The Efficacy and Effectiveness of Online CBT - Jeroen Ruwaard

88 Chapter 5. Online CBT of Bulimic Symptomstoo greatly from the intended pace.The treatment is structured into five phases and defines 24 scheduled therapistfeedback moments (phase 1-4: five feedback texts; phase 4: four feedback texts). Fulltreatment requires approximately 13 hours of therapist time.Phase 1 serves to raise client awareness and defines the goals for treatment. Clientsreceive psycho-education on causes and maintaining factors of BN, and engage in selfmonitoringand structured writing exercises to gain insight into their eating problems.Next, they are introduced to a generic set of self-control procedures designed to reducethe probability of binge eating and compensatory behavior. With therapist assistance,clients learn how to prepare a personal self-control plan by tailoring these genericprocedures to their specific situation. In the early phase of treatment, the clientsreceive psycho-education with regard to the differences in dynamics between bingeeating and compensatory behavior. While binge eating is considered to be triggeredby a loss of impulse control, compensatory behavior is considered to be a deliberate,voluntary and ’rational’ response to reduce weight increase after binge eating episodes(Lange et al., 1994). Accordingly, clients are requested to sign an agreement to quitcompensatory behavior.In phase 2, clients begin to apply their personalized self-control plan and postregular reports of successes and difficulties in executing the plan. Clients evaluate theirplan based upon their experiences and make adjustments, if needed. Self-monitoringis intensified by planning meals and daily activities ahead of time, to gain betterinsight in the pattern of binge eating and compensatory behaviors, and to learn howto prevent these behaviors. In this phase, clients are also encouraged to disclose theireating problems to a trusted person.In phase 3, cognitive restructuring techniques are introduced. Clients compose alist of short statements reflecting dysfunctional attitudes and opinions, and challengethese statements by formulating alternative interpretations. In addition, clientsconduct several behavioral experiments to challenge key attitudes and opinions inreal-life situations. They carefully prepare these experiments and anticipate onpossible outcomes. Before the client actually conducts the experiment, the therapistensures that the experiments are practicable and realistic, and have a good chance ofsuccess. As in phase 2, experiences are used to evaluate and adjust the self-control