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Overview of Cognitive-Behavioral Therapy and Guided Self-Help

CBT is widely considered to be the treatment of choice for BN and BED (Wilson, Grilo, & Vitousek, 2007). According to the cognitive-behavioral model, the core psychopathology of binge eating is a negative overconcern with body shape and weight that leads to dysfunctional dieting and other unhealthy weight control behaviors. The dysfunctional dieting in turn predisposes an individual to binge eating. CBT consists of cognitive and behavioral procedures designed to enhance motivation for change, replace dysfunctional dieting with a regular and flexible pattern of eating, decrease undue concern with body shape and weight, and prevent relapse. CBT for EDs involves three basic stages: In Stage 1, self-monitoring of eating and techniques to help the client establish normalized eating patterns are introduced. Coping mechanisms are also taught to deal with emotional distress. Stage 2 focuses on cognitive restructuring, including identifying and challenging maladaptive cognitions such as the overvaluation of weight and shape. In Stage 3, relapse prevention techniques are taught to promote the maintenance of change after treatment (Fairburn, 1995; Grilo, 2006). CBT requires specialized training and expertise for delivery, making it less readily available to a wide range of clients. Hence, implementation science researchers have begun to examine the effectiveness of CBT-based guided self-help (GSH) as a more easily disseminable intervention or first step in the treatment of binge eating-related problems (DeBar et al., 2011; Lynch et al., 2010; Striegel-Moore et al., 2010). CBT-GSH is a low- intensity intervention in which clients use a self-help manual with only limited support and instruction from either a specialist or a nonspecialist in clinical or nonclinical settings. A typical CBT-GSH program consists of following a self-help manual with programmatic steps based in CBT and attending regular guidance and support sessions with a coach or supporter. A few such programs have been developed with similar components (e.g., Masheb & Grilo, 2008; Traviss, Heywood-Everett, & Hill, 2011). The most commonly evaluated CBT-GSH program is the one developed by Fairburn (1995), Overcoming Binge Eating. This program consists of following six steps of a self-help manual accompanied by eight guidance and support sessions (25 minutes in duration each), with more sessions clustered early in the treatment period: four weekly sessions followed by four biweekly sessions. The program is designed to be delivered by personnel with no background in the use of CBT or expertise in the treatment of BN or BED. The book is available in English and Spanish and has two sections. The first section is educational and summarizes current knowledge about binge eating, BED, and BN and provides the rationale for the self-help program. The second section of the book presents the program itself, which consists of six steps on how to change eating habits or other associated problems. The steps are additive and meant to be followed in sequence: Step 1, getting started – self-monitoring and weekly weighing; Step 2, establishing a pattern of regular eating and stopping vomiting and laxative misuse; Step 3, substituting alternative activities for binge eating; Step 4, practicing problem solving and reviewing progress; Step 5, tackling dieting and other forms of avoidance of eating; and Step 6, preventing relapse and dealing with other problems. The programs primary focus is to develop a regular pattern of moderate eating using self-monitoring, self-control strategies, and problem solving. Additionally, relapse prevention is emphasized to promote maintenance of behavioral change.

The principal role of the guide or supporter is to explain the rationale for using the self-help book, generate a reasonable expectancy for a successful outcome, and motivate the participant to use the book as a guide for proceeding through the program steps. The support sessions are program led and follow the therapist's manual developed by Fairburn (1998). The manual specifies the length and tone of the sessions, how the supporters should prepare in advance for them, and the elements that should be followed in each session. It is important to note that the role of the supporter is not to provide education or skills training to the participant (which would undermine the self-help nature of the program). Prior research has demonstrated the effectiveness of nonspecialists as supporters for such CBT-GSH programs (Bailer et al., 2004; Dunn, Neighbors, & Larimer, 2006).

CBT-GSH is most appropriate for adult men and women ages 18 and older whose primary symptom is binge eating, who have less severe eating pathology, and who have lower levels of psychiatric comorbidity. As a minimal or first-step intervention, it is not indicated for those with anorexia nervosa, who need medical and clinical attention to address low weight; those who are morbidly obese and need targeted behavioral weight loss strategies; or those with more serious clinical concerns (such as suicidality or severe depression). In a specialty clinic setting, CBT-GSH can be used as the first step in a stepped care approach and can even prime response to further treatment (Wilson, Wilfley, Agras, & Bryson, 2010). In nonspecialty settings, it can be delivered by nonspecialists (e.g., nurses, primary care physicians) to individuals who would otherwise not be able to access care.

Given the collaborative nature of guided self-help, the time-limited modality, and the lower implementation cost, this CBT intervention is suitable for use in school, college, and community mental health settings where counselors can play an important role as the guide or supporter. Because the program can be completed in a less formal and nonstigmatizing setting (e.g., student's home) and on a more flexible schedule, it reduces or eliminates some of the help-seeking barriers faced by clients (such as shame, stigma, long commute to and from health care services), making it a more feasible choice for those who would not consider or seek professional psychological services. Moreover, the emphasis on self-help may enhance clients' understanding of their disordered eating and empower them with a sense of self-efficacy in coping and problem solving. If the program is successfully implemented, it may also provide a positive framework for clients with regard to psychological interventions and encourage them to seek further treatment and services if needed.

Research conducted primarily with White women has demonstrated that CBT GSH is effective in reducing binge eating and vomiting, decreasing shape and weight concerns and related eating disorder pathology, and improving depression and self-esteem (Sysko & Walsh, 2008; Wilson et al., 2007). Reported remission rates from binge eating range from 24% to 74%, and improvement is typically maintained at 12- and 18-month follow-ups (Bailer et al., 2004; Grilo, 2006). It has also been shown to be as effective as specialty interpersonal therapy and significantly superior to behavioral weight loss in treating BED (Grilo & Masheb, 2005; Wilson et al., 2010). Despite its promise, experts have agreed that considerably more community-based research is needed before CBT-GSH can be disseminated widely (Grilo, 2006; Sysko & Walsh, 2008). Most notable is the lack of ethnic or cultural representation in these treatment studies.

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