Consiliere Bulimia Nervoasa

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Received 08/26/11 Revised 10/28/11 Accepted 02/10/12 DOI: 10.1002/j.1556-6676.2013.00083.x
Counseling and Guided Self-Help Outcomes for Clients With Bulimia Nervosa: A Meta-Analysis of Clinical Trials From 1980 to 2010
Bradley T. Erford, 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 effectiveness of counseling/psychotherapy and guided self-help approaches in the treatment of bulimia nervosa. In general, single-group studies supported higher efficacy of counseling/psychotherapy, whereas wait-list, treatment-as-usual, and placebo studies indicated both approaches were equally effective at termination (posttest) and follow-up in altering binging, purging, laxative use, and self-reported bulimia or body dissatisfaction perceptions in nearly all comparisons. Keywords: meta-analysis, bulimia nervosa, guided self-help, counseling, psychotherapy
Bulimia nervosa is an eating disorder associated with a drive for thinness or frequent episodes of binge eating and harmful compensatory behaviors to avoid an increase in weight (American Psychiatric Association, 2000). A binge eating episode involves a lack of control over the intake of substantial amounts of food. Compensatory behaviors can include vomiting, laxatives, diuretics, fasting, and extreme exercise (Keel & Haedt, 2008; Shapiro et al., 2007). Characteristics of bulimia nervosa also include a severe concern with ones body shape and weight (Stefano, Bacaltchuk, Blay, & Hay, 2006) and perceptual distortion and extreme body dissatisfaction (Cash & Deagle, 1997). Cash and Deagle (1997) found that 73% of patients with bulimia nervosa perceived their body size to be larger than it actually was, and their body dissatisfaction attitudes exceeded 87% of the control participants. Hudson, Hiripi, Pope, and Kessler (2007) estimated that bulimia nervosa affected 0.5% of males and 1.5% of females over their lifetime, with prevalence rates increasing in recent generations. The estimated mean age of onset was 19.7 years, and the average duration of the disorder was 8.3 years (Hudson et al., 2007). Hudson and colleagues reported that 94.5% of participants with bulimia nervosa had at least one other diagnosed mental disorder, and most participants had received mental health assistance for other emotional issues. Seventy-eight percent of participants reported significant role impairments in their home, work, personal, or social life, and 43.9% reported a severe impairment. However, only 48.3% of individuals with bulimia nervosa sought treatment for their eating disorder. Although the full syndromal incidence of bulimia nervosa has been stable over time, the report of bulimia nervosa is on the
rise. With less than half of those diagnosed seeking treatment, it is important to determine the most effective and accessible treatment modalities available to restore individuals to a healthy level of functioning. Common treatment approaches for bulimia nervosa include counseling/psychotherapy, pharmacotherapy, and guided self-help. There is debate over which approach is most effective. For example, many studies have reported the efficacy of counseling and psychotherapy in the treatment of bulimia nervosa (Fettes & Peters, 1992; Ghaderi & Anderson, 1999; Lewandowski, Gebing, Anthony, & OBrien, 1997; Shapiro et al., 2007; Thompson-Brenner, Glass, & Westen, 2003; Whitbread & Mcgown, 1994; Whittal, Agras, & Gould, 1999). Although medication alone produced an initial positive result, Nakash-Eisikovits, Dierberger, and Westen (2002) concluded that the effects did not last, and better results were obtained when medication was combined with psychotherapy. Counseling/psychotherapy alone, as well as in combination with pharmacotherapy, requires highly trained mental health and/or medical professionals working in outpatient or inpatient facilities, and these treatments can be quite expensive. At the same time, there have been studies on client-directed (pure) self-help and therapist-directed guided self-help approaches, and clinical trials have yielded mixed results. Shapiro et al. (2007) reported that the guided self-help approach yielded smaller effects than psychotherapy, whereas Stefano et al. (2006) recommended the self-help approach as an effective and less expensive alternative to psychotherapy and medication for the treatment of bulimia nervosa. Significant advantages of the guided self-help approach are lower cost, convenience, and accessibility of services in rural locales.
Bradley T. Erford, Taryn Richards, Elizabeth Peacock, Karen Voith, Heather McGair, and Brooke Muller, Education Specialties Department, Loyola University Maryland; Kelly Duncan, Division of Counseling and Psychology in Education, University of South Dakota; Catherine Y. Chang, Department of Counseling and Psychological Services, Georgia State University. Correspondence concerning this article should be addressed to Bradley T. Erford, School Counseling Program, Education Specialties Department, Loyola University Maryland, Timonium Graduate Center, 2034 Greenspring Drive, Timonium, MD 21093 (e-mail: berford@loyola.edu). 2013 by the American Counseling Association. All rights reserved.
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Journal of Counseling & Development April 2013 Volume 91
Counseling and Guided Self-Help Outcomes for Clients With Bulimia Nervosa Counseling/psychotherapy was the most common treatment approach for clients with eating disorders, and effect sizes of clinical trials were generally positive (i.e., d > 0). Simultaneously, recent research also inconsistently supported the use of guided self-help, although far fewer clinical trials on this approach were reported. Professional counselors who treat clients with bulimia nervosa should be interested in the efficacy and staying power of these therapeutic approaches. Our current meta-analytic study was undertaken to answer three general questions: (a) Is counseling/psychotherapy an effective treatment for clients with bulimia nervosa, and if so, do the results last? (b) Is guided self-help an effective treatment for clients with bulimia nervosa, and if so, do the results last? and (c) Is there a difference between counseling/ psychotherapy and guided self-help interventions in the treatment of clients with bulimia nervosa? = 1.32) and small to medium mean difference effect sizes (comparison-group studies) for binge eating (d = 0.47) and purging (d = 0.58). In general, CBT was superior to other psychotherapy treatments and pharmacotherapy. However, these researchers found little evidence that these gains were maintained at follow-up. Whittal et al. (1999) compared 39 studies of psychotherapy and pharmacology treatments for bulimia nervosa and concluded that CBT was superior to pharmacotherapy. Average effect sizes for bulimic behaviors, attitudes, and depression were reportedly 1.22 to 1.35 for CBT and 0.39 to 0.73 for the medication trials. The efficacy of the combination of psychotherapy and pharmacology was explored; however, the small number of studies led to inconclusive results. Whitbread and Mcgown (1994) conducted a fixed-effects meta-analysis using a mean gain formula (single group) because many clinical trials lacked a control group. They reported an average effect size of d = 1.72 for CBT trials and concluded that CBT was superior to behavior therapy (d = 1.05), short-term psychotherapy (d = 1.01), family therapy (d = 1.00), and pharmacotherapy (d = 0.98). Whitbread and Mcgown attributed the success of CBT to participant training in assertiveness, communication, problem solving, and social skills. CBT also addressed the cognitive distortions that affected the body shape attitudes often expressed by clients with bulimia nervosa. Although the majority of clinical trials supported the superiority of CBT over all other approaches to counseling and psychotherapy, Thompson-Brenner et al. (2003) concluded that behavior therapy was actually more effective than CBT. Their meta-analytic results indicated that 44% of patients receiving behavior therapy were fully recovered at the conclusion of treatment compared with 39.6% of CBT patients. Mean difference effect sizes (comparison group) for binge eating behaviors across three CBT studies averaged d = 0.52 compared with d = 0.83 across three behavior therapy studies. Mean difference effect sizes for purging behaviors were d = 0.79 across five CBT studies compared with d = 0.90 across five behavior therapy treatments. Unfortunately, no follow-up results were reported. Another issue embedded in the question of treatment efficacy was the effectiveness of group versus individual approaches to counseling and psychotherapy. Fettes and Peters (1992) concluded that group therapy was moderately effective and was superior to individual therapy alone. Fettes and Peters reported that 25% of group therapy participants were in remission from symptoms at termination and maintained abstinence at the 1-year follow-up. Average group therapy effect sizes were d = 0.89 for 3 to 6 months of follow-up and d = 1.17 for 9 to 12 months of follow-up. Conversely, using a random-effects model, ThompsonBrenner et al. (2003) concluded that individual therapy was more effective than group therapy because 45.6% of individual therapy patients stopped displaying binging and 153
The Effectiveness of Counseling/Psychotherapy

