacy o guided
sel-help approaches to helping clients with bulimia.
Limitations of This Meta-Analysis
The current meta-analysis used rigorous methodological
procedures. We conducted exhaustive searches o published
literature and required a nine-level process or inclusion o
relevant studies, including that each use a standardized outcome
measure. When analyzing results, we used a random-eects
model to enhance generalizability and conservative statistical
assumptions, such as weighting eect sizes or inverse variance
and conducting two tests or homogeneity. We also assessed
or publication bias using both unnel plots and computation
o ail-saeNs.As a result, the aorementioned conclusions areprobably generalizable across relevant populations, treatment
variations, outcome variables, and research designs.
Despite, or because o, these selection protocols, some
study limitations may still exist. For example, the rigorous
selection criteria meant to enhance study quality may have
led to the elimination o viable studies, thus resulting in some
publication bias. Although we maintain that study quality
is important, inclusion o lower quality studies sometimes
alters the results o a meta-analysis (Whiston, Rahardja,
Eder, & Tai, 2011). O course, variations in characteristics
o clinical trials did occur; or example, ewer than hal o
all clinical trials used a standardized treatment manual, and
others ailed to provide sufcient inormation related to
some design sample or treatment procedures. Fortunately, all
random-eects analyses indicated signifcant homogeneity o
eect size estimates, so the absence o this inormation didnot aect mediator analyses.
However, perhaps the greatest limitation was the small
number o studies available or some comparisons. As
Cornwell (1993) and Cornwell and Ladd (1993) indicated,
sufcient power is generally gained in a meta-analysis when
the number o studies approaches or exceeds 20 clinical trials.
Although most o the single-group comparisons or counseling/
psychotherapy easily exceeded this criterion, most o the
analyses conducted on comparison conditions or or the
guided sel-help analyses did not. As additional studies o
the treatment o bulimia nervosa accumulate in uture years,
the power o these analyses can be expected to increase, thus
avoiding Type II errors. This was a particularly problematic
issue in analyses o ollow-up results to determine the staying
power o interventions.
Implications for Counseling Practiceand Research
The current meta-analysis represents the most recent and
largest study o treatment efcacy or bulimia nervosa. It
used a random-eects model, which yields a conservative
estimate o outcomes counselors can reasonably expect in
clinical practice. Both counseling/psychotherapy and guided
sel-help approaches appear to lead to clinically signifcant re-ductions in binging, purging, laxative use, sel-report bulimia
ratings, and body dissatisaction ratings. The eect sizes are
generally medium (d+ ~.50) and have been substantiated by
previous meta-analytic studies (Ghaderi & Anderson, 1999;
Lewandoski et al., 1997; Thompson-Brenner et al., 2003;
Whitbread & Mcgown, 1994; Whittal et al., 1999). Evidence
o long-term efcacy o bulimia treatment is inconsistent,
although guided sel-help approaches appear to hold up
better over time than counseling/psychotherapy. The lack o
consistent display o long-term efcacy could be due to the
relatively smaller numbers o ollow-up studies available in
the extant literature, which reduces the power o analyses.
This suspicion is bolstered given that most o the ollow-upcomparisons in this meta-analysis resulted in moderate eect
sizes. Additional clinical trials with ollow-up phases that
use wait-list, TAU, and placebo control designs are needed
to clariy the issue o long-term efcacy.
It is possible that booster or ollow-up sessions could also
enhance the long-term efcacy o counseling/psychotherapy
treatment, as has been suggested or the treatment o depres-
sion (Erord et al., 2011). It is unortunate that time and
resources are expended by clients with bulimia nervosa to
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Counseling and Guided Sel-Help Outcomes or Clients With Bulimia Nervosa
gain improvement over debilitating symptoms, oten resulting
in medium to large eects o treatment, only to have those
gains reduced ater treatment terminates. Critics o mental
health care treatment and a fnancially burdened public are
right to be skeptical o such here today, gone tomorrow
treatment results. So it is incumbent on counselors and
counseling researchers to determine i certain approachesto the treatment o bulimia and implementation o booster
or ollow-up sessions lead to consistently positive outcomes
over the long term.
Cost-eectiveness is an essential consideration in the
context o the current health care debate. It is interesting
that not a single study or meta-analysis on the treatment
o bulimia nervosa measured the cost-eectiveness o the
interventions used, whether or counseling/psychotherapy or
guided sel-help. Counselors and counseling researchers must
explore the costs involved in dierent approaches to treating
bulimia nervosa and other disorders or issues that clients
present to surmise and put into practice the most time- and
cost-eective practices.
An interesting result with implications or clinical
practice was that, with only a ew exceptions, counseling/
psychotherapy and guided sel-help were equally eective,
and perhaps the latter had even better long-term efcacy.
Additional research is needed to confrm and extend these
results and the cost-eectiveness o each approach, but it
is interesting to postulate that sel-help or guided sel-help
approaches may be an eective initial intervention to help
sel-motivated individuals with bulimia nervosa signifcantly
reduce symptoms o binging, purging, and laxative use, as
well as reduce problematic cognitive displays or perceptions
related to bulimia or body dissatisaction. It will be importantthat any protocol or implementing sel-help treatment, either
in written or online ormats, should be standardized and
thoroughly evaluated to enhance eectiveness and minimize
risk to a vulnerable clientele.
At this point in the genesis o treatment or bulimia ner-
vosa, we need more RCTs that measure efcacy at termina-
tion, but especially at short- and long-term ollow-up points.
Even though wait-list and placebo studies are valuable, TAU
studies are needed most. TAU studies have the advantage
o not withholding active treatment rom control group
participants, instead providing participants with a treatment
approach they would normally receive i they presented
or treatment o bulimia at an outpatient acility. Ater all,although it is valuable to know that an intervention is better
than nothing, it is more valuable to know whether the planned
bulimia intervention is better than what the client would
have received under regular circumstances (e.g., supportive
counseling, case management). Use o a TAU comparison
group also minimizes the ethical dilemma o withholding a
viable treatment rom participants in the wait-list or placebo
condition until the completion o the control phase (Erord
et al., 2011; Weisz, McCarthy, & Valeri, 2006).
Finally, even though each study selected into the current
meta-analysis was published in a reereed journal, and even
though the studies were published over a 30-year period, the
adequacy o descriptions o study and sample characteris-
tics was highly variable. Oten, critical inormation needed
to replicate the procedures o the treatment in research or
clinical practice was absent. Such lapses render the studiesunhelpul in moving counseling practice orward. That is, i
a studys results show a particular treatment to be eective in
reducing the requency o binging and purging episodes but
practitioners reading the article cannot replicate the treatment,
what has been gained by publishing the research? Although
much progress has been made over the past several decades,
journal editors and editorial board members must redouble
their insistence that critical study and sample characteristics
be included in published articles. Relatedly, it is incumbent
on researchers to use standardized treatment protocols that
interested readers and publishers can access to better under-
stand and replicate treatment procedures.
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