Psychotherapy Brown Bag

Moderatedrinking.com - Examining the impact of a new online intervention

by Michael D. Anestis, M.S.

I'm a big fan of innovations in health care aimed towards reaching broad groups of individuals in need and helping them meet their health goals.  The bottom line is that a large proportion of individuals in need of mental health care do not have access to effective treatments for a variety of reasons (e.g., unable to travel to treatment center, no treatment centers in area offering evidence-based care) and others have access but choose not to use it.  Interventions capable of reaching these individuals and engaging them in treatment offer immense potential value.  Recently, I wrote a PBB post about telehealth treatment for PTSD and today I want to discuss another technology-based treatment: moderatedrinking.com.  

In an article published in the current issue of the Journal of Consulting and Clinical Psychology by PBB guest author Reid Hester, Harold Delaney, and PBB guest author William Campbell, the authors described an effectiveness trial comparing their new program in combination with moderation management (MM) - another online treatment tool - to MM on its own in the treatment of problem drinking.  The study included follow-ups at 3, 6, and 12 months post-baseline, allowing for an analysis of sustained benefits.

The authors had two central hypotheses:

1. Both groups would demonstrate reductions in alcohol-related problems and drinking at follow-ups
2. The individuals using moderatedrinking.com as well as MM would exhibit greater reduction in alcohol-related problems and drinking relative to individuals only using MM.

Importantly, the goals of this trial were very specific.  The authors were not claiming that individuals with severe mental illnesses would benefit from treatment or that individuals with alcohol dependence would be treated effectively through the protocol.  Rather, they were aiming to help individuals with moderate drinking problems looking to decrease the problems in their lives associated with that particular behavior.  The authors had detailed inclusion (must have in order to participate) and exclusion (must not have in order to participate) criteria:

Inclusion criteria:

1. A score on the Alcohol Use Disorder Identification Test (AUDIT; Saunders, Aasland, Babor, de la Fuente, & Grant, 1993) greater than 7
2. Self-report that the individual is drinking at least 10 standard drinks per week during the past 30 days
3. Individual is not currently abstaining from alcohol
4. Individual expresses an interest in moderate drinking
5. Individual is at least 21 years old
6. Individual has a computer with internet access at home

Exclusion criteria:

1. History of treatment for substance abuse
2. Already member of MM
3. History of hospitalization for alcohol or drug dependence or detoxification
4. Past or current diagnosis of drug abuse or dependence
5. Evidence of past or present physical dependence
6. Current indication of psychosis or bipolar spectrum disorder
7. Evidence of significant cognitive impairment from brain dysfunction
8. Evidence of health-oriented contraindications to any further drinking
9. English reading below 8th grade level
10. Unwilling/unable to attend follow-ups
11. Unwilling/unable to provide significant other to corroborate self-report of drinking

Now, you might look at these criteria and think "hey, they're exclusing a lot of people who need treatment for alcohol use disorders!"  You're right...and the authors are up front about that.  Again, the point here is not that this treatment is going to be the best thing for everyone, but rather that, for individuals with only moderate problems with drinking, an online intervention might enable them to attain moderation in their behavior and improvement in a range of important variables.  Given that many of these individuals are not going to seek or be referred to more intensive treatment programs, either because they do not meet diagnostic criteria for dependence or because abstinance, which is the sole focus in most treatments, is not their goal, this provides a potential opportunity to use technology to reach an underserved population in need of help.

In total, 40 individuals were randomly assigned to the moderatedrinking.com + MM group and 44 were randomly assigned to the MM only group.  30 participants from the moderatedrinking.com + MM group were assessed at all four time points and 29 from the MM only group were assessed at all four time points.  Here's what they found:

Looking at both groups together, they found significant improvement from baseline through 12-months post-baseline, with evidence for increased improvement from 6 to 12 months post-baseline (meaning that the effects not only held over time, but actually continued to improve).  At baseline, participants, on average, were at the 54th percentile for women and 65th for men.  At 12 months, they were at the 29th for women and 38th for men.  Reduction in overall alcohol consumption was significant, as were increases in percentage of days abstinant and decreases in number of drinks per drinking day and blood alcohol content (BAC) on drinking days.  More specifically, average drinks per drinking day dropped from 5.35 at baseline to 3.28 at 12 months and BAC on drinking days dropped from 102 mg% to 58 mg%.

Looking at the groups separately, improvement from baseline to average at follow-ups was twice as large in the moderatedrinking.com + MM group than in the MM group.  That being said, while the improvement was significantly greater in the combined group than in the MM only group at 3 months, that difference was non-significant at the other follow-ups (meaning the two groups did not differ on level of improvement at those times).  Additionally, individuals in the combined group demonstrated a greater improvment in the number of days abstinent from alcohol than did folks in the MM only group.  Finally, lighter drinkers in the combined group had better outcomes in terms of BAC on drinking days than did folks in the MM only group, but heavier drinkers in the combined group did not have significantly better results.  This last result further supports the notion that this treatment option is not aimed at individuals with severe alcohol use problems, but rather individuals who are developing problems and would like to adjust their behavior and its associated outcomes.

Okay...I threw a lot of results at you there (and there are some I left out).  The overall point here from this study is that there is some compelling preliminary evidence that a new online intervention can, in combination with another online resource, prove incrementally useful for non-severe problem drinkers.  Again, I love that this study uses technology to reach individuals outside of the clinic.  As much as I love the idea of people in need of mental health care travelling to local clinics to receive evidence-based care, that simply is not realistic in a lot of cases, so programs like this offer another potential method of providing evidence-based care to large groups of people in need.

