Behaviour Research and Therapy 39 (2001) 299–308www.elsevier.com/locate/bratShorter CommunicationEvaluation of manual-based cognitive-behavioral therapy forbulimia nervosa in a service settingBrunna Tuschen-Caffiera,*, Martin Pooka, Monika FrankbaDepartment of Psychology, Philipps University, Gutenbergstrasse 18, 35032, Marburg, GermanybChristoph Dornier Foundation for Clinical Psychology, Ernst-Giller-Strasse 20, 35039, Marburg, GermanyReceived 29 September 1999AbstractIn the present study manual-based cognitive-behavioral therapy for bulimia nervosa was evaluated onan unselected sample of an out-patient service facility. A total of 73 female patients who asked for treatmentreceived the primary diagnosis of bulimia nervosa. Of these, 67 took up treatment. Treatment was completedby 66 patients. Outcome variables were the number of binge episodes along with questionnaire scores forrestraint eating, emotional eating, body dissatisfaction and depressiveness. At the end of treatment and 1year after the end of treatment significant improvements were found in all outcome variables. Effect sizesfor outcome variables were within the range of those of controlled research. Therefore, the present studydelivered empirical evidence that manual-based cognitive-behavioral therapy is an effective treatment forbulimia nervosa not only within the restricted area of research. 2001 Elsevier Science Ltd. All rightsreserved.1. IntroductionMany studies employing randomized controlled design have demonstrated that cognitivebehavior therapy is effective in the treatment of bulimia nervosa (cf. Wilson & Fairburn, 1998,for a detailed review). Evaluated treatment components were available for core features of bulimianervosa such as binge eating, negative body attitudes, dietary-restraint and mood-related eatingbehavior as well as for related non-specific features like depressive mood. These componentswere described in several manuals (e.g. Fairburn, Marcus & Wilson, 1993) so that they could beapplied in clinical practice.There is no doubt that controlled randomized studies are needed to deliver evidence for the* Corresponding author. Tel.: +49-6421-2823656; fax: +49-6421-2828904.E-mail address: [email protected] (B. Tuschen-Caffier).0005-7967/01/$ - see front matter 2001 Elsevier Science Ltd. All rights reserved.PII: S0005-7967(00)00004-8300 B. Tuschen-Caffier et al. / Behaviour Research and Therapy 39 (2001) 299–308efficacy of a treatment. On the other hand, it is generally a serious problem of these outcomestudies that they are unrepresentative of clinical practice (cf. Wilson, 1996). In particular, highlyhomogenous samples were studied in most of the studies in which a treatment for bulimia nervosawas evaluated. However, any selection of patients with regard to comorbidity, weight, age, etc.limits the comparability to the general population of bulimic patients. Mitchel, Hoberman, Peter-son, Mussell and Pyle (1996) pointed out further aspects that limit the generalizability of studiesnot carried out in a natural setting. For example, it remains unclear whether the study participantsrepresent treatment-seeking patients when participants are recruited through newspaper advertise-ments or by selected general practitioners. Moreover, little is known about whether patients whoshare at least some financial responsibility for their treatment are more or less motivated thanthose who do not pay any fees because of their participation in a study. In addition, not only thepatients, but also the therapists, participating in clinical studies are assumed to be different fromthose in natural settings (Mitchel et al., 1996). For instance, it might make a difference whethertherapists are especially trained for the treatment program under study or whether bulimia nervosais one among other disorders the therapists treat in their clinical routine.For generalization of the research results it is essential to evaluate evidence-based treatmentsin different settings with heterogeneous patient groups and a variety of therapists. The bench-marking strategy described by Wade, Treat and Stuart (1998) is an excellent approach for examin-ing the generalizability of proven treatment components. Here, a manual-based treatment for panicdisorder which had been evaluated in two controlled studies was applied by several therapists tounselected patients of a community mental health center. Employing the same questionnaires asthose in the controlled research the percentages of patients that score in the normal range werecompared. The benchmarking strategy represents a standard, however, that is hard to achieve forevaluating a cognitive-behavioral therapy as it is routinely employed in a service setting. Thedifficulties become obvious in a study by Wetzel, Bents and Florin (1999). These authors evalu-ated a high-density exposure therapy for patients with obsessive-compulsive disorder that wasprovided by numerous therapists to an unselected sample of an in-patient treatment center. Intheir study, evaluation was not based on exactly the same questionnaires as in a particular studyemploying controlled design, but on questionnaires that were employed as a matter of routine inthe treatment center. As a consequence, in a naturalistic study like the one by Wetzel et al.(1999) the comparisons of effect sizes to those of controlled research are less conclusive than ina benchmarking study. Moreover, the percentage of patients willing to complete questionnairesat follow-up among the unselected patients in the study of Wetzel et al. (1999) was much smallerthan among participants of controlled trials.Despite these difficulties, the study by Wetzel et al. (1999) revealed important informationabout the clinical utility of manual-based treatment for obsessive-compulsive disorder in a servicesetting. To our knowledge, neither a benchmarking study nor even a naturalistic study like theone by Wetzel et al. (1999) has been conducted to evaluate a manual-based treatment for bulimianervosa in an unselected sample. However, as Wilson (1999) pointed out, “manual-based cogni-tive-behavioral therapy for bulimia nervosa is ripe for similar evaluations in service settings”(p. S86).301B. Tuschen-Caffier et al. / Behaviour Research and Therapy 39 (2001) 299–3082. Method2.1. SubjectsA total of 73 women asking for therapy at an out-patient treatment center received the primarydiagnosis of bulimia nervosa. The diagnosis was given on the basis
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