Many clinical trials support the effectiveness of counseling and psychotherapy for the treatment of bulimia nervosa, with a majority of studies using cognitive behavior therapy (CBT) as a primary treatment. Many researchers stated that CBT is the treatment of choice for bulimia nervosa (Ghaderi & Anderson, 1999; Lewandowski et al., 1997; Shapiro et al., 2007; Whitbread & Mcgown, 2008; Whittal et al., 1999). Lewandowski et al. (1997) attributed the popularity of CBT to the availability of published, standardized treatment manuals and CBTs focus on clients cognitive distortions and negative attitudes, which are common symptoms reported by clients with bulimia nervosa. Many CBT studies found moderate to large effect sizes in the reduction of bulimic symptoms and body dissatisfaction attitudes (e.g., Agras et al., 1994; P. J. Cooper & Steere, 1995; Ghaderi, 2006a; Griffiths, Hadzi-Pavlovic, & ChannonLittle, 1994; Nevonen & Broberg, 2006; Tasca et al., 2006; Wilfley & Agras, 1993). Several previous attempts have been made to synthesize these findings. Lewandowski et al. (1997) conducted a fixed-effects model meta-analysis of 25 studies using behavioral outcome measures and 17 studies using cognitive-attitudinal outcome measures. They reported average correlations of .69 for behavioral outcomes and .67 for attitude-related outcomes. Lewandowski et al. concluded that CBT effectively reduced behavioral symptoms and cognitive distortions, such as concern with body shape/weight and depressive symptoms. These researchers found an effect size of d = 0.27 for follow-up results over a small number of studies reporting results at varying lengths of time. Using a fixed-effects model, Ghaderi and Anderson (1999) performed a meta-analysis on randomized controlled trials (RCTs) to assess the effectiveness of CBT. Ghaderi and Anderson reported large mean gain effect sizes (singlegroup studies) for binge eating (d = 1.32) and purging (d
Erford et al. purging symptoms at treatment conclusion compared with only 26.7% of group therapy patients. Shapiro et al. (2007) also concluded that individual psychotherapy resulted in a greater percentage of participants without bulimic behaviors than was true for group therapy participants. Support for CBT and behavior therapy and individual and group approaches in the treatment of bulimia nervosa suggested the general efficacy of counseling and psychotherapy. However, with a lack of information on the lasting effects, it is not clear whether these treatments are effective for the treatment of bulimia nervosa over the long term (Ghaderi & Anderson, 1999; Lewandowski et al., 1997; Whitbread & Mcgown, 1994). Prior to 2003, all meta-analyses of bulimia treatment used the fixed-effects model. The most recent metaanalyses on the effectiveness of counseling and psychotherapy for the treatment of bulimia nervosa were published in 2003 (Thompson et al; diverse clinical trials) and 2007 (Shapiro et al.; RCTs only), both using a random-effects model. In addition, numerous additional clinical trials have appeared in the literature over the past decade, many with better follow-up procedures, which could shed light on the question of treatment efficacy at both termination and follow-up.
The Differences Between Counseling/ Psychotherapy and Guided Self-Help

Few studies have directly compared counseling/psychotherapy with self-help trials. Stefano et al. (2006) reported no difference between the remission rates of self-help and individual or group CBT, supporting the use of the self-help approach as a more accessible and cost-effective preliminary treatment. However, this conclusion should be viewed with caution because it was based on few trials; small sample sizes; and diverse treatment lengths (e.g., several sessions to multiple months of treatment), therapist qualifications (e.g., professional counselors, psychologists, graduate research assistants), and outcome measures. Similarly, Keel and Haedt (2008) reviewed studies that compared psychotherapy with a CBT-based guided self-help program for adolescent patients with bulimia nervosa and reported no differences in bulimic behavior abstinence rates. However, the guided self-help condition had more patients demonstrating no binge eating behaviors at termination. Several additional guided self-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 of the differential treatment efficacy of traditional counseling/ psychotherapy and guided self-help approaches. In the current meta-analysis, we addressed the three main questions noted earlier by searching the extant literature for published clinical trials that used quasi-experimental or true experimental designs of interventions for bulimia nervosa
The Effectiveness of Guided Self-Help