As I write this, I am aware that the goal of this program - and, in fact, the name itself - may seem odd to some readers.  After all, isn't abstinance the only goal in alcohol use treatment?  The short answer is that the evidence says differently - that for those who seek moderation as an outcome, this is, in fact, an attainable goal.  Keep in mind, however, that neither PBB nor moderatedrinking.com is proclaiming abstinance from drinking to be a bad goal or that all individuals with alcohol use disorders can attain a healthy level of moderate drinking.  This is simply one means towards attaining one goal that could fit for certain individuals.

***********

If you would like to learn more about this or other topics discussed on PBB, we recommend that you consult our online store for scientifically-based psychological resources.

Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology program at Florida State University

Treating PTSD in veterans using telehealth: A potential path towards increasing access to evidence-based mental health treatments

by Michael D. Anestis, M.S.

I came across an interesting study today examining the effectiveness of exposure therapy for post-traumatic stress disorder (PTSD) via telehealth.  Telehealth technology uses television screens that enable therapists and clients to see and interact with one another from a great distance.  At first glance, you might read something like that and wonder why such technology needs to enter the equation in what is typically viewed as a highly personal interaction, but its potential value is actually very high.  Over the past year, as I have completed my residency in Mississippi, I have come to appreciate a point that I was beginning to understand as a graduate student in the panhandle of Florida: for some individuals, evidence-based mental health care is located too far away to be accessible.  Here in Jackson, it is not at all uncommon for a patient to have to drive several hours each way in order to attend a therapy session.  They might be able to find non-evidence-based care closer to home, but treatments supported by scientific evidence require an absurdly long commute.  Now, imagine if you are suffering from a debilitating mental illness like PTSD and you are short on cash: would long drives with high fuel costs seem appealing to you?  Given that the average patient attends only one session of psychotherapy before dropping out, adding these types of obstacles seems certain to diminish the likelihood that those in need will receive proper care.  All this being said, the potential value of a service does not always line up with reality and, rather than simply assuming something like telehealth is capable of filling - or partially filling - this important gap, we need to test its performance, both in general and relative to in-person treatments so as to fully understand its true benefits.

In the study I will detail today, which is in press at Behavior Therapy, Daniel Gros, Matthew Yoder, Peter Tuerk, Brian Lozano, and Ron Acierno of the Ralph H Johnson Veterans Administration Medical Center and the Medical University of South Carolina took these important steps to offer an initial glimpse at the actual value of telehealth administered exposure therapy for PTSD.  Before describing the study, however, it should be noted that there is preliminary supportive evidence for the use of telehealth in the administration of cognitive behavioral therapy for a range of anxiety disoders, including panic disorder and agoraphobia (Bouchard et al., 2004), obsessive compulsive disorder (Himle et al., 2006), social anxiety disorder (Pelletier, 2003) and PTSD (Germain, Marchand, Bouchard, Drouin, & Guay, 2009).  Gros et al (in press) describe this evidence in greater detail in their paper and I encourage you to read their descriptions.

The current study included participants selected from a VA medical center in the southeastern United States.  The telehealth condition included 62 veterans.  The comparison group in this study included 27 veterans receiving in-person exposure therapy for PTSD.  See below for demographic information:

Telehealth:
Average age = 45.1
Sex distribution = 93.5% male
Racial distribution = 50.0% Caucasian, 45.2% African American
Deployment history = 45.2% OIF/OEF, 40.3% Vietnam

In-person:
Average age = 45.2
Sex distribution = 88.9% male
Racial distribution = 51.9% Caucasian, 48.1% African American
Deployment history = 48.1% OIF/OEF, 51.9% Vietnam

Although the phrase "prolonged exposure" was not utilized in this manuscript, the authors indicated that treatment in both conditions was most consistent with the model described by Foa, Hembree, and Rothbaum (2007), the developers of PE.  That being said, to be consistent with the terminology used by the authors, we will continue to simpy use the phrase "exposure therapy."

The analyses were set up to examine outcomes after 12 sessions and included not only participants who completed treatment within that timeframe, but also those who were not yet finished with treatment.  Additionally, in the telehealth condition, treatment non-completers (e.g., drop-outs) and completers (n = 38) were included so as to enable analyses predicting whether or not an individual completed treatment.

Results:

Individuals in the telehealth condition completed measures of total PTSD symptoms, depression, anxiety, stress, and illness intrusiveness.  Individuals with the in-person condition only completed measures of PTSD severity and depression.  Importantly, in both conditions, statistically significant reductions in symptoms from baseline to post-treatment.  Now, without a control condition not receiving therapy, we can not determine the degree to which those reductions were due to the treatment rather than something else (e.g., the simple passage of time); however, there is a litany of research out there demonstrating that exposure therapy for PTSD produces symptom reductions that far exceed that of waitlist control groups.  Given that the in-person condition only completed measures of PTSD severity and depression, the two conditions could only be compared on those two variables.  The results indicated that individuals who received in-person exposure treatment demonstrated greater improvement on both variables than did individuals who received telehealth exposure therapy.  So, telehealth had a significant impact on these symptoms, but not as significant as the impact of in-person treatment.

The authors were also interested in determining whether particular individuals were more likely than others to complete telehealth treatment rather than dropping out.  They found that OIF/OEF veterans were more likely to drop out than were Vietnam war veterans and that younger veterans were more likely to drop out than were older veterans (this second finding likely explains the first).  Interestingly, severity of illness did not predict drop-out status, meaning that telehealth is just as viable for severely impaired individuals as it is for mildly impaired individuals.

The final set of analyses the authors ran examined predictors of treatment outcome in telehealth patients.  They examined demographic variables (e.g., sex, age), combat theater (e.g., Vietnam vs OIF/OEF), and disability status but none of these variables were significantly related to treatment outcome.  As such, they were unable to identify any reliable predictors of who is most likely to benefit from telehealth delivered exposure therapy for PTSD.

