REGULAR ARTICLE

Who is Providing what Type of Psychotherapy to Eating

Disorder Clients? A Survey
Kristin M. von Ranson, PhD*
Kathleen E. Robinson, BA
and addiction-based therapy (6%). Most
ABSTRACT
clinicians (87%) reported frequently using
Objective: Little is known about the
psychotherapies delivered to eating-dis-
CBT techniques with eating-disordered cli-
ents. The reasons given for using primary
ordered clients by community therapists.
therapeutic approaches varied by clini-
We sought to describe the education and
cians’ preferred therapeutic approach
training of psychotherapists working
and education level.
with eating-disordered clients, the psy-
chotherapeutic approaches used, and Conclusion: Clinicians generally choose
the reasons for use. to tailor treatment to individual needs
rather than base decisions on the level
Method: Eligible Calgary clinicians
of empirical support. These findings
were identified and asked to complete
have implications for dissemination of
a 25-item telephone interview.
empirically supported psychotherapies.
Results: The response rate was 74%. ª 2005 by Wiley Periodicals, Inc.
Educational backgrounds and fields of
specialization of clinicians who completed Keywords: psychotherapy; eating-dis-
the survey (n ¼ 52) varied widely, as did ordered patients; cognitive-behavior
the psychotherapies used. The most com- therapy; evidence based practice
mon primary therapeutic orientations of
respondents were eclectic therapy (50%), (Int J Eat Disord 2006; 39:27–34)
cognitive-behavioral therapy (CBT; 33%),

the first-line treatment of choice for bulimia nervosa

Introduction
A recent movement centers on the identification and
use of empirically supported treatments (ESTs)—or
evidence-based psychotherapies—for specific psy-
chological disorders, defined as psychotherapies
whose efficacy has been demonstrated in randomized
controlled trials to be equal to or better than an estab-
lished therapy, or better than an assessment-only
control group (Chambless & Hollon, 1998). Two psy-
chological interventions have demonstrated efficacy
in improving eating disorder symptoms. Cognitive-
behavior therapy (CBT) is generally considered to be
Accepted 26 December 2004
Portions of the current article were presented April 29–May 2,
2004, International Conference on Eating Disorders in Montreal,
Quebec, April 28–30, 2005, and Eating Disorders Research Society
annual meeting in Toronto, Ontario, September 29–October 1,
2005.
The current article is based on Kathleen E. Robinson’s B.A.
Honors research project, which was completed under the
supervision of Kristin M. von Ranson.
*Correspondence to: Kristin M. von Ranson, PhD, Department of
Psychology, University of Calgary, 2500 University Drive NW,
Calgary, Alberta T2N 1N4, Canada. E-mail: kvonrans@ucalgary.ca
Department of Psychology, University of Calgary, Calgary,
Canada
Published online 17 October 2005 in Wiley InterScience
(www.interscience.wiley.com). DOI: 10.1002/eat.20201
ª 2005 Wiley Periodicals, Inc.
(BN; Thompson-Brenner, Glass, & Westen, 2003), and
has also been applied to anorexia nervosa (AN; Vitou-
sek, 2002) and binge eating disorder (BED; Wilfley et
al., 2002). Interpersonal psychotherapy (IPT) has simi-
lar efficacy for BN as CBT, although its effects appear
more slowly (Wilson & Pike, 2001). Group IPT and CBT
appear similarly effective for BED (Wilfley et al., 2002).
In general, most clinicians do not use ESTs,
including for treating eating disorders. Only one
third of psychologists in one survey reported their
primary treatment approach with eating-disor-
dered clients was CBT (Mussell et al., 2000). Seven-
teen percent of psychologists in another survey
indicated that they ‘‘definitely’’ used an empirically
validated treatment with eating-disordered clients
(Haas & Clopton, 2003). In a third study, only 7% of
patients reported having received CBT to treat their
BN (Crow, Mussell, Peterson, Knopke, & Mitchell,
1999). In contrast, a survey of academic medical
center providers found higher rates of use of CBT:
60% recommended CBT for BN frequently and 79%
reported that CBT was available for BN patients
(McAlpine, Schroder, Pankratz, & Maurer, 2004).
Use of IPT for eating disorders appears to be very
limited. Reasons for the underutilization of ESTs
for the treatment of BN have included therapists’
doubts about the generalization of randomized
controlled efficacy trials, perceived constraints of