Far fewer clinical trials have studied the efficacy of the guided self-help approach for the treatment of bulimia nervosa, and those that have been conducted have found mixed results. No studies found to date used standardized meta-analytic procedures to produce effect sizes for self-help procedures on behavioral and attitudinal symptoms. Stefano et al. (2006) conducted a systematic review of self-help RCTs and found significant reductions in binge eating frequency at termination compared with the wait-list control. Unfortunately, these researchers could not locate adequate information about the lasting effects of self-help treatments because of the lack of follow-up studies. Stefano et al. recommended the use of selfhelp for initial treatment of bulimia nervosa but emphasized the need for additional RCTs to assess the efficacy of self-help and follow-up effects. Sysko and Walsh (2008) reviewed client-directed self-help trials and revealed generally positive results, with an abstinence rate of 26.8% to 50% for bulimia symptoms. These researchers found that self-help was superior to the wait-list control condition, with reduction in symptoms ranging from 25% to 87% for the self-help participants compared with 6% to 19% for those in the no-treatment condition. Sysko and Walsh concluded that therapist-guided self-help reduced binging and purging frequency when compared with pure client-initiated self-help. Still, self-help was somewhat beneficial if no other treatment option was available. Sysko and Walsh found that reductions in symptoms were maintained from follow-up until 3 to 18 months. However, the lack of self-help RCTs limits confidence in pure client-initiated self-help efficacy. 154
Method
For this meta-analysis, counseling or psychotherapy was defined as any intervention or treatment performed by a mental health practitioner or practitioner-in-training meant to reduce the symptomatic display of bulimia nervosa. Self-help or guided self-help was defined as any intervention primarily performed by a client with or without guidance from a mental health practitioner or practitioner-in-training meant to reduce the symptomatic display of bulimia nervosa. Inclusion and Exclusion Criteria We used nine criteria to facilitate study selection procedures to obtain a robust set of moderate to high-quality clinical trials on the treatment of 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 of origin. 3. A treatment or intervention was implemented to directly reduce the symptoms of participants diagnosed with bulimia nervosa. 4. Treatment involved individual, group, or family approaches to counseling or psychotherapy. Drug trials were excluded.
Counseling and Guided Self-Help Outcomes for Clients With Bulimia Nervosa 5. Symptoms of bulimia nervosa were assessed by at least one standardized measurement procedure (e.g., self-report rating scale, frequency count). 6. Output data (means and standard deviations) were available for computation of mean gain effect sizes or mean difference effect sizes. 7. Participants were adolescents (age 13 years and older) or adults. 8. Studies had a minimum sample size of six participants. 9. Studies included quasi-experimental or true experimental 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. If multiple studies were published using results from the same sample, redundant studies were eliminated to preserve the independence of results. Search Strategies Candidate studies were identified through redundant computerized searches, review of reference lists from previous meta-analyses and clinical trials, and hand searches of the journals most likely to publish clinical trials on the treatment of bulimia nervosa. We conducted computerized searches of PsycINFO, Academic Search Premier, and MEDLINE from 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 trials. Next, reference lists of previously published synthesis articles and clinical trials were searched for additional candidate articles. Finally, journals with high frequencies of candidate studies were searched (i.e., International Journal of Eating Disorders, Behavior Research and Therapy, European Eating Disorders Review, Journal of Consulting and Clinical Psychology, American Journal of Psychiatry, and Archives of General Psychiatry). Dissertation abstracts were not searched because we assumed that moderate- to high-quality dissertation candidates would have been submitted to a peer-reviewed journal for publication. The third and fourth authors provided independent judgments while applying inclusion/exclusion criteria to information garnered from the title, abstract, and full text (when available) of each candidate study. Disagreements were resolved by consensus-building processes, and the first author adjudicated final selection decisions. Coding Procedures Coding of 25 participant (e.g., sample size, age, sex, ethnicity), design (e.g., randomization, recruitment method, setting of treatment, type of treatment, type of comparison group), and method (e.g., blind assessment, treatment manual, individual or group method, number of sessions, duration of sessions) characteristics was completed to facilitate later moderator or mediator analysis should sets of effect sizes lack homogeneity. Each article was independently coded by two authors (from among the second to sixth author, with different authors coding different articles), each of whom was a graduate counseling student who excelled in research and assessment course work, completed a training session conducted by the first author, and underwent rigorous supervision during the coding process. Full text versions of each selected article were obtained, and the first author refereed any discrepancies among coder ratings. Peer review of selected clinical trials, all of which used true or quasi-experimental designs, served as a proxy for study quality. Outcome Measures Outcome measures were required to be direct assessments of one of the five dependent variables: binging, purging, laxative usage, bulimia rating (specific subscales from self-report instruments), and body dissatisfaction. Within the 111 selected articles, nearly all outcome measures used were standardized self-report measures. The Eating Disorders Inventory (Garner, Olmstead, & Polivy, 1983) was used in 30% of the trials, the Eating Attitudes Test (Garner & Garfinkel, 1979) was used in 8% of the trials, the Body Shape Questionnaire (P. J. Cooper, Taylor, Cooper, & Fairburn, 1987) was used in 7% of the trials, and the Bulimic Investigatory Test, Edinburgh (Henderson & Freeman, 1987) was used in 8% of the trials. The Eating Disorder Examination (Z. Cooper & Fairburn, 1987) was a clinician-administered interview that was used in 30% of the trials. Statistical Methods As per Erford, Savin-Murphy, and Butler (2010), effect sizes (i.e., mean difference or mean gain effect size) from similar study designs (i.e., all wait-list, all placebo, all TAU, or all single-group designs separately) were combined. All effect sizes were independent. We analyzed posttreatment effects by combining effect sizes generated immediately after the bulimia treatment. Follow-up effects were analyzed by advancing the last (i.e., most conservative) follow-up effect size. Cohens d with pooled variance was used to compute standardized mean difference effect sizes for comparison-group studies; positive effect sizes indicated a positive effect of treatment. Computation of standardized mean gain effect sizes for single-group samples (dsg) followed a formula suggested by Lipsey and Wilson (2001) and used a default reliability estimate of .80 in cases where sample reliabilities were not reported. All effect size estimates (d) were then corrected for sample bias (Erford et al., 2010), and then these unbiased estimates (d) were again corrected using an inverse weighting procedure (Erford et al., 2010; Lipsey & Wilson, 2001), producing the corrected effect size (d+). Finally, effect size 155
Erford et al. estimates from similar study designs and dependent variables were combined and averaged for hypothesis and homogeneity testing (Cochrans Q and I2; see Erford et al., 2010) using a random-effects model (Hedges & Olkin, 1985). Within homogeneity studies, if p < .05 for the Q statistic, the null hypothesis of homogeneity could be rejected and potential mediation or moderation explored. Likewise, Higgins, Thompson, Deeks, and Altman (2003) recommended I2 interpretations of 0% indicating total homogeneity, 25% low, 50% moderate, 75% high, and 100% total heterogeneity. If I2 > 50%, exploration of mediator or moderator variables may be warranted. Finally, hypothesis testing of d+ > 0 was facilitated by the computation of 95% confidence intervals (CIs; Erford et al., 2010; Lipsey & Wilson, 2001). Thus, if 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 of data. Ordinarily, meta-analytic summary statistics based on k > 20 studies have sufficient power (Cornwell, 1993; Cornwell & Ladd, 1993), reducing the probability of Type II errors. In this meta-analysis of bulimia treatment outcome research, nearly all comparison-group d+ analyses were underpowered (k < 20). In contrast, most of the single-group, posttest, and follow-up d+ analyses had k > 20, thus demonstrating sufficient 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) fail-safe N procedure were conducted on each set of effect sizes to assess for publication bias. The fail-safe N procedure provides information about the stability of a meta-analysis by calculating the number of studies needed to bring a significant p level to a nonsignificant level of .01. Few outliers were noted, because the effect sizes basically conformed to expected graphical configurations, and these few outliers tended to reflect both high and low estimates in equal proportion. As a result, these few outliers were retained in the analyses rather than removed or trimmed. Fail-safe N estimates for each analysis are included in the tables.
Potentially relevant articles identified through computerized search of PsycINFO and MEDLINE 19902008 (k = 1,441)
Potentially relevant additional articles identified through search of article reference lists and hand search of prominent journals (k = 65)
Total number of relevant articles identified and screened for inclusion (k = 1,506) Articles excluded after title and abstract review for failure to meet all inclusion criteria (k = 1,346) Articles potentially appropriate to be included in the review and procured in full text (k = 160)
Excluded articles (k = 49), including: No direct measure of bulimia outcomes (k = 12) Treatment not counseling/ psychotherapy (k = 3) Appropriate effect size data not available (k = 28) Duplicate study/sample (k = 6)
Articles finally included in the meta-analysis with usable information (k = 111; n = 4,926; 142 posttest comparisons; 75 follow-up comparisons), including: Single-study groups (k = 82; n = 3,272; 102 posttest comparisons; 65 follow-up comparisons) Wait-list control groups (k = 15; n = 852; 23 posttest comparisons; 2 follow-up comparisons) Placebo study groups (k = 8; n = 394; 11 posttest comparisons; 7 follow-up comparisons) Treatment-as-usual comparison groups (k = 6; n = 408; 6 posttest comparisons; 1 follow-up comparison)
Figure 1 Flow Chart of Included Studies