Thoughts:

This kind of study really intrigues me because it takes a tangible step towards developing methods of reaching people in need who might struggle to connect with evidence-based care.  Obviously equipment like this can be expensive, but when efficacy and effectiveness data are accumulated demonstrating that these methods work, funding agencies become more likely to provide grants that will make it possible to acquired what is needed and get it set up.

Part of the quest to advance the availability and prominence of evidence-based mental health care involves education, and we're certainly trying to do that here, but there are many other fronts on which this battle must be waged.  Clinicians in the community must be trained (and the University of Mississippi Medical Center is doing an impressive job with that as well) and potential patients must be connected with services.  This study addresses that last point very well.  Yes, in-person treatment produced better results than did telehealth and we need more data comparing telehealth to treatment as usual to ensure that it is incrementally valuable, but if people are not going to be able to obtain in-person evidence-based care, the pragmatic thing to do is to give them the next best thing.  This might be it.

It will be interesting to see how technology enters the equation in the field of mental health care in the coming years.  It seems to be a potentially remarkable opportunity to expand the reach of effective treatments, but only time will tell.

************

If you want to learn more about this or other topics discussed on PBB, we recommend that you consult our online store for scientfically-based psychological resources.

Mike Anestis is a psychology resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University.

Guest Article - Impediments to progress in psychotherapy and new ways to address them

by William Campbell, B.A. and Reid Hester, Ph.D.

Clinicians who don’t regularly treat patients with alcohol use disorders might be surprised to discover that one quarter of all clinical patients engage in heavy, problematic drinking. Even clinicians who are well aware of their patient’s misuse of alcohol often struggle with how to incorporate a treatment of the drinking behavior into their overall therapeutic plan. This is important, because unless clinicians have assessed and accounted for their client’s drinking habits, they may not suspect that a “hidden” behavior is inhibiting the course of treatment.

When most of us think of evidence supported treatments for substance abusing clients, we probably think of intensive motivational and behavioral regimens like the Community Reinforcement Approach and Motivational Interviewing, usually for severely dependent clients. But what about less dependent or abusive drinkers, who for one reason or another are struggling to control their drinking, but otherwise have no desire to quit? What treatments exist for them? This question is especially pressing in light of the fact that the vast majority of people struggling with their drinking belong to this latter group; they account for the larger proportion of the costs to society associated with alcohol abuse and, as a group, they tend to have much better treatment outcomes than more dependant drinkers. Epidemiological research suggests that there are four times as many individuals with alcohol problems with no evidence of dependence relative to those who meet the criteria for dependence (NIAAA, 2000). Furthermore, a recent report indicates that this group is increasing in size while the prevalence of alcohol dependence is declining (NIAAA, 2004).

With just such a treatment population in mind, Dr. Reid Hester has been working since the early 1990’s on interventions to help struggling drinkers moderate their consumption, specifically through the use of computer and internet-based interventions. Dr. Hester has developed programs like Drinker’s Check-up that combine assessment and feedback to help people curious about the severity of their drinking get an accurate idea of how they relate to other people with similar problems. More recently Dr. Hester developed the intervention Moderate Drinking (MD), that combines a similar assessment process with a self-directed intervention based on the methods of Behavioral Self-Control Training (BSCT). BSCT is a behaviorally focused protocol that utilizes elements of self-assessment, monitoring, goal setting, and the exploration of drinking “triggers” to help self-motivated drinkers either regain control of their habit, or find their way to abstinence. BSCT, delivered in various formats, has been tested in more clinical trials than any other intervention devoted to alcohol problems, and its efficacy has been consistently supported by this research. As one prominent researcher noted, "BSCT has become the standard moderation-oriented treatment” (Heather et al., 2000).

Funded by NIH, we recently conducted a randomized clinical trial with 80 heavy drinkers to test MD’s effectiveness. Participants randomly assigned to the experimental group had access to both the MD program and use of the resources of Moderation Management (MM), an on-line support-group for people wishing to change their drinking. Those in the control group were enrolled in MM but did not have access to the MD program. We hypothesized that both groups would reduce their drinking and alcohol-related problems and those who had access to the MD program would have better outcomes than the control group.  And they did (Hester, Delaney, Campbell, & Handmaker, 2009).

At 3-month follow-up, individuals in both groups reduced how much they drank per drinking occasion, as well as reducing how intoxicated they got on those occasions by drinking more slowly.  What’s more, the participants with access to the MD program actually drank on fewer days. They also reported a greater reduction in the following alcohol related problems compared to the control group: physical and psychological health; interpersonal issues; and taking care of one’s responsibilities.

There was a notable exception: binge drinkers, who are defined by the NIAAA as having 4-5 drinks on average per occasion, did not do as well in either group—an indication that the degree of severity of abuse may moderate success in a self-directed protocol like BSCT. However, the corollary is not true, in that severity of clinical distress, as measured by the Brief Symptom Inventory, was not a mediator of drinking outcome.  In other words, the level of psychological distress in our study participants did not have a negative impact on their success with changing their drinking.

This latter finding has a direct implication for clinical practice. Clinicians with depressed or anxious clients, who happen also to be struggling with their drinking, ought to explore the possible benefits of referring their clients to Moderate Drinking or other available BSCT protocols. Behavioral programs like the one employed by MD can be helpful to therapists because of the clarity of their therapeutic targets, and the client will have direct tie-ins between the companion motivational and affective exercises and the work done in session. Assigning such “homework” might help clients get a handle on their drinking, increase their sense of self-efficacy, and enhance the overall course of therapy.

We have completed our 12 month follow-ups and are currently preparing a manuscript that reports those outcomes. Twelve months is the minimum time period to examine long-term outcomes because relapse rates flatten out by that time. Stay tuned.

************

If you would like to learn more about this and other topics discussed on PBB, Psychotherapy Brown Bag recommends that you consult their online store of scientifically-based psychological resources.