Int J Eat Disord 39:1 27–34 2006 27

VON RANSON AND ROBINSON
manual-based treatments, and lack of training in
ESTs (Arnow, 1999).
If ESTs are being used by only a few clinicians to
treat eating disorders, what psychotherapies are the
majority of clinicians using? Anecdotal evidence sug-
gests that a variety of therapeutic approaches are
used (c.f., Wilson & Pike, 2001), but no systematic
details are available describing the use of psychother-
apeutic approaches other than CBT and IPT. Virtually
no data are available on the extent of use of such
controversial approaches as addiction-based thera-
pies and eye movement desensitization and repro-
cessing (EMDR; Hudson, Chase, & Pope, 1998;
Wilson, 1999). Delineating untested psychotherapies
is important because it may help to identify promis-
ing treatments and expand the theoretical base of
treatment for eating-disordered clients.
Surveys of clinicians regarding EST use with eat-
ing-disordered clients have focused on psycholo-
gists (Haas & Clopton, 2003; Mussell et al., 2000) or
academic medical center affiliates (McAlpine et al.,
2004). We know little about the frequency of use of,
or attitudes about, psychotherapies by the range of
other community therapists working with those
with eating disorders, such as social workers,
nurses, and paraprofessional counselors, who
have varying training and values (Garfield & Bergin,
1994). It is unknown whether level of education or
primary therapeutic allegiance is associated with
the types of psychotherapy used with eating-disor-
dered clients, including ESTs. In addition, sampling
problems may have affected the reliability of
results obtained in previous research. Surveys of
clinicians have had low to moderate response
rates, ranging from 20% to 55% (Haas & Clopton,
2003; McAlpine et al., 2004; Mussell et al., 2000).
Particularly when response rates are low, results
may be biased if nonrespondents differ from
respondents in important ways (Gore-Felton,
Koopman, Bridges, Thoresen, & Spiegel, 2002). No
information was presented about nonrespondents
in these studies, so this significant potential bias
cannot be evaluated.
The current study ascertained the psychothera-
pies used by community clinicians with their eat-
ing-disordered clients. Telephone interviews were
used because they tend to yield better response
rates than written questionnaires (Miller & Salkind,
2002). Specific aims were to (a) identify psy-
chotherapists in a large metropolitan area who reg-
ularly treated individuals with eating disorders; (b)
describe their training and theoretical orientations;
(c) describe the psychotherapeutic approaches
used with eating-disordered clients; (d) describe
reasons for use of specific therapeutic approaches;
28
and (e) examine whether reasons given for selec-
tion of a therapeutic approach varied as a function
of therapists’ level of education or their primary
therapeutic approach.
Methods
Participants
Individuals eligible to participate included Calgary-
area psychologists, psychiatrists, social workers, and
counselors whose caseloads consistently included indivi-
duals with eating disorders. We made efforts to identify
the full range of mental health professionals and para-
professionals (clinicians or respondents) providing psy-
chotherapy for eating disorders. As no discipline-specific
or comprehensive lists of mental health professionals in
the province were available free of charge, we used three
methods to compile a comprehensive list of potential
participants: (a) individuals and agencies listed in the
Counseling Services and Psychologists sections of the
Calgary Yellow Pages were identified; (b) two local agen-
cies—the Calgary Eating Disorder Program (CEDP) and
the Calgary Distress Centre—and an organization of local
clinicians specializing in eating disorders (Calgary Eating
Disorders Education Network [CEDEN]) were asked to
provide names of mental health clinicians who provided
eating disorder treatment; and (3) we solicited names of
mental health professionals conducting eating disorder
treatment from respondents as well as those who were
ineligible to participate (i.e., ‘‘snowball’’ recruitment).
Materials
We developed a 25-item interview by adapting and
expanding a survey used by Mussell et al. (2000). Six
CEDEN members reviewed a draft of the interview. Mod-
ifications were made according to their feedback, which
primarily involved adding to a list of types of therapeutic
approaches.
The interview contained four sections. Section one
included questions describing the participant’s clientele
(e.g., percentage of their typical caseload comprising indi-
viduals with an eating disorder) and treatment modalities
and settings used (individual/group/family counseling;
outpatient/day/inpatient). Section two assessed the fre-
quency with which respondents used specific treatment
approaches with this population (never/sometimes/
often/always) and respondents’ primary treatment
approach. The following 10 therapeutic approaches were
presented in alphabetical order: addiction-based model
(including a 12-step model), CBT, eclectic therapy,
EMDR, family therapy, IPT, narrative therapy, medication,
psychodynamic therapy, and supportive therapy. Respon-
dents were asked if they used any other approaches or
Int J Eat Disord 39:1 27–34 2006