Note. k = number of studies.
Results
The decision-making flow process for article selection is outlined in Figure 1. Electronic search procedures identified 1,441 candidate articles, whereas hand searching of reference lists and target journal tables of contents identified 65 more articles, for a total of 1,506 candidate articles. Of these candidate articles, 1,346 were excluded for violation of at least one of the inclusion criteria on cursory inspection, and an additional 49 were excluded after closer scrutiny through a full-text review (e.g., no direct outcome measurement, no appropriate data to compute d, duplicate study). Judges agreed on 97.0% ( = .93) of independent selection decisions 156
and reached consensus on the rest. Landis and Koch (1977) provided the following interpretations for kappas: .41 to .60 were moderate and sufficient for research purposes, .61 to .80 were substantial, and .81 to 1.00 were almost perfect. In the reference list, a single asterisk preceding an article indicates the article was advanced into the meta-analysis. Study Characteristics Of the 111 articles advanced to the coding process, 82 were single-group pretestposttest designs, and 29 used randomized samples with a comparison-group design (15 wait-list, 8 placebo, and 6 TAU). The total number of participants was
Counseling and Guided Self-Help Outcomes for Clients With Bulimia Nervosa 4,926. Across all 25 coded characteristics, intercoder agreement ranged from 73% to 100%, with a median percentage agreement of 97%. Related kappas ranged from .47 to 1.00, with a median kappa of .93. Erford et al. (2011) pointed out that effect sizes vary depending on the comparison condition. For example, single-group mean gain effect sizes are usually higher, on average, than comparison-group effect sizes. Among comparison-group effect 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, different study conditions may yield varying results on the same outcome variable (Thompson, 2002, 2006). Caution is therefore warranted in the interpretation of effect size magnitudes, because each must be interpreted as embedded in the appropriate context of condition, outcome variable, number of studies, and sample sizes. Finally, for interpretation of effect sizes, Cohen (1988) suggested d = 0.20 (small), d = 0.50 (medium), and d = 0.80 (large). Because d+ can be converted to a percentile rank using the z transformation, an effect size of 1.00 means that the average treatment group participant scored at the 84th percentile of the comparison-group distribution (for mean differences), or for single-group studies (mean gain), the average posttest score falls at the 84th percentile of the pretest score distribution. Is Counseling/Psychotherapy Effective for the Treatment of Clients With Bulimia Nervosa? And If So, Do the Results Last? The results of the current meta-analysis of the effectiveness of counseling/psychotherapy on the treatment of bulimia nervosa were analyzed by condition (single group, wait-list, placebo, and TAU) across five relevant bulimia outcome variables (frequency of binging, frequency of purging [vomiting], frequency of use of laxatives, self-reported bulimia characteristics, and self-reported body dissatisfaction). The second part of the question involves the assessment of lasting effects of bulimia treatments. Unfortunately, only slightly more than half of all identified clinical trials conducted follow-up studies to determine the staying power of treatments for bulimia nervosa after the conclusion of treatment. Furthermore, these follow-up studies varied markedly in the time after termination that the follow-up measurement was assessed. When follow-up effect sizes were reported for studies with multiple follow-up measurements, the effects were reported at the point most distant from termination, thus giving the most conservative estimate of the lasting effects. We present the results by outcome variable across comparison conditions, where k indicates number of studies and i indicates the number of effect sizes derived. Frequency of binging for counseling/psychotherapy. Table 1 presents summary results at the end of treatment (posttest) for binging behaviors across the comparison conditions. Effect size averages across all conditions were positive, meaning that the treatments had positive average treatment results, except in the placebo condition. A portion of the TAU condition 95% CI range (d+ = 0.28; 95% CI [0.18, 0.74]) was not above zero, thus the null hypothesis of no difference could not be rejected. This was probably due to the small number of studies and sample size in the TAU condition (i = 3, n = 168), because the placebo condition had virtually the same d+ (0.26), but with i = 8 and n = 282, the 95% CI [0.01, 0.51] had sufficient control of standard error to reject the null. Still, both of these d+ analyses displayed small magnitudes. The single-group d+ was 0.71 (medium to large effect size; i = 70, n = 2,322), and, surprisingly, the wait-list condition was still larger, at d+ = 0.99 (large effect; i = 14, n = 475), indicating robust, effective treatment results. All analyses displayed homogeneous effect size groupings, so no moderator or mediator analyses were conducted. Also, the fail-safe Ns were quite robust. For example, the TAU condition with only three studies and d+ of 0.28 still would require the location of an additional 83 unpublished, unlocated TAU studies with effect sizes of zero to reduce the observed effect size to a nonsignificant d+ of 0.01. Regarding the staying power of the treatment for reduction of binging behaviors (see Table 1), both single-group (d+ = 0.75; medium to large effect; i = 49, n = 1,193) and placebo (d+ = 0.77; medium to large effect; i = 6, n = 223) conditions yielded average effect sizes greater than zero. Wait-list (d+ = 0.56; medium effect; i = 2, n = 117) and TAU (d+ = 0.11; small effect; i = 1, n = 71) conditions did not, but again, these analyses involved only two and one located studies, respectively. It is important to note that a few additional follow-up studies with similar results would have provided enough power for the wait-list condition (d+ = 0.56) to reject the null hypothesis of no difference from zero. All group effect size estimates were homogeneous. Frequency of purging for counseling/psychotherapy. According to Table 2, the d+ was 0.63 (medium effect; i = 63, n = 1,961) for the single-group condition, 0.98 (large effect; i = 16, n = 491) for the wait-list condition, 0.57 (medium effect; i = 3, n = 168) for TAU, and 0.36 (small to medium effect; i = 6, n = 235) for placebo studies. All of these conditions displayed average effect sizes greater than zero, and all effect size groupings were homogeneous. Follow-up for single-group studies resulted in a significant positive result (d+ = 0.71; medium to large effect; i = 36, n = 885), but the wait-list (d+ = 0.66; medium effect; i = 2, n = 117), TAU (d+ = 0.18; small effect; i = 1, n = 71), and placebo (d+ = 0.31; small effect; i = 4, n = 135) conditions were not greater than zero, again probably because of the small number of studies reporting follow-up results. All effect size groupings were homogeneous. Frequency of laxative use for counseling/psychotherapy. Few articles reported on frequency of laxative use, but of those that did, all showed a significant effect of treatment (see Table 3). The d+ was 0.45 (small effect; i = 17, n = 654) for 157
158 Table 1 Summary Statistics for the Frequency of Binging Outcome Variable
Treatment i Yes Yes [0.63, 0.79] [0.38, 0.85] [0.76, 1.20] [0.47, 0.98] [0.18, 0.74] No No [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] No Yes No No Yes No Yes Yes No Yes Yes Yes Yes No n d+ >0 Sig Diff Fail-Safe N k 95% CI Q(df) 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) I2 Homogeneous Yes Yes Yes Yes Yes Yes Yes Yes Yes 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 4,956 1,046 1,385 421 83 206 50 3,690 737 111 11 461 13 4.65 (5) 10.4 32.5 0.0 0.0 1.0 0.0 0.0 36.4 0.0 0.0 Yes
Comparison Group
Time
Single group Single group Wait-list Wait-list TAU TAU Placebo Placebo Single group Single group Wait-list Wait-list TAU TAU Placebo 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. Binging is the dependent variable. k = number of studies; i = number of effect sizes derived; d + = mean effect size estimate; 95% CI = 95% confidence interval; > 0 = the d + was greater than 0; Sig Diff = significant difference between the counseling/psychotherapy and guided self-help conditions (Yes = significant difference; No = no significant differences); Q(df) = the homogeneity index for the given degrees of freedom; I 2 = a homogeneity index presented as a percentage; Yes in the Homogeneous column means the d + comprises a homogeneous grouping of effect sizes. Posttest = the measurement was taken at the termination of treatment; TAU = treatment-as-usual condition; Follow-up = the measurement was taken at the longest posttreatment follow-up available.
Table 2 Summary Statistics for the Frequency of Purging (Vomiting) Outcome Variable
Treatment i Yes No [0.55, 0.71] [0.28, 0.71] [0.59, 1.38] [0.36, 2.37] [0.26, 0.89] No No [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] No No No No Yes No Yes Yes No Yes Yes Yes Yes Yes n d+ >0 Sig Diff Fail-Safe N k 95% CI Q(df) 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) I2 Homogeneous Yes Yes Yes Yes Yes Yes Yes Yes Yes
Comparison Group
Time
Single group Single group Wait-list Wait-list TAU TAU Placebo Placebo Single group Single group Wait-list Wait-list TAU TAU Placebo Placebo 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 3,938 845 1,574 410 172 214 48 2,538 718 131 18 124 17
Counseling Self-help Counseling Self-help Counseling Self-help Counseling Self-help Counseling Self-help Counseling Self-help Counseling Self-help Counseling Self-help
2.38 (3)