William Campbell is enrolled in the clinical psychology doctoral program at the University of New Mexico and works as a research assistant at Behavior Therapy Associates

Dr.Reid Hester, a long time investigator of substance use disorders, is Director of the Research Division at Behavior Therapy Associates in Albuquerque, New Mexico.

Alternative treatment delivery: Part 3, using online interventions to treat insomnia

by Joye C. Anestis

It has been a while since I made a contribution to my series evaluating alternative treatment delivery mechanisms.  In a previous article, I examined available evidence for online treatments geared toward preventing eating disorders.  Today I am focusing on online interventions to treat primary insomnia.  Cognitive-behavioral therapy and other behavioral treatments are already considered empirically-supported treatments (ESTs)...but can these therapies be adapted into an online format and thus, theoretically, reach a maximum number of folks who need them?  Unfortunately, online interventions for insomnia have not been as extensively researched as other conditions.

In the most recent (2009) investigation of this question, Lee Ritterband and colleagues randomly assigned adults to a wait-list control group or to the Sleep Healthy Using the Internet, or SHUTi, intervention.  SHUTi is a structured internet intervention based on standard CBT for insomnia (check it out at www.shuti.net).  Clients complete 6 core modules, including stimulus control, sleep hygiene, and cognitive restructuring.  In an interesting aspect of this program, after the completing of each core, participants receive personalized feedback based on their previous week of sleep diaries.  Participants had to meet DSM-IV-TR criteria for primary insomnia, have sleep difficulties for at least 6 months and for at least 3 nights per week, report significant daytime impairments due to sleep problems, and have Internet access.  After initial in-person assessments, all participants completed 10 sleep diary entries over two weeks before being notified of their group assignment.  Those assigned to SHUTi were then given access to the SHUTi website for the 9-week intervention.  After the 9 weeks, all participants (both treatment and control conditions) then completed a 2nd in-person assessment.  Those in the treatment group also completed 6-month follow-up assessments.  Control participants were given access to SHUTi post-intervention.  Results from the study indicate that SHUTi produced statistically significant improvements for the treatment group in comparison to the control group.  Treatment gains included score reductions on the Insomnia Severity Index, a valid and reliable index of the severity of sleep problems, at both post-treatment and 6-month follow-up; clinically significant change on the Insomnia Severity Index; and, based on the sleep diary data, significant improvements for wake after sleep onset, sleep efficiency, and number of nighttime awakenings for those who received SHUTi.

Only one other study has examined an online intervention for insomnia.  Published in 2004, Lars Strom and colleagues randomly assigned participants to either a cognitive-behavioral self-help program or a wait-list control group.  The program was developed and administered in Sweden.  Like the previous study, the 5-week online sleep management program contained the key features of a CBT program for insomnia.  The results of this study were not as promising as those in the Ritterband study.  The treatment group demonstrated improvement on a number of measures, but the control group, who only received information about the study and completed sleep diaries and questionnaires, also improved on several measures. Strong between-group differences were found on only one measure, the Dysfunctional Beliefs and Attitudes about Sleep Scale.

It is difficult to draw conclusions about the efficacy of online CBT for insomnia at the present time based on these 2 findings.  I'm hopeful that more interventions of this kind are being examined...given that many people are reluctant to seek out a therapist to assist with mental conditions for a variety of reasons (e.g., feelings of shame, social stigma, financial reasons), internet interventions as well as other alternative treatment delivery systems demonstrate great promise in making treatments already determined to be effective in a standard therapeutic format more accessible to the public. 

Look for the next installment of this series soon...

Joye Anestis is a doctoral candidate in clincial psychology at Florida State University.

Internet-based cognitive behavioral therapy for adolescents with bulimia nervosa: Can it work?

by Michael D. Anestis, M.S.

In the current issue of Behaviour Research and Therapy, Natalie Pretorius and colleagues (2009) published a study that examined the degree to which an internet-based approach to cognitive behavioral therapy (CBT) might prove useful in the treatment of bulimia nervosa (BN) in adolescents.  As we have discussed on PBB in prior articles, Division 12 of the American Psychological Association lists CBT as one of the gold standard treatments for BN, describing its research based, as well as that of interpersonal psychotherapy (IPT), as strong.  Like most other mental illnesses, however, a significant number of individuals who meet criteria for BN do not seek treatment.  This is true for a variety of reasons, including shame about symptoms, stigma about seeking treatment, and a lack of effective diagnostic procedures and treatment referrals in primary care environments.  Finding ways to increase remote access to empirically supported treatments (ESTs) thus appears to be of potentially great value, as this would allow individuals to privately seek treatment in an environment of their choosing. Along these lines, James Mitchell and colleagues (2008) found that there was no statistically significant difference in outcomes for individuals who received CBT over the phone compared to those who received CBT face-to-face, thereby offering empirical support for the potential value of remote treatments.  Such findings provide a strong rationale for examining other forms of remote treatments, including those based on the internet.

Pretorius and her colleagues (2009) thus attempted to examine the degree to which the apparent potential of web-based CBT would translate to actual results.  To do so, they recruited a sample of 101 participants (98 females, 3 males) from eating disorder clinics across the United Kingdom as well as from BEAT (Beating Eating Disorders), a charity specializing in helping individuals with eating disorders find useful resources.  All participants were diagnosed through a semi-structured clinical interview and met DSM-IV-TR criteria for either BN or eating disorder not otherwise specified with bulimic symptoms (EDNOS-BN).  Individuals in the latter category either did not binge or purge often enough to meet BN criteria (on average twice per week for at least three months) or they used compensatory behaviors in the absence of objective binges.  All participants were between the ages of 13 and 20.