techniques not already mentioned. Section two also
assessed the use of specific CBT techniques and training
received in manual-based CBT and IPT for the treatment of
eating disorders. Section three assessed reasons for the
respondents’ primary treatment approach, as well as inter-
est in obtaining training for manual-based CBT and IPT for
eating disorders. Section four collected demographic data,
including information about highest educational degree,
field of training, and licensing status. Finally, respondents
were offered the opportunity to be listed in the provincially
funded CEDP’s community resource directory. If they
responded positively, their contact information was for-
warded to the CEDP.
Procedure
The current study received approval from the Univer-
sity of Calgary’s research ethics board and informed con-
sent was obtained from all participants. Potential
participants were contacted by telephone and informed
about the study and eligibility requirements. An inter-
view was scheduled if a clinician was interested. If the
researcher did not reach a potential participant directly,
a message was left. If no response was received within 2
weeks, the researcher made a second call. After data
collection was completed, responses to open-ended
questions (e.g., ‘‘other’’ responses) were coded to enable
analysis. Chi-square tests of group differences, when
used, are described. Otherwise group differences were
not assessed.
This research was reviewed and approved by an insti-
tutional review board.
Results
Sample
A total of 355 potential participants were identi-
fied and contacted. Eighty-one percent (n ¼ 287)
returned the researcher’s telephone calls. Of these,
26% (n ¼ 74) regularly treated individuals with
eating disorders and were eligible to participate in
the study. By the end of data collection, no new
clinicians’ names were being suggested by respon-
dents, suggesting the identification strategy for eli-
gible clinicians was adequately comprehensive.
Fifty-five eligible respondents completed the inter-
view (a response rate of 74%), and 95% (n ¼ 52) of
completed interviews were eligible for analyses.
Two interviews were removed from analysis
because eating disorder symptoms were not a
focus of treatment, and one was removed because
the counseling provided was nutritional, not psy-
chotherapeutic. Completed interviews ranged from
Int J Eat Disord 39:1 27–34 2006
PSYCHOTHERAPY SURVEY
20 to 25 min in duration. The following results are
based on the 52 eligible interviews.
The sample included 43 women (83%) and 9 men
(17%). Respondents’ mean age was 45.9 (SD ¼ 9.3)
years, and the mean number of years since receiving
their most advanced degree was 13.2 (SD ¼ 9.5). Most
respondents were Caucasian (84.6%). The remaining
respondents were Asian (3.8%), of mixed ethnicity
(3.8%), or described their ethnicity as ‘‘other’’ (7.7%).
Eating-disorders patients comprised a median of
12% of respondents’ caseloads and a mean of
29.8% (SD ¼ 32.8%, range ¼ 1%–100%). All respon-
dents provided psychotherapy for individuals with
eating disorder diagnoses as defined in the 4th ed.,
text revision, of the Diagnostic and Statistical Man-
ual of Mental Disordfers (American Psychiatric
Association, 2000). However, individual clinicians
did not necessarily treat all eating disorder types:
80.8% treated BN, 69.2% treated AN, 59.6% treated
BED, and 50.0% treated eating disorders not other-
wise specified (EDNOS). All respondents con-
ducted psychotherapy with eating-disordered
adults older than age 17 years; 59.6% also treated
adolescents and 17.3% also treated children
younger than age 13 years with eating disorders.
Modalities of treatment included individual ther-
apy (100%), family therapy (61.6%), group therapy
(36.5%), couples’ therapy (30.8%), and day treat-
ment (7.6%) for eating disorders.
Education, Licensing, and Training of
Clinicians
Participants’ educational attainment ranged
from graduate degrees—50.0% had master’s
degrees and 34.6% had doctorate degrees—to
bachelor’s degrees (9.6%) and high school diplo-
mas or less education (5.7%). In subsequent ana-
lyses involving education level, we combined
individuals with bachelor’s degrees and less edu-
cation. Fields of highest degree included counsel-
ing psychology (38.5%), clinical psychology
(21.2%), social work (19.2%), nursing (3.8%), edu-
cation (1.9%), marriage and family counseling
(1.9%), medicine (1.9%), occupational therapy
(1.9%), psychiatry (1.9%), general psychology
(1.9%), and social psychology (1.9%). Most
respondents were licensed through the College of
Alberta Psychologists (48.1%), the Alberta College
of Social Work (26.9%), the American Association
of Marriage and Family Therapy (9.6%), or the
Canadian College of Physicians and Surgeons
(1.9%). Alberta does not regulate the provision of
psychotherapy or counseling, or require licensing
of marriage and family therapists—hence not all
29
VON RANSON AND ROBINSON

