In a recently published randomized controlled trial, 70 patients suffering from bulimia nervosa were randomly assigned to either weekly psychoanalytic psychotherapy for 2 years or 20 sessions of Cognitive Behavioral Therapy (CBT) over 5 months. Despite the large disparity in sessions, 20 sessions of CBT was found to be markedly superior when compared to 2 years of psychoanalytic psychotherapy. Shockingly, after 5 months of treatment only 6 % of patients receiving psychoanalytic therapy stopped binge eating and purging compared to 42% of those receiving CBT. After 2 years of psychoanalytic therapy only 15% had stopped binge eating and purging compared to 44% in the CBT group. Now this is worth repeating, those in the CBT group were limited to 20 sessions over 5 months compared to 2 years of weekly psychoanalytic therapy.
As Holon and Wilson (2014) point out, what makes these findings so remarkable is that the two lead authors (who developed the psychoanalytic treatment used in the trial) conducted the treatments at a clinic that specializes in psychoanalytic therapy. In the past, differences in outcomes across studies have been attributed to allegiance effects. In this study, the allegiance effects worked against the more efficacious CBT. Also of significance, the clinicians in the study administering CBT were relatively new to the field and not considered experts in cognitive behavioral therapy.
The Need for Specialized Care
These results support previous research indicating the effectiveness of CBT as a treatment for Bulimia Nervosa. Despite these findings, those administering evidence- based treatments, such as CBT for Bulimia Nervosa, remain in the minority. These findings stand in stark contrast to the widespread claim that there are no differences in outcomes between the various psychological treatments and they all work through common (“nonspecific”) processes. What is even more frightening is the complete dismissal of psychological research when results contradict ones own theoretical orientation. In fact, across the United States this particular study was dismissed by many in the field who specialize in the treatment of eating disorders. A common claim, “CBT only treats symptoms!” This is particularly confounding given the life threatening nature of eating disorder symptoms and reflects a dangerous reality in our field. Fortunately, the authors of this study do not support this notion and have been vocal about CBT as the front line treatment for bulimia. Those supporting specialized care fervently believe that each condition requires a distinct treatment approach targeting the factors that maintain the disorder. Specialized care believes psychological symptoms are serious, potentially life threatening, and diminishes quality of life. Specialized care supports the scientific scrutiny of psychological treatments and believes those suffering from specific disorders deserve treatments proven to be effective. If your loved one were suffering from Bulimia what treatment would you choose?
The Power of CBT
The effectiveness of Cognitive Behavioral Treatments can be directly attributed to its goal of targeting the maintaining factors of specific disorders. For bulimia nervosa and other eating disorders, CBT directly addresses the overvaluation of body shape and weight, extreme dietary restraint, and difficulties regulating mood and behavior in response to adverse events. CBT offers a conceptualization of client difficulties through a functional analysis of factors maintaining disordered eating. Real time self-monitoring provides invaluable information informing conceptualization, while concurrently developing skills related to self-awareness, mindfulness, and emotion regulation. CBT disrupts the powerful cycle maintaining disordered eating and provides a credible account of its function. The role of the therapist differs significantly from those practicing psychoanalytically/dynamically. The CBT therapist is collaborative, directive, motivating, and educative. Clients learn skills to become their own therapist and between session assignments support new learning. Given this approach, it is not surprising 20 sessions of CBT would outperform 2 years of psychoanalytic treatment.
Although CBT is markedly superior to psychoanalytic therapy for the treatment of bulimia outcomes can be improved. This study only provided 20 sessions of CBT. What would the results indicate if those who failed to achieve remission of symptoms remained in treatment? What if the therapists were experienced experts in CBT? How can treatment be enhanced for those who continue to suffer? What specific factors distinguish those who fail to respond to CBT from those who improve? Regardless, the focus should be clearly on developing effective treatments and investigating its effectiveness. Specialty care requires an adherence to the science rather than dogma. Our credibility as psychologists/therapists requires it.