The treatment itself consisted of eight interactive online sessions, each of which required 30-40 minutes to complete.  Based upon their responses to interactive sections of each session, participants received personalized feedback.  In addition, each participant was provided with workbooks, homework, and an audio session on controlling anxiety to accompany each session.  Participants were able to access an online message board moderated by the researchers in order to ensure peer support throughout treatment.  Additionally, participants received weekly email support from a therapist trained in CBT.

The results from this study, while promising to some degree, were fairly mixed.  17% of the participants did not complete a single web-based session and the average number of sessions completed was only 3 out of 8.  In other words, on average, participants took part in less than half of the treatment protocol.   Follow-up data was attained at three months and six months after the initial interview; however, only 51.5% of the sample provided information at the 3-month and only 62.3% provided information at the 6-month.  So, in addition to the large number of individuals who did not complete much or any of the treatment, many individuals did complete treatment did not report on their symptoms throughout the course of the study. 

Despite the low level of overall participation, the authors were able to examine the impact of treatment on BN symptoms.  Participants showed improvement on their number of objective binge episodes, vomit episodes, laxative episodes, overall eating disorder symptoms levels, and body mass index (BMI).  This is promising; however, a closer look at the numbers diminishes that promise quite a bit.  At baseline, 1% of the sample who ended up completing treatment had been free of objective binges, vomiting, and laxative use for one month.  At three months, this number increased to 10%.  At six months, the number increased to 17%.  When the authors looked at a less stringent outcome measure - percentage of participants who were either abstinent from or sub-clinical in binge episodes, vomiting, and laxative use - the numbers improved a bit.  9% met this criteria at baseline, 25% at three months, and 29% at six months.  When the entire sample was considered, those numbers decreased.

So, 71% of the sample that completed treatment still utilized binge eating, vomiting, and/or laxatives at a clinically significant level and 83% reported that they were using these behaviors at least sub-clinically.  These numbers, quite frankly, are unimpressive. As a comparison, face-to-face CBT tends to result in abstinence rates of 30-50% and a reduction of binge eating and purging behaviors of 80% (Wilson & Fairburn, 2002).  In one of the better trials of CBT for BN, Wilson, Fairburn, Agras, Walsh, and Kraemer (2002) found that, on average, purging behaviors were reduced by 62% and binge eating was reduced by 72%.  Clearly then, Pretorius and colleagues (2009) did not find results for internet-based CBT that compare to traditional face-to-face therapy.  Additionally, because the authors did not have any form of control group, there is absolutely no way to determine the degree to which the internet-based treatment had any impact on BN symptoms.  For all we know, the meager improvements were better accounted for by the mere passage of time.

Are these results consistent across other studies using adult populations?  Not necessarily.  Studies using adult samples have produced somewhat better results.  For instance, Fernandez-Aranda and colleagues (2009) found that, while only 15% of participants receiving internet-based CBT for BN abstained from binge eating and purging after one month, the overall rates of abstinence for binge eating and purging after three months were 55% and 73% respectively.  Similarly, Ljotsson and colleagues (2007) found a 64% decrease in objective binge episodes for individuals who received a copy of the book Overcoming Binge Eating as well as email support and access to a moderated message board.

So, what do we know overall about the use of CBT to treatment BN?  First of all, face-to-face CBT is an effective treatment that tends to produce strong results.  Additionally, there is compelling evidence that CBT can be effectively administered over the phone and, for adults, the internet may also be a successful medium for treatment delivery.  The Pretorius et al. (2009) study, however, indicates that internet-based CBT is not yet an effective method for the treatment of BN in adolescents.  Alterations to the protocol need to be made in order to ensure a greater level of participation by the client as well as a significantly greater level of symptom reduction.  So, if an adolescent is showing signs of BN, the best course of action remains seeking face-to-face help from a therapist trained in empirically supported treatments.  If you would like to find such resources in your local area, please consult our EST clinics page.

If you would like to learn more about empirically supported treatments for bulimia, we recommend the following resources, all of which are available through our online store:

Overcoming Binge Eating - Christopher Fairburn, DM, FMedSci, FRCPsych

Cognitive Behavior Therapy and Eating Disorders - Christopher Fairburn, DM, FMedSci, FRCPsych

Crave: Why You Binge Eat and How to Stop - Cynthia Bulik, Ph.D.

Dialectical Behavior Therapy for Binge Eating and Bulimia - Debra Safer, M.D.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

Pro-anorexia websites: What are they and why are they harmful?

by Michael D. Anestis, M.S.