respondents were licensed—but does require the
licensing of practicing psychologists, social work-
ers, and physicians.
Training in Eating Disorder Treatment
Ninety-six percent of respondents (n ¼ 50)
reported having received training in eating disor-
ders treatment. The most common training
received was attending workshops or seminars
(71.2%), followed by self-education/reading
(53.8%), informal supervision (receiving ad hoc
feedback from a trained colleague; 57.7%), clinical
training (formal education received in the context
of graduate training; 42.3%), and formal supervi-
sion (regular, planned supervision meetings with a
trained colleague; 32.7%). Eight percent received
training after being hired at a clinic specializing in
eating disorder treatment. A few respondents
reported having received training in the use of
manual-based CBT (38.5%) or IPT (17.3%) for eat-
ing disorders, but few could name the author(s) of
the manuals on which their training was based.
Most respondents indicated they would like to
receive training in CBT (82.7%) or IPT (76.9%) for
eating disorders if it were readily available.
Psychotherapeutic Orientation and
Approaches
Primary Orientation. Table 1 presents the primary
psychotherapeutic approaches for the entire sample
as well as subdivided by clinicians’ educational level.
One half of respondents described their primary psy-
chotherapeutic approach as eclectic, and one third
reported using CBT as their primary psychotherapeu-
tic approach. The remaining respondents identified a
range of other therapies as their primary approaches.
Clinicians’ primary therapeutic approach varied sig-
nificantly as a function of level of education. For
example, more highly educated respondents were
more apt to report using CBT with eating disorder
clients, whereas respondents with less formal educa-
tion were more apt to report using an addiction-
based approach, w2(10, N ¼ 50) ¼ 23.98, p < .01.
Only master’s level clinicians reported using IPT
and EMDR as primary treatment approaches.
Use of Therapeutic Approaches. Regardless of the pri-
mary approach, the therapeutic approach most fre-
quently used was CBT, which a majority (59.6%) of
clinicians endorsed always using. Other treatment
techniques used by a majority of clinicians often or
always included eclectic therapy, IPT, supportive
therapy, and other therapy. Eclectic approaches
were described as mixing CBT (44.2%), IPT
(13.5%), EMDR (11.5%), strategic or solution-
focused therapy (11.5%), addiction-based therapy
(11.5%), feminist therapy (9.6%), narrative therapy
(9.6%), hypnosis (7.7%), and systems theory (5.8%).
Other approaches included team-based therapy
(17.3%), feminist therapy (9.6%), solution-focused
therapy (9.6%), spirituality (3.8%), self-disclosure
(3.8%), psychoeducation (3.8%), and play therapy
(3.8%). In addition, 61.5% of respondents indicated
that they often or always worked with, or referred
eating disorder clients to, a physician.
Respondents reported using the following CBT
techniques often or always: relapse prevention
(92.3%), cognitive restructuring (90.4%), self-mon-
itoring (86.6%), stimulus control techniques