3.5 19.0 0.0 0.0 0.0 0.0 7.4 28.4 0.0 0.0
Yes
Note. Purging is the dependent variable. k = number of studies; i = number of effect sizes derived; d + = mean effect size estimate; 95% CI = 95% confidence interval; > 0 = the d+ was greater than 0; Sig Diff = significant difference between the counseling/psychotherapy and guided self-help conditions (Yes = significant difference; No = no significant differences); Q(df) = the homogeneity index for the given degrees of freedom; I 2 = a homogeneity index presented as a percentage; Yes in the Homogeneous column means the d + comprises a homogeneous grouping of effect sizes. Posttest = the measurement was taken at the termination of treatment; TAU = treatment-as-usual condition; Follow-up = the measurement was taken at the longest posttreatment follow-up available.
159
160 Table 3 Summary Statistics for the Frequency of Use of Laxatives Outcome Variable
Treatment i [0.32, 0.59] [0.14, 0.37] [0.18, 1.18] Yes Yes Yes Yes n d+ >0 Sig Diff Fail-Safe N k 95% CI Q(df) 14.43 (16) 3.47 (8) 0.82 (2) I2 0.0 0.0 0.0 4.12 (4) 4.57 (5) Yes 2.9 0.0 Yes Yes Homogeneous Yes Yes Yes 0.45 0.26 0.68 0.58 [0.00, 1.16] [0.01, 0.49] [0.08, 1.00] No Yes Yes 0.24 0.54 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 50 154 163 770 230 205 58 121 324
Comparison Group
Time
Note. Use of laxatives is the dependent variable. k = number of studies; i = number of effect sizes derived; d + = mean effect size estimate; 95% CI = 95% confidence interval; > 0 = the d+ was greater than 0; Sig Diff = significant difference between the counseling/psychotherapy and guided self-help conditions (Yes = significant difference; No = no significant differences); Q(df) = the homogeneity index for the given degrees of freedom; I 2 = a homogeneity index presented as a percentage; Yes in the Homogeneous column means the d + comprises a homogeneous grouping of effect sizes. Posttest = the measurement was taken at the termination of treatment; TAU = treatment-as-usual condition; Follow-up = the measurement was taken at the longest posttreatment follow-up available.
Counseling and Guided Self-Help Outcomes for Clients With Bulimia Nervosa the single-group condition, 0.68 (medium to large effect; i = 3, n = 112) for the wait-list condition, and 0.58 (medium to large effect; i = 1, n = 50) for the placebo condition. No TAU studies assessing for laxative use were identified. Again, no heterogeneity was detected. Follow-up for treatment of bulimia with laxative use as the outcome measure did not result in a significant positive effect for single-group studies (d+ = 0.24; small effect; i = 5, n = 154). This effect size grouping was homogeneous. Unfortunately, no follow-up studies were located and selected on laxative use for the wait-list, TAU, or placebo conditions. Self-report bulimia ratings for counseling/psychotherapy. Table 4 provides summary statistics for self-report bulimia ratings. Again, all conditions were significantly higher than zero, even though several of the analyses had few studies and small sample sizes. The d+ was 0.81 (large effect; i = 44, n = 1,151) for the single-group condition, 0.99 (large effect; i = 5, n = 143) for the wait-list condition, 0.93 (large effect; i = 3, n = 112) for the TAU condition, and 0.62 (medium to large effect; i = 4, n = 158) for the placebo condition. All conditions yielded homogeneous effect size estimates. Follow-up for bulimia self-ratings on single-group studies resulted in a significant positive result (d+ = 0.88; large effect; i = 29, n = 709), but not for the placebo condition (d+ = 0.38; small effect; i = 4, n = 158). Both effect size groupings were homogeneous. No TAU or wait-list follow-up studies were located. Self-reported body dissatisfaction for counseling/psychotherapy. Table 5 provides summary statistics for client self-report of body dissatisfaction. No placebo studies were located, but all other conditions resulted in d+ greater than zero, and all conditions displayed homogeneous effect size groupings. The d+ was 0.50 (medium effect; i = 41, n = 1,424) for the single-group condition, 0.66 (medium effect; i = 5, n = 143) for the wait-list condition, and 0.60 (medium effect; i = 4, n = 218) for the TAU condition. Follow-up for body dissatisfaction self-ratings was significantly greater than zero for both the single-group (d+ = 0.56; medium effect; i = 24, n = 768) and TAU (d+ = 0.58; small effect; i = 1, n = 71) conditions, with both effect size groupings displaying homogeneity. No wait-list or placebo follow-up trials were located. Is Guided Self-Help Effective for the Treatment of Clients With Bulimia Nervosa? And If So, Do the Results Last? Far fewer articles were located evaluating the effectiveness of self-help interventions for the treatment of clients with bulimia nervosa compared with counseling and psychotherapy, and some of these trials described guided help procedures that involved minimal interventions and educational support by mental health or medical professionals. These were combined for convenience in the following analyses and referred to as guided self-help. The same procedures and variables were examined to determine the effectiveness of guided self-help interventions with clients with bulimia nervosa, including posttreatment and follow-up assessment at the most distant follow-up point. Frequency of binging for guided self-help. According to Table 1, the d+ was 0.62 (medium effect; i = 17, n = 472) for the single-group guided self-help condition and 0.70 (medium to large effect; i = 6, n = 263) for the wait-list condition. Both were significantly higher than zero, meaning the null hypothesis could be rejected and a conclusion made that the treatment was effective. Homogeneity was displayed within both effect size groupings. No TAU trials were located, and a nonsignificant d+ of 0.50 (medium effect; i = 1, n = 39) was derived for the single placebo trial. For the guided self-help treatment, follow-up studies using a single-group analysis resulted in a significant positive result (d+ = 0.67; medium to large effect; i = 11, n = 337), but the single placebo study (d+ = 0.13; small effect; i = 1, n = 39) was not different from zero. No TAU or wait-list guided self-help follow-up trials were located. The distribution of effect sizes for the single-group analysis was homogeneous. Frequency of purging for guided self-help. Purging behavior results for the guided self-help condition are presented in Table 2. The d+ was 0.50 (medium effect; i = 17, n = 482) for the single-group guided self-help condition and 1.37 (large effect; i = 3, n = 151) for the wait-list condition. Both were significantly higher than zero and displayed homogeneity within both effect size groupings. No TAU trials were located, and a nonsignificant d+ of 0.48 (medium effect; i = 1, n = 39) was derived for the single-placebo trial. For the guided self-help treatment, follow-up studies using single-group methodology resulted in a significant positive result (d+ = 0.65; medium to large effect; i = 11, n = 337), but the single-placebo study (d+ = 0.17; small effect; i = 1, n = 39) was not different from zero. No TAU or wait-list guided self-help follow-up trials were located. The distribution of effect sizes for the single-group analysis was homogeneous. Frequency of laxative use for guided self-help. No wait-list, TAU, or placebo trials were located for the posttreatment or the follow-up conditions for laxative use. According to Table 3, the d+ for the single-group guided self-help condition was 0.26 (small effect; i = 9, n = 217), which was significantly higher than zero and represented a homogeneous grouping of effect sizes. On follow-up, the single-group set of studies also yielded a homogeneous set of effect sizes and a significant d+ of 0.54 (medium effect; i = 6, n = 163), indicating that participants actually used laxatives less on follow-up than at the conclusion of treatment. Bulimia self-ratings for guided self-help. No placebo trials were located, but Table 4 indicates that the other three conditions were significantly higher than zero for the bulimia self-rating outcome variable analysis. The d+ was 0.58 (medium effect; i = 7, n = 220) for the single-group guided self-help condition, 1.25 for the wait-list condition (large effect; i = 3, n = 192), and 0.61 161
162 Table 4 Summary Statistics for the Self-Report Bulimia Outcome Variable
Treatment i Yes No No 0.81 0.58 0.99 1.25 0.93 0.61 0.62 [0.76, 1.01] [0.45, 0.93 Yes Yes Yes [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] 3,551 409 496 374 278 122 249 1,764 344 Yes Yes Yes Yes Yes Yes Yes n d+ >0 Sig Diff Fail-Safe N k 95% CI Q(df) 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) I2 0.0 2.9 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Homogeneous Yes Yes Yes Yes Yes Yes Yes Yes Yes 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 0.88 0.69 0.53 0.38 [0.14, 0.92] [0.11, 0.87] Yes No 53 153 44 7 5 3 3 2 4 29 5 1 4 1,151 220 143 192 112 125 158 709 157 109 158 3.21 (3) 0.0 Yes
Comparison Group
Time
Note. Self-report bulimia is the dependent variable. k = number of studies; i = number of effect sizes derived; d + = mean effect size estimate; 95% CI = 95% confidence interval; > 0 = the d+ was greater than 0; Sig Diff = significant difference between the counseling/psychotherapy and guided self-help conditions (Yes = significant difference; No = no significant differences); Q(df) = the homogeneity index for the given degrees of freedom; I 2 = a homogeneity index presented as a percentage; Yes in the Homogeneous column means the d + comprises a homogeneous grouping of effect sizes. Posttest = the measurement was taken at the termination of treatment; TAU = treatment-as-usual condition; Follow-up = the measurement was taken at the longest posttreatment follow-up available.
Table 5 Summary Statistics for the Body Dissatisfaction Outcome Variable