We have addressed anorexia nervosa (AN) several times on Psychotherapy Brown Bag.  Up to now, our focus has been on describing the nature of the disorder itself and what treatments are available.  Today, however, I would like to shift focus to an entirely different area: pro-anorexia websites.  Also known as pro-ana websites, these web pages promote AN as an alternative lifestyle rather than a mental illness.  At first glance, this might seem like a legitimate perspective - after all, homosexuality was once labeled a mental illness, so the field of clinical psychology is certainly not immune to making errors in classification.  For a variety of reasons, however, I believe this comparison is entirely invalid and that pro-ana websites serve a destructive role for individuals struggling with AN.
    Pro-ana websites present AN as an alternative lifestyle through a variety of methods.  Although hundreds of sites exist, many of which differ from one another in substantial ways, there are certain themes and areas of content that appear regularly across sites (Bardone-Cone & Cass, 2007).  Many of the sites promote a view of AN as akin to a religion, presenting "Ana's Creed" (e.g., "I will be thin, at all costs, it is the most important thing; nothing else matters.") and the "Thin Commandments" (e.g., "Being thin is more important than being healthy.").  As Clarke (2008) argued, this helps to create a sense of community amongst individuals viewing the site by developing a set of rules to follow and promoting the idea that anorexia is a common, healthy shared pursuit amongst members.  Individuals with AN are often isolated due to the nature of their illness.  They tend to avoid interactions that might involve eating and, quite often, become estranged from peers.  The potential social capital available through membership in an online community promoting the very lifestyle that led to social isolation can thus be quite alluring.  Pro-ana websites thus fill a niche, capitalizing on vulnerability and preying upon the distorted cognitions of individuals struggling with AN.
    Readers of pro-ana websites are thus met with content that promotes the idea that individuals have the innate right to self-starve and that pathologizing the behavior is unfair.  There is validity to the idea that labeling something that is simply different from the norm can be harmful.  This, however, is not the goal of mental illness diagnoses in general or AN in particular.  The DSM-IV-TR requires that symptoms cause distress and/or dysfunction in order for a syndrome to be classified as a mental illness.  Individuals with AN can, at times, feel empowered by the sense of control inherent in chronic dietary restriction.  Driven by perfectionism, individuals with AN can develop a sense of pride in their ability to persist in the presence of chronic, significant pain and the desire to eat.  Finding like-minded individuals who share in their beliefs can therefore be highly reinforcing.  In the case of AN, while distress is thus often not an issue, dysfunction is undeniable.  As mentioned in an earlier PBB article, AN has one of the highest early mortality rates of any mental illness (Sullivan, 1995), with most of these deaths due to suicide and the side effects of nutritional deficits (Crisp, Callender, Halek, & Hsu, 1992).  Clinicians and researchers are not aiming to marginalize an alternative lifestyle they simply do not understand.  They are attempting to reduce early mortality rates in a population that appears to be driven by distorted cognitions and perceptions of their own bodies.  Pro-ana websites, on the other hand, reinforce the behavior and perpetuate false beliefs.
    In addition to the overlapping theme of "alternative lifestyle," pro-ana websites also often share particular content.  "Thinspiration" models - images of thin women, often celebrities - are posted in an effort to provide readers with prototypes to which they can aspire.  Additionally, most pro-ana websites include a section of "tips and tricks."  This section provides insights to readers on ways to resist hunger, lose weight, hide weight loss, and deceive family and peers regarding eating behaviors.  For a variety of reasons, the "tips and tricks" section of these sites is particularly dangerous.  Pro-ana websites are not regulated and, as such, the information provided as safety measures is often full of misinformation capable of causing fatal physiological consequences.  Also, by teaching individuals to better deceive friends, family, and clinicians, the websites serve as an obstacle to early symptom reduction.  There is some evidence that early detection and treatment is a strong prognostic indicator (Herzog, Rathner, & Vandereycken, 1992) and, as such, by obstructing treatment, pro-ana websites may serve as a risk factor for a more dangerous course.
    Harshbarger, Ahlers-Schmidt, Mayans, Mayans, and Hawkins (2009) conducted a study of the content of pro-ana websites in an effort to provide clinicians with a better sense of the material that appears on these web pages.  The most common theme across sites was instructions on ways to reduce caloric intake.  The second most common theme was ways to distract from hunger, followed by tricks for deceiving others and methods for burning calories.  Harshbarger and colleagues' primary goal was to provide clinicians with a basic understanding of the nature of pro-ana websites while also motivating them to educate themselves further.  By better understanding the resources to which clients are turning, clinicians can be better prepared to face therapeutic obstacles and to anticipate areas of resistance.
In one of the few studies to experimentally examine the impact of pro-ana websites, Bardone-Cone and Cass (2007) divided a sample of female undergraduates into three conditions.  In the first condition, students viewed a pro-ana website designed by the authors after careful examination of actual pro-ana sites.  In the second condition, students viewed a female fashion website.  In the third condition, students viewed a website devoted to home decor.  The authors found that students in the pro-ana website condition reported greater levels of negative affect, lower levels of social self-esteem, and lower levels of appearance self-efficacy than did students who viewed either of the other two websites.  Additionally, individuals in the pro-ana website condition viewed themselves as heavier and reported that they were more likely to exercise, think about their weight, and compare themselves to others than were individuals in the other two conditions.  This study had several limitations, including the use of a non-clinical undergraduate population, but it also provided compelling initial findings that pro-ana websites can have deleterious effects on viewers.
    So, given the apparent harmful nature of pro-ana websites, what can be done to remedy this situation?  The answer, unfortunately, is unclear.  Banning such sites, in addition to raising ethical issues relative to the first amendment, would be unlikely to actually diminish the existence of pro-ana communities.  New sites would likely develop despite laws and, regardless, pro-ana individuals promote their beliefs in non-web-based methods as well (e.g., ana bracelets; Norris, Boydell, Pinhas, & Katzman, 2006), an approach that would likely become more prominent in the absence of websites.  The most effective approach might be a combination of factors, most of which are based on education and dissemination.  The efforts of Harshbarger and colleagues (2009) to educate clinicians is a strong start.  Further efforts to provide accurate, up-to-date information to both clinicians and the general public are necessary as well.  Additionally, the general public needs to be provided with readily available information on the most effective interventions for AN so as to increase the prevalence of smart consumers who actively shop for the best care as early as possible.  Given the ego-syntonic nature of AN, it is unlikely that pro-ana websites will ever fully disappear.  Their impact, however, can be mitigated through the creation of an equally prominent campaign advertising effective care and accurate information regarding the effects of AN.  Such campaigns should include celebrities, researchers, clinicians, AN survivors, and anyone else who can provide a unique and compelling perspective based upon accurate, data-driven information.
    As an internet service provider aimed at promoting scientifically-based information on clinical psychology, the authors of Psychotherapy Brown Bag are acutely aware of the impact of the internet on information acquisition.  While we hold ourselves accountable for the information we write - citing empirical studies and making those citations available through our references page for readers interested in fact checking or learning more on particular topics, other sites choose not to do so, presenting themselves instead as experts who should simply be trusted.  Our hope is that, in the future, this type of assumption will become less common amongst internet consumers as the dangers of misinformation become better understood.  In the meantime, I hope that you will provide your thoughts on whether pro-ana websites are problematic and, if so, what can be done to effectively diminish their impact.