TABLE 1. Clinicians’ use of psychotherapeutic techniques with eating disorder clients, as endorsed by the sample
overall and as cross-classified by respondents’ level of education (in percent)
Total Sample (N ¼ 52)  Bachelor’s (n ¼ 8) Master’s (n ¼ 26) PhD (n ¼ 18)

Primary Often/Always Primary Often/Always Primary Often/Always Primary Often/Always

Addictions 5.8 23.1 42.9 50.0 0 19.2 0 16.7

CBT 32.7 86.5 0 87.5 42.3 84.6 35.3 88.9
Eclectic 50.0 75.0 57.1 62.5 46.2 80.8 58.8 72.2
EMDR 1.9 15.4 0 0 3.8 15.4 0 22.2
Family 0 28.8 0 25.0 0 38.5 0 16.7
IPT 1.9 53.8 0 62.5 3.8 53.8 0 50.0
Narrative 1.9 25.0 12.5 37.5 0 26.9 0 16.7
Psychodynamic 0 19.2 0 25.0 0 26.9 0 5.6
Supportive 0 71.2 0 62.5 0 84.6 0 55.6
Hypnotherapy 0 11.5 0 12.5 0 11.5 0 11.1
Meditation 0 3.8 0 0 0 3.8 0 5.6
TFT 0 0 0 0 0 0 0 0
Alternativea 1.9 1.9 0 0 0 3.8 5.6 0
Otherb 3.8 34.6 0 42.9 3.8 29.2 5.6 33.3

Note: Percentages are given with respect to the n stated for each column. Primary ¼ primary psychotherapeutic approach used; often/always ¼
approach used often or always; CBT ¼ cognitive-behavioral therapy; EMDR ¼ eye movement desensitization and reprocessing; IPT ¼ interpersonal
psychotherapy; TFT ¼ thought field therapy.
a
Naturopathy, guided imagery, integrative body psychotherapy.
b
Other ¼ feminist (n ¼ 1 PhD), solution-focused (n ¼ 1 Master’s).