Treatment i Yes No No 0.50 0.38 0.66 0.71 0.60 0.42 [0.46, 0.66] [0.34, 0.74] [0.10, 1.06] [0.12, 0.90] Yes Yes Yes Yes No [0.40, 0.59] [0.23, 0.54] [0.29, 1.03] [0.26, 1.15] [0.33, 0.88] [0.04, 0.80] 2,034 420 143 282 241 42 1,349 429 No 58 51 Yes Yes Yes Yes Yes Yes n d+ >0 Sig Diff Fail-Safe N k 95% CI Q(df) 35.65 (40) 8.47 (10) 3.00 (4) 2.70 (3) 0.52 (3) I2 0.0 0.0 0.0 0.0 0.0 21.80 (23) 8.22 (7) 0.0 14.8 Homogeneous Yes Yes Yes Yes Yes
Comparison Group
Time
Single group Single group Wait-list Wait-list TAU TAU Placebo Placebo Single group Single group Wait-list Wait-list TAU TAU Placebo Placebo 28 11 3 3 4 1 0 0 17 8 0 0 1 1 0 0 0.56 0.54 0.58 0.51 41 11 5 4 4 1 24 8 1 1 1,424 384 143 222 218 112 768 268 71 109
Counseling Self-help Counseling Self-help Counseling Self-help Counseling Self-help Counseling Self-help Counseling Self-help Counseling Self-help Counseling Self-help
Yes Yes
Note. Body dissatisfaction is the dependent variable. k = number of studies; i = number of effect sizes derived; d+ = mean effect size estimate; 95% CI = 95% confidence interval; > 0 = the d+ was greater than 0; Sig Diff = significant difference between the counseling/psychotherapy and guided self-help conditions (Yes = significant difference; No = no significant differences); Q(df) = the homogeneity index for the given degrees of freedom; I 2 = a homogeneity index presented as a percentage; Yes in the Homogeneous column means the d + comprises a homogeneous grouping of effect sizes. Posttest = the measurement was taken at the termination of treatment; TAU = treatment-as-usual condition; Follow-up = the measurement was taken at the longest posttreatment follow-up available.
163
Erford et al. (medium to large effect; i = 2, n = 125) for the TAU condition. Homogeneity was demonstrated in all conditions. For the guided self-help treatment, no placebo or wait-list follow-up trials were located. Follow-up studies using a single group resulted in a significant positive result (d+ = 0.69; medium to large effect; i = 5, n = 157), as did the single TAU study (d+ = 0.53; medium effect; i = 1, n = 109). The distribution of effect sizes for the single-group analysis was homogeneous. Body dissatisfaction self-ratings for guided self-help. According to Table 5, the d+ was 0.38 (small to medium effect; i = 11, n = 384) for the single-group guided self-help condition, 0.71 (medium to large effect; i = 4, n = 222) for the wait-list condition, and 0.42 (small to medium effect; i = 1, n = 112) for the TAU condition. All three conditions were significantly higher than zero, and homogeneity was displayed within each effect size grouping. No placebo trials were located. For the guided self-help treatment, follow-up studies using a single-group design (d+ = 0.54; medium effect; i = 8, n = 268) and a single TAU study (d+ = 0.51; medium effect; i = 1, n = 109) resulted in significant positive results. No placebo or wait-list self-help follow-up trials were located. The distribution of effect sizes for the single-group analysis was homogeneous. Is There a Difference Between Counseling/ Psychotherapy and Guided Self-Help Interventions in the Treatment of Clients With Bulimia Nervosa? Differences between combined effect sizes for counseling/ psychotherapy and guided self-help conditions were determined by comparing the d+ of the guided self-help condition with the 95% CI range associated with the counseling/psychotherapy d+. We reasoned that the higher number of studies and samples sizes accompanying the counseling/psychotherapy d+ made that range more stable than the range associated with the guided self-help studies. This comparison is similar to the null testing procedure used earlier; that is, if the d+ for the guided self-help condition falls outside of the 95% CI range for the counseling/psychotherapy d+, the null hypothesis of no difference can be rejected and the possibility of a significant difference between mean effect sizes of the two conditions can be considered. The summary decision for each comparison is designated in the Sig Diff column of Tables 1 to 5. If the designation is yes, then a significant difference does exist; if the designation is no, the null hypothesis was retained. Binging. According to the results reported in Table 1, counseling/psychotherapy was significantly more effective than guided self-help at treatment termination for both the single-group (counseling/psychotherapy d+ = 0.71, i = 70; guided self-help d+ = 0.62, i = 17) and wait-list (counseling/ psychotherapy d+ = 0.99, i = 14; guided self-help d+ = 0.70, i = 6) comparisons. No difference was noted in the placebo comparison (counseling/psychotherapy d+ = 0.26, i = 8; guided self-help d+ = 0.50, i = 1). At follow-up, there was no significant difference for either the single-group (counseling/ psychotherapy d+ = 0.75, i = 49; guided self-help d+ = 0.67, 164 i = 11) or the placebo (counseling/psychotherapy d+ = 0.77, i = 6; guided self-help d+ = 0.13, i = 1) conditions. Purging. The results in Table 2 indicate that counseling/ psychotherapy yielded significantly better results than guided self-help for the single-group condition (counseling/psychotherapy d+ = 0.63, i = 63; guided self-help d+ = 0.50, i = 17) but not for the wait-list (counseling/psychotherapy d+ = 0.98, i = 16; guided self-help d+ = 1.37, i = 3) or placebo (counseling/ psychotherapy d+ = 0.36, i = 6; guided self-help d+ = 0.48, i = 1) conditions. No difference was noted at follow-up for either the single-group (counseling/psychotherapy d+ = 0.71, i = 36; guided self-help d+ = 0.65, i = 11) or the placebo (counseling/psychotherapy d+ = 0.31, i = 4; guided self-help d+ = 0.17, i = 1) conditions. Laxatives. The results in Table 3 indicate that counseling/ psychotherapy was significantly better at reducing the use of laxatives than guided self-help in single-group trials (counseling/psychotherapy d+ = 0.45, i = 17; guided self-help d+ = 0.26, i = 9), but at follow-up, guided self-help was superior to counseling/psychotherapy (counseling/psychotherapy d+ = 0.24, i = 5; guided self-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 significantly better self-report bulimia scale outcomes for the single-group comparison (counseling/ psychotherapy d+ = 0.81, i = 44; guided self-help d+ = 0.58, i = 7) but no significant differences for the wait-list (counseling/ psychotherapy d+ = 0.99, i = 5; guided self-help d+ = 1.25, i = 3) or TAU (counseling/psychotherapy d+ = 0.93, i = 3; guided self-help d+ = 0.61, i = 2) conditions. On follow-up, the superiority of counseling/psychotherapy over guided self-help was maintained (counseling/psychotherapy d+ = 0.88, i = 29; guided self-help d+ = 0.69, i = 5). No wait-list, TAU, or placebo followup comparisons were available for self-report bulimia scales. Body dissatisfaction. Table 5 results indicate that counseling/ psychotherapy was superior to guided self-help interventions in single-group studies (counseling/psychotherapy d+ = 0.50, i = 41; guided self-help d+ = 0.38, i = 11) but not wait-list (counseling/psychotherapy d+ = 0.66, i = 5; guided self-help d+ = 0.71, i = 4) or TAU (counseling/psychotherapy d+ = 0.60, i = 4; guided self-help d+ = 0.42, i = 1) comparison studies. There were no differences between counseling/psychotherapy and guided self-help on follow-up for either single-group (counseling/psychotherapy d+ = 0.56, i = 24; guided selfhelp d+ = 0.54, i = 8) or TAU (counseling/psychotherapy d+ = 0.58, i = 1; guided self-help d+ = 0.51, i = 1) conditions.
Discussion
Is Counseling/Psychotherapy Effective for the Treatment of Clients With Bulimia Nervosa? And If So, Do the Results Last? Counseling/psychotherapy is quite effective in the treatment of clients with bulimia nervosa. In nearly all the observed