If you would like to learn more about anorexia nervosa, we recommend the following products, all of which are available through our online store:   

DVD:

• NOVA: Dying to Be Thin

Books:

• Eating with Your Anorexic: How My Child Recovered Through Family-Based Treatment and Yours Can Too

• Treatment Manual for Anorexia Nervosa: A Family-Based Approach

• Help Your Teenager Beat an Eating Disorder

• Eating Disorders

• Eating Disorders Review: Part 1

• Eating Disorders Review: Part 2

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.

Attentional training in social anxiety disorder: A novel computer-based treatment approach

by Michael D. Anestis, M.S.

I came across a study this morning with startlingly impressive findings.  What's more, the article was published in the most prestigious clinical psychology journal (Journal of Abnormal Psychology) and was written by several of my current colleagues at Florida State University and an FSU alum, and yet I did not know about it until just hours ago.  This goes to show just how difficult it is to keep up with all of the research transpiring in this field, even when it takes place in the same building as my own office.
    In this particular study, Brad Schmidt, Tony Richey, Julie Buckner, and Kiara Timpano (2009) investigated the potential utility of a computer-based intervention for social anxiety disorder (SAD) that aims to adjust the degree to which individuals with SAD attend to threat cues (e.g., facial expressions that might indicate others are evaluating them negatively).  The rationale for this particular study was based on a rich, although not universally consistent, literature indicating that individuals with SAD demonstrate an attentional bias towards threat (e.g., Amir, Freshman, & Foa, 2002; Rapee & Heimberg, 1997).   What this means is that individuals with SAD are hypervigilant towards threat, utilizing many of their attentional resources to scan their environment for evidence that they are currently being evaluated poorly.  Individuals with high levels of social anxiety have been shown to detect greater amounts of negative audience behavior relative to individuals with low levels of social anxiety (Valjaca & Rapee, 1998). 
    An argument could be made that attending to threat cues is an adaptive tendency.  After all, shouldn't we be aware of moments in which we are in danger?  If the question is phrased in this manner, the answer would be yes; however, this question misses the point.  Individuals with SAD are not attending to threats that put them in physical harm.  Instead, because this disorder is characterized by a fear of negative evaluation, the focus is on cues that, while likely to cause discomfort, are not truly representative of actual danger.  Additionally, constant hypervigilance towards threat serves to increase and sustain anxiety (Beck, Emery, & Greenberg, 1985).  So the actual result of this attentional bias is an overestimation of the likelihood and severity of threat as well as increased and prolonged negative mood.
    Schmidt and colleagues (2009), thus, set out to address the attentional biases of individuals with SAD by training them to control their attention and shift focus away from threat cues.  In this study, the authors places 18 individuals with SAD into a treatment condition and 18 individuals with SAD into a control (placebo) condition.  Both the treatment condition and the control condition consisted of a computer task that presented participants with a series of pairs of pictures, in addition to probes that prompted them to identify letters.  More specifically, participants were told to look at a screen while a series of photos were presented to them.  Prior to the presentation of each pair of photos, a fixation cross was displayed on the screen for 500ms.  Two photos were then presented on the screen, one immediately above the placement of the cross and one immediately below it.  Photos were either threat-based (a disgusted facial expression) or neutral (neutral facial expression).  Additionally, in both conditions, one of the photos was followed by a probe (either a letter E or a letter F).  When a probe appeared, the participant was told to indicate which letter had been presented.  Participants were instructed to perform this task as quickly as possible without sacrificing accuracy.
The difference between the two conditions was based on the placement of the probe.  In the treatment condition - individuals with SAD receiving attentional control training - the probe appeared in the place previously occupied by a neutral face in 80% of the pairings.  In this way, even though participants in this condition were not told to look away from disgusted faces, they learned that, when they saw disgusted faces, they should look elsewhere to find the probe. As a result, seeing a disgusted face became a cue to look elsewhere.  In the control condition, the probe appeared in the location previously occupied by the disgusted face as often as it appeared in the location previously occupied by the neutral face.
    Now, at first glance, the therapeutic value of this type of task may seem minimal.  How can looking at photos and identifying letters impact social anxiety?  Well, this is where data comes in handy, as it helps us get past strong but inaccurate gut reactions.  In this study, the authors measured SAD symptoms through self-report but also, more importantly, through a structured diagnostic interview, the most valid and reliable manner for reaching diagnostic decisions.  Symptoms were measured pretreatment, post-treatment, and at a 4-month follow-up.  Amazingly, the authors found that, at termination, 72% of individuals in the treatment conditions no longer met criteria for SAD compared to 11% of individuals in the control condition.  Additionally, these benefits were maintained at 4-month follow-up.  Even more astoundingly, only one participant in the treatment condition correctly guessed that he or she was receiving treatment.  In other words, every person in the study except one believed that they were in the no-treatment condition, so the belief that they were being treated can not account for these effects.
    Perhaps even more impressive than the magnitude of these findings was the amount of time it took to attain them.  Treatment consisted of eight 15-minute sessions, typically twice per week.  The average amount of time between pre- and post-treatment assessments was 36.8 days.  Additionally, these effects were attained with almost no contact with an actual therapist.  What this means is that the authors were able to help a substantial number of individuals with SAD remit from their illness in very little time entirely through a computer task that the individuals themselves believed was not even a treatment. 
    There are many benefits to research like this.  First, even though there are already empirically supported treatments for SAD (see Lora Rose Hunter's PBB article on cognitive behavioral group therapy for SAD), not every individual responds to the front line treatment or has access to clinicians trained to administer empirically supported treatments.  Secondly, creating effective, empirically supported online treatments might increase the degree to which individuals with SAD seek and attain proper treatment.
    Ultimately, this study accomplished several admirable goals.  First, it presented initial empirical evidence in support of a brief, inexpensive treatment for SAD that maintains treatment benefits well beyond the end of treatment.  Second, it provided an example of a thorough assessment approach utilizing scientifically tested tools (see our Assessment Tools page for more examples). Finally, this study is a prime example of the need to take a scientific approach to clinical psychology.  The most effective means for reducing symptoms of mental illness are not always the most philosophically appealing or intuitively obvious.  The reduction of symptoms for clients is more important than intellectual satisfaction for clinicians, and science and data are the most effective means for ensuring that such reductions remain our highest priority.
    To learn more about treatments for social anxiety disorder or methods for developing attentional control, please refer to our online store for recommended products.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Using Technology to Keep Up with Current Research