30 Int J Eat Disord 39:1 27–34 2006

 PSYCHOTHERAPY SURVEY

(69.2%), formal problem solving (65.4%), written
homework (63.5%), and prescribing distracting
activities (57.7%). Rates of use of these key compo-
nents of CBT indicate adequate agreement
between our and respondents’ definitions of CBT.
Reasons for Use of Primary Therapeutic
Approach
Respondents were allowed to endorse multiple
reasons for use of approaches they used. The
most common reason clinicians gave for using
their primary treatment approach was that perso-
nal clinical experience indicated it was effective
(Table 2). Other frequently endorsed reasons were
that it was supported by research or consistent with
their theoretical orientation. When asked for the
single most important reason for using their pri-
mary treatment approach, the most common
responses were that it was supported by research
and that it was flexible and could be tailored to
individual client needs. However, fewer than one
half of the clinicians rated these two reasons as
most important. Responses were divided across a
number of reasons.
Clinicians without a graduate degree were signif-
icantly more likely than those with a graduate
degree to report they used an approach because it
was recommended by supervisors or colleagues, w2
(2, N ¼ 52) ¼ 11.44, p < .01, and because they were
trained in that approach, w2 (2, N ¼ 52) ¼ 8.96, p <
.05. However, no differences were found for other
reasons given. No significant differences for most
important reasons for use as a function of educa-
tion level emerged (p > .05).
We also examined whether the most important
reasons given for the use of a primary psychother-
apeutic approach varied as a function of clinicians’
primary approach. Reasons given differed signifi-
cantly by the type of primary approach used, w2
(35, N ¼ 52) ¼ 49.97, p < .05. CBT clinicians were
more likely to report that they used CBT because it
is supported by research (52.9%) and consistent
with their theoretical orientation (23.5%), whereas
clinicians who used addiction-based or IPT
approaches were more likely to report using those
approaches because their personal clinical experi-
ence indicated their effectiveness (66.7% and 100%,
respectively). The most common reasons endorsed
by eclectic clinicians for use of their approach
included the following: it was flexible and could be
tailored to each client (38.5%), it was consistent with
their theoretical orientation (15.4%), it was sup-
ported by research (11.5%), or their personal clinical
experience indicated it was effective (11.5%). Simi-
larly, 33.3% of addiction-based clinicians and the
sole EMDR clinician used their approach because
it had worked for their own recovery.
Finally, 26.9% of participants used, and 15.4%
referred eating disorder clients to, addiction-based
treatment approach often or always. The most
common reasons given for using an addiction-
based approach were client preference (28.8%),
the view that behavior patterns in eating disorders
were similar to those of traditional addictions such
as substance abuse (15.4%), to provide clients with
added support (11.5%), and because their clinical
experience suggested it was effective (9.6%).
Conclusion
This telephone interview study ascertained the
educational and training backgrounds and treat-
ment preferences of Calgary psychotherapists who
regularly treated individuals with eating disorders.
A high response rate (74%) was obtained, indicat-
ing we may have a greater degree of confidence
that these findings represent the views of commu-
nity eating disorder clinicians than findings of pre-
vious research, which had uniformly lower rates of

TABLE 2. Clinicians’ reasons for use of primary psychotherapeutic approach with eating disorder clients, as
endorsed by the sample overall and cross-classified by respondents’ highest educational degree (in percent)
Total Sample (n ¼ 52)  Bachelor’s (n ¼ 8) Master’s (n ¼ 26) PhD (n ¼ 18)

Reason Most Reason Most Reason Most Reason Most

for Use Important for Use Important for Use Important for Use Important

Supported by research 38.5 23.1 25.0 0 38.5 26.9 44.4 27.8

Recommended by others** 3.8 0 25.0 0 0 0 0 0
Consistent with own orientation 38.5 17.3 37.5 0 30.8 23.1 50.0 16.7
Compatible with own clinical style 11.5 1.9 12.5 0 11.5 0 11.1 5.6
Experience indicates effective 59.6 15.4 75.0 37.5 69.2 11.5 38.9 11.1
Trained in approach* 23.1 5.8 62.5 12.5 11.5 3.8 22.2 5.6
Other 73.1 36.5 87.5 50.0 69.2 34.6 72.2 33.3
Flexible 26.9 19.2 12.5 12.5 26.9 19.2 33.3 22.2
Worked for own eating disorder recovery 9.6 5.8 37.5 12.5 3.8 3.8 5.6 5.6

Note: Percentages given are with respect to the n stated for each column.
*p  .05. **p  .01; indicates statistically significant effect of level of education on reasons given for use of a psychotherapeutic technique.