Counseling and Guided Self-Help Outcomes for Clients With Bulimia Nervosa comparisons in our meta-analysis, counseling and psychotherapy resulted in positive average weighted effect sizes (d+) of at least small to medium effects that were significantly higher than zero at termination of treatment (17 of 18 comparisons; 94%) across all four conditions (single group, wait-list, TAU, and placebo) and all five outcome measures (binging, purging, laxative use, bulimia self-ratings, and body dissatisfaction self-ratings). However, only about half of all follow-up study comparisons (six of 13 comparisons; 46%) across all conditions and outcome variables resulted in effect size averages significantly greater than zero, although these effects were also primarily medium in size. All tests of homogeneity (Cochrans Q and I2) indicated significant homogeneity and no effects of moderating or mediating variables. So counseling/psychotherapy is effective in producing short-term positive therapeutic changes in clients with symptoms of bulimia but is inconsistently long-lasting and resistant to relapse. The results of the current meta-analysis are similar to previous meta-analyses of 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 far more clinical trials of recent publication, with more diverse study designs, and with disaggregated outcome variables. It is also the first to use a random-effects model on a large sample of theoretically diverse approaches, which tends to result in more conservative effect size estimates. The absence of mediator or moderator variables means that no differences 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 of these findings may help clarify previous contrary conclusions. For example, Thompson-Brenner et al. (2003) concluded in a random-effects meta-analysis that strict behavior therapy (with no cognitive component) was more effective than CBT in reducing purging behaviors, although these results were based on a handful of trials in each condition. Likewise, the study of differential effectiveness of 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 of clinical trials of treatment of bulimia nervosa continues to accumulate, the power of such analyses also increases (Cornwell, 1993; Cornwell & Ladd, 1993). Therefore, as evidence continues to accumulate, these previous conclusions will be reexamined and refined in the aggregated context provided by meta-analyses. A continuing concern is the lack of substantive evidence of the lasting effects of counseling/psychotherapy in the treatment of clients with bulimia nervosa. Half of the comparisons in the current meta-analysis indicate lasting effects at follow-up, whereas the other half do not. Perhaps this is due to the observation that fewer than half of all clinical trials conducted follow-up components. Fewer studies reduce the power of analyses, and some optimism can be gained by inspecting the follow-up categories in Tables 1 to 5 and learning that many of these average effect sizes are medium in magnitude despite the fact that they are composed of fewer than five studies. Is Guided Self-Help Effective for the Treatment of Clients With Bulimia Nervosa? And If So, Do the Results Last? A number of studies have been published recently exploring the efficacy of self-help and guided-help interventions. Similar to the results for counseling/psychotherapy, in nearly all observed instances, self-help or guided self-help resulted in positive average weighted effect sizes (d+) of medium effects that were significantly higher than zero at termination of treatment (11 of 13 comparisons; 85%) across all four conditions (single group, wait-list, TAU, and placebo) and all five outcome measures (binging, purging, laxative use, bulimia self-ratings, and body dissatisfaction self-ratings). But the follow-up study comparisons were a bit more positive than for counseling/psychotherapy, because seven of nine comparisons (78%) resulted in effect size averages significantly greater than zero. These effects were also primarily medium in size. More important, all tests of homogeneity (Cochrans Q and I2) indicated significant homogeneity and no effects of moderating or mediating variables. Therefore, as with counseling/psychotherapy, guided selfhelp is also effective in producing short-term positive changes in clients with symptoms of bulimia nervosa and appears to yield more substantial lasting results that display greater resistance to relapse than does counseling/psychotherapy. This is not so surprising when one considers that guided self-help interventions rely on client motivation for success. Although this selection factor is potentially problematic in all experimental research, it may be particularly problematic when researchers recruit participants specifically for a selfhelp study; that is, participants who are not self-motivated may remove themselves from the study at higher rates than highly motivated participants. Also, only 29 guided self-help articles were selected into this meta-analysis, far fewer than the 82 articles exploring the effectiveness of counseling/ psychotherapy, so the results of the current meta-analysis must be viewed with caution. Is There a Difference Between Counseling/ Psychotherapy and Guided Self-Help Interventions in the Treatment of Clients With Bulimia Nervosa? Few head-to-head studies pitting counseling/psychotherapy against guided self-help were available, so the comparisons between these two broad approaches to the treatment of clients with bulimia nervosa were based on studies contained in 111 different articles conducted by a multitude of researchers 165
Erford et al. around the world and summarized in this meta-analysis. In single-group study comparisons, which had the largest number of trials by far, counseling/psychotherapy was superior to guided self-help interventions across all five outcome variables of binging, purging, use of laxatives, self-report bulimia ratings, and body dissatisfaction. However, this advantage was only maintained at follow-up on the outcome measures of laxative use and self-report bulimia ratings. In all other conditions (i.e., wait-list, TAU, and placebo) and for all other outcome variables (i.e., binging, purging, and body dissatisfaction), guided self-help interventions were just as effective as counseling/psychotherapy at both termination and follow-up. Of course, far fewer studies using wait-list, TAU, and placebo comparison conditions are currently available in the literature than studies using single-group designs. The results of any meta-analysis must be interpreted with caution because of methodological limitations. Overall, however, these results provide positive indications for the effectiveness of both counseling/psychotherapy and guided self-help for the treatment of clients with bulimia nervosa. The results also suggest the need for head-to-head RCTs of these two increasingly common approaches. In addition, although cost analyses were not available, it stands to reason that the guided self-help approach may be available to clients at a lower cost compared with counseling/ psychotherapy. This consideration, coupled with the importance of self-motivation in any guided self-help procedures, may make self-help or guided self-help an efficacious first line of defense in helping clients with bulimia nervosa. Further research should certainly explore the cost-effectiveness, time-effectiveness, and overall treatment efficacy of guided self-help approaches to helping clients with bulimia. Eder, & Tai, 2011). Of course, variations in characteristics of clinical trials did occur; for example, fewer than half of all clinical trials used a standardized treatment manual, and others failed to provide sufficient information related to some design sample or treatment procedures. Fortunately, all random-effects analyses indicated significant homogeneity of effect size estimates, so the absence of this information did not affect mediator analyses. However, perhaps the greatest limitation was the small number of studies available for some comparisons. As Cornwell (1993) and Cornwell and Ladd (1993) indicated, sufficient power is generally gained in a meta-analysis when the number of studies approaches or exceeds 20 clinical trials. Although most of the single-group comparisons for counseling/ psychotherapy easily exceeded this criterion, most of the analyses conducted on comparison conditions or for the guided self-help analyses did not. As additional studies of the treatment of bulimia nervosa accumulate in future years, the power of these analyses can be expected to increase, thus avoiding Type II errors. This was a particularly problematic issue in analyses of follow-up results to determine the staying power of interventions.
Implications for Counseling Practice and Research