by Joye C. Anestis, M.S.

While an avid Internet user for years, I still consider myself to be a technology neophyte.  Case in point, Monday night I began to brainstorm this post & inadvertently published my rough draft to the website.  My apologies to those of you unfortunate enough to open the site while that was the leading topic - I'm sure it was confusing (& I'm sure it'll happen again).

My emerging technology infancy is such that I consider Psychotherapy Brown Bag (PBB) to be my first real venture into the blogosphere.  Before undertaking this project, I read a few blogs sporadically (i.e., when I remembered that they existed) but never commented on one, wrote a post for one, or even really understood what they were all about.  When I began to immerse myself into the blogosphere (I find that word really fun), I discovered a lot of interesting things.  So for all of our readers who consider themselves emerging technology neophytes as well, I thought I would write about the cool things I discovered - especially quick & easy ways to keep up with research in clinical psychology without leaving your web browser.

1)  "I can't remember to keep refreshing all of the websites to see if they've posted anything new": The most important technology facet I learned about is feed subscription.  Before PBB, I wasn't a very reliable blog consumer mostly because I forgot to go to the website & look for new posts.  What I discovered is that almost every news source on the internet has an RSS feed that you can subscribe to (you can find them by looking for the orange logo - see it to your right on PBB next to "Subscribe in a reader"). By subscribing to a site's RSS feed, & then subscribing to a feed reader, you can get information from 100s of websites (blogs, newspapers, etc.) all in one screen.  I use Google Reader because it's free & because I use Google for almost everything else in my life.  Within Google Reader, I can get updated headlines from People.com & the New York Times Health section alongside the latest articles published in JAMA & Archives of General Psychiatry.  This is a valuable resource for keeping current with the latest clinical psychology research.  Most empirical journals have a feed you can subscribe to & when a new issue is published or a new study is posted early online you get an update in your reader.  Some sources only provide the article title, others give you the full abstract or a some other summary.  It varies greatly.  But by subscribing to a feed, you can gather as much in-depth information as you want - & you won't miss out on any important empirical research!  Here's just a sample of some journals that have feeds: Science, Journal of Abnormal Psychology (actually all of the APA journals), International Journal of Eating Disorders, and Clinical Psychology: Science & Practice.  And when you're setting up your reader, don't forget to subscribe to the PBB feed!

     - if you want to learn more technical information about RSS feeds, check out this really handy New York Times article: "Fine-Tuning Your Filter for Online Information."

2) "That still seems complicated.  I mostly use the Internet for e-mail.": Have no fear, if you don't want to subscribe to a new online service or aren't interested in learning about RSS readers, but you still want to research updates, many journals, blogs, & other news sources will send you e-mail updates.  For example, APA PsycALERT allows you to pick favorite APA journals & then will send you an e-mail when they release a new issue.  Blogs (like PBB) will send you daily summaries of the previous day's posts if you subscribe to them via e-mail. 

3) "Isn't blogging pretty self-indulgent?": That's definitely what I thought when I began really exploring the world of blogs.  In fact, I prefer to call PBB an e-magazine instead of a blog for this very reason.  What I discovered: sure, some blogs are rather self-interested...but there are hundreds of blogs out there that serve as legitimate sources of information. You can get tips on the best tomatoes to grow in a container garden, what's the best wine to serve with chicken tikka masala, or an update on the theories of non-suicidal self-injury (shameless self-promotion).  Several prominent clinical psychologists maintain blogs - Dr. Leahy (see his awesome PBB post on financial worries) blogs at PsychologyToday.com, offering self-help CBT for anxiety and worry. I'm really enjoying Jonathan Kaplan's blog on mindfulness.  Blogs do appear to be an exciting way to disseminate therapy skills, as well as learn about & discuss new trends in therapy, so I am embracing blogs as a way to further educate myself (& the world), in a new & (usually) easier to digest format. 

4) "I only use Facebook for high school reunions.":  Although originally, most of us used social networking sites like Facebook to reconnect with old friends, they are quickly becoming a source for professional networking.  If you are a Facebook subscriber, you might be amazed to discover what kind of information you can gather there.  For example, I was recently made aware of the Preacher & Hayes Facebook group for statistical mediation analysis.  Joining this group provides a direct forum to get advice about mediational analysis & other statistical conundrums.  The Association for Behavioral and Cognitive Therapies has also recently entered the Facebook world, & the National Suicide Prevention Lifeline maintains a Facebook presence.  And don't forget that PBB is on Facebook, too!

And so ends my brief discussion of how to make the Internet work for you - by keeping you updated with findings & trends in the empirical literature.  I'm positive there are many other ways to use the Internet to connect with new empirical research in clinical psychology.  Do you know of any that I have not yet discovered?  Do you have any thoughts or tips on the information above?  If so, please comment on this post, so we can all benefit & discuss.  Happy browsing!