Int J Eat Disord 39:1 27–34 2006 31

VON RANSON AND ROBINSON
response. Overall, approximately one fourth of
community clinicians conducting psychotherapy
in Calgary regularly treated eating-disordered cli-
ents. These clinicians had diverse educational
backgrounds, both in the area of focus and in the
level of training. Most clinicians (85%) had gradu-
ate degrees.
Clinicians endorsed using varied psychotherapeu-
tic approaches with their eating-disordered clients,
including ESTs such as CBT and IPT as well as
numerous other approaches, including EMDR,
addiction-based, feminist, and narrative therapy, to
name just a few. The current study identified a
greater number of psychotherapeutic approaches in
use by therapists than had previous research. One
third of respondents reported using ‘‘other’’
approaches that were not included in our lengthy
list of approaches believed to be used with eating-
disordered clients. The diversity of approaches
endorsed reflects a recent trend toward a prolifera-
tion of psychotherapies (Garfield & Bergin, 1994) and
presents challenges in defining and distinguishing
among specific therapies. To evaluate the efficacy
of more diverse psychotherapies in use, it will be
essential to identify both commonalities among
and boundaries between distinct approaches.
Consistent with previous research (Haas & Clop-
ton, 2003; Mussell et al., 2000), the psychotherapy
most commonly used by these community clini-
cians with their eating-disordered clients was
CBT. Although slightly fewer clinicians in the cur-
rent study reported using CBT as their primary
therapeutic approach than in previous research
(33% vs. 39%), more (87% vs. 65%) reported fre-
quently using CBT techniques (Mussell et al.,
2000). This finding may result, in part, from sam-
pling differences. The current sample was limited
to clinicians who regularly treated individuals with
eating disorders and so may have had elevated
awareness of the empirical support for CBT for
BN, or may reflect regional differences in training
in specific psychotherapeutic approaches. CBT was
used by many clinicians who identified their pri-
mary treatment approach as other than CBT. One
half of clinicians described their primary treatment
approach as eclectic. Although this rate was almost
double that reported in previous research (Mussell
et al., 2000), the high rate of eclecticism found in
the current study is not entirely surprising given
that previous studies of psychotherapists have
shown that 29%–68% considered their treatment
approach to be eclectic or integrative (Garfield &
Bergin, 1994). More and more psychotherapists
have been embracing eclecticism (Garfield & Ber-
gin, 1994). We found that CBT was the most com-
32
mon therapeutic element in clinicians’ eclectic
approaches, although other forms of psychother-
apy, including IPT, EMDR, strategic or solution-
focused, and addiction-based therapy, were also
incorporated.
Despite the frequent use of CBT with eating-dis-
ordered clients, relatively few clinicians have had
training in manual-based CBT for eating disorders.
That very few clinicians could name the primary
author of the CBT and IPT manuals with which
they were trained raises questions about the treat-
ment they obtained and whether they were really
using those ESTs. Previous research also has found
relatively low rates of training in EST manuals for
eating disorders (Mussell et al., 2000). Strong inter-
est was expressed by respondents in obtaining
training in manual-based CBT and IPT for eating
disorders, however.
A unique, novel finding of the current study is
that level of education and allegiance to a primary
treatment approach each was associated with the
treatment approaches chosen as well as reasons
given for using a therapeutic approach with eat-
ing-disordered clients. CBT was used more often
by more highly educated respondents, whereas an
addiction-based approach was used more often
by less educated respondents. Different reasons
tended to be given by adherents to different pri-
mary therapeutic approaches. For example, CBT
was used because it is supported by research and
was consistent with the respondents’ theoretical
orientation. Eclectic approaches were used because
respondents wished to tailor treatment compo-
nents to individual client needs and get at ‘‘root
issues’’. Addiction-based, IPT, eclectic, and EMDR
approaches were used because respondents’ clini-
cal experience suggested they were effective, espe-
cially because they had worked for clinicians’
personal eating disorder recovery. These findings
likely reflect, in part, fundamental, discipline-spe-
cific differences in values regarding and training in
psychotherapy. Insight into differing treatment-
related motivations and perspectives of clinicians
may help inform future EST dissemination efforts.
Given that the most common reason overall for
selecting a primary therapeutic approach was that
clinicians’ personal clinical experience indicates
the approach is effective, we conclude that clini-
cians prefer to use their judgment about what psy-
chological treatment(s) will best help an individual
client. Although this desire to tailor treatments to
individual needs has face validity, it may be mis-
guided. Reliance on clinical judgment is at odds
with a body of research on clinical versus actuarial
prediction indicating that, on the whole, actuarial
Int J Eat Disord 39:1 27–34 2006