The current meta-analysis represents the most recent and largest study of treatment efficacy for bulimia nervosa. It used a random-effects model, which yields a conservative estimate of outcomes counselors can reasonably expect in clinical practice. Both counseling/psychotherapy and guided self-help approaches appear to lead to clinically significant reductions in binging, purging, laxative use, self-report bulimia ratings, and body dissatisfaction ratings. The effect 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 of long-term efficacy of bulimia treatment is inconsistent, although guided self-help approaches appear to hold up better over time than counseling/psychotherapy. The lack of consistent display of long-term efficacy could be due to the relatively smaller numbers of follow-up studies available in the extant literature, which reduces the power of analyses. This suspicion is bolstered given that most of the follow-up comparisons in this meta-analysis resulted in moderate effect sizes. Additional clinical trials with follow-up phases that use wait-list, TAU, and placebo control designs are needed to clarify the issue of long-term efficacy. It is possible that booster or follow-up sessions could also enhance the long-term efficacy of counseling/psychotherapy treatment, as has been suggested for the treatment of depression (Erford et al., 2011). It is unfortunate that time and resources are expended by clients with bulimia nervosa to
Limitations of This Meta-Analysis

The current meta-analysis used rigorous methodological procedures. We conducted exhaustive searches of published literature and required a nine-level process for inclusion of relevant studies, including that each use a standardized outcome measure. When analyzing results, we used a random-effects model to enhance generalizability and conservative statistical assumptions, such as weighting effect sizes for inverse variance and conducting two tests for homogeneity. We also assessed for publication bias using both funnel plots and computation of fail-safe Ns. As a result, the aforementioned conclusions are probably generalizable across relevant populations, treatment variations, outcome variables, and research designs. Despite, or because of, 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 of viable studies, thus resulting in some publication bias. Although we maintain that study quality is important, inclusion of lower quality studies sometimes alters the results of a meta-analysis (Whiston, Rahardja,
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Counseling and Guided Self-Help Outcomes for Clients With Bulimia Nervosa gain improvement over debilitating symptoms, often resulting in medium to large effects of treatment, only to have those gains reduced after treatment terminates. Critics of mental health care treatment and a financially burdened public are right to be skeptical of such here today, gone tomorrow treatment results. So it is incumbent on counselors and counseling researchers to determine if certain approaches to the treatment of bulimia and implementation of booster or follow-up sessions lead to consistently positive outcomes over the long term. Cost-effectiveness is an essential consideration in the context of the current health care debate. It is interesting that not a single study or meta-analysis on the treatment of bulimia nervosa measured the cost-effectiveness of the interventions used, whether for counseling/psychotherapy or guided self-help. Counselors and counseling researchers must explore the costs involved in different approaches to treating bulimia nervosa and other disorders or issues that clients present to surmise and put into practice the most time- and cost-effective practices. An interesting result with implications for clinical practice was that, with only a few exceptions, counseling/ psychotherapy and guided self-help were equally effective, and perhaps the latter had even better long-term efficacy. Additional research is needed to confirm and extend these results and the cost-effectiveness of each approach, but it is interesting to postulate that self-help or guided self-help approaches may be an effective initial intervention to help self-motivated individuals with bulimia nervosa significantly reduce symptoms of binging, purging, and laxative use, as well as reduce problematic cognitive displays or perceptions related to bulimia or body dissatisfaction. It will be important that any protocol for implementing self-help treatment, either in written or online formats, should be standardized and thoroughly evaluated to enhance effectiveness and minimize risk to a vulnerable clientele. At this point in the genesis of treatment for bulimia nervosa, we need more RCTs that measure efficacy at termination, but especially at short- and long-term follow-up points. Even though wait-list and placebo studies are valuable, TAU studies are needed most. TAU studies have the advantage of not withholding active treatment from control group participants, instead providing participants with a treatment approach they would normally receive if they presented for treatment of bulimia at an outpatient facility. After 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 of a TAU comparison group also minimizes the ethical dilemma of withholding a viable treatment from participants in the wait-list or placebo condition until the completion of the control phase (Erford et al., 2011; Weisz, McCarthy, & Valeri, 2006). Finally, even though each study selected into the current meta-analysis was published in a refereed journal, and even though the studies were published over a 30-year period, the adequacy of descriptions of study and sample characteristics was highly variable. Often, critical information needed to replicate the procedures of the treatment in research or clinical practice was absent. Such lapses render the studies unhelpful in moving counseling practice forward. That is, if a studys results show a particular treatment to be effective in reducing the frequency of 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 understand and replicate treatment procedures.
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Received 08/26/11 Revised 10/28/11 Accepted 02/10/12 DOI: 10.1002/j.1556-6676.2013.00083.x

Journal of Counseling & Development April 2013 Volume 91

The Effectiveness of Counseling/Psychotherapy

Journal of Counseling & Development April 2013 Volume 91

The Differences Between Counseling/ Psychotherapy and Guided Self-Help

The Effectiveness of Guided Self-Help

Journal of Counseling & Development April 2013 Volume 91

Journal of Counseling & Development April 2013 Volume 91

Figure 1 Flow Chart of Included Studies

Journal of Counseling & Development April 2013 Volume 91

Journal of Counseling & Development April 2013 Volume 91

Journal of Counseling & Development April 2013 Volume 91

Table 5 Summary Statistics for the Body Dissatisfaction Outcome Variable

Journal of Counseling & Development April 2013 Volume 91

Journal of Counseling & Development April 2013 Volume 91

Implications for Counseling Practice and Research

Limitations of This Meta-Analysis

Journal of Counseling & Development April 2013 Volume 91

Journal of Counseling & Development April 2013 Volume 91

Journal of Counseling & Development April 2013 Volume 91

Journal of Counseling & Development April 2013 Volume 91

Journal of Counseling & Development April 2013 Volume 91

Journal of Counseling & Development April 2013 Volume 91

Journal of Counseling & Development April 2013 Volume 91

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