methods are superior, in part, because clinicians
tend to identify too many exceptions to effective
rules (Dawes, Faust, & Meehl, 1989). Controlled
research has demonstrated that CBT and, seconda-
rily, IPT, have the greatest efficacy for BN (National
Institute for Clinical Excellence, 2004; Thompson’-
Brenner et al., 2003), so these are the treatment
decisions with the greatest likelihood for success.
However, community clinicians are not basing
treatment decisions on this evidence. Future
research should explicitly examine clinicians’
awareness of the literature on eating disorder treat-
ment efficacy and the fallibility of human judgment
when selecting treatments for clients.
We also conclude that numerous psychothera-
pies that have been the focus of little or no empiri-
cal research to date are in use by psychotherapists
in the treatment of eating disorders. For example,
an addiction-based approach was the third most
commonly used primary approach endorsed, after
eclectic therapy and CBT, by the clinicians sur-
veyed. Almost one fourth of respondents used prin-
ciples of the addictions model of eating disorders
often or always with their eating disorder clients,
and more than one half used addiction-based
approaches at least sometimes. Most respondents
either applied the 12-step approach, typically
incorporating it into sessions, or referred clients
to 12-step groups. The current study is the first to
document the common use of addiction-based
approaches with eating-disordered clients.
Whereas some advocate integrating the 12-step
model with traditional psychotherapy to treat
some adults with eating disorders (e.g., Johnson &
Sansone, 1993), others argue that the empirical
literature does not support this conceptualization
(Wilson, 2002). There is a pressing need to recon-
cile theory and empirical findings related to the
addiction-based model of eating disorders, given
the frequent use of addiction-based therapeutic
approaches with eating-disordered clients.
One study limitation is that it is unclear how the
results of the current study, because of the restricted
geographic area involved, would generalize to other
locations. Although we pursued as inclusive a strat-
egy as we were able in identifying the range of
clinicians who were performing psychotherapy
with eating-disordered clients, it is difficult to be
certain that we successfully identified every indivi-
dual or class of therapists. A listing in the Yellow
Pages costs money, which could have biased the
sampling. However, we were aware of no other
means by which to identify all (or a majority of)
city therapists. This study focused on describing
psychotherapy use by clinicians with differing train-
Int J Eat Disord 39:1 27–34 2006
PSYCHOTHERAPY SURVEY
ing backgrounds, rather than for specific eating dis-
order diagnoses or specific age groups. Future
research that obtains a more fine-grained descrip-
tion and analysis of therapeutic approaches used
with specific eating disorder diagnoses, ideally
divided by age groups, would be valuable. Finally,
the results may have suffered from response biases,
such as for questions eliciting particular responses,
for example, whether the respondent was trained in
manual-based CBT for eating disorders.
In sum, the current study provides a description
of the psychotherapeutic practices of clinicians
who work with eating-disordered clients and
insight into their reasons for selecting particular
treatment approaches, and may inform future
research into the dissemination of ESTs and alter-
native therapies to evaluate in efficacy research. If
many researchers value using ESTs with eating-dis-
ordered clients, it is evident that many clinicians
do not share this perspective. Continued research
into psychotherapeutic choices made by front-line
clinicians will be essential in bridging this gap
between researchers and clinicians and providing
optimally effective psychotherapies to eating- dis-
ordered clients.
The authors thank Melissa P. Mussell, PhD for kindly
sharing her survey, Jean E. Wallace, PhD, for generously
sharing her expertise on survey design and imple-
mentation, Carol B. Peterson, PhD, for her helpful
comments on a previous version of the current article, and
the clinicians whose participation made this research
possible.
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