Psychotherapy Research

ISSN: 1050-3307 (Print) 1468-4381 (Online) Journal homepage: http://www.tandfonline.com/loi/tpsr20

Patient baseline interpersonal problems as

moderators of outcome in two psychotherapies
for bulimia nervosa

Juan Martin Gomez Penedo, Michael J. Constantino, Alice E. Coyne,

Samantha L. Bernecker & Lotte Smith-Hansen

To cite this article: Juan Martin Gomez Penedo, Michael J. Constantino, Alice E. Coyne,
Samantha L. Bernecker & Lotte Smith-Hansen (2018): Patient baseline interpersonal problems as
moderators of outcome in two psychotherapies for bulimia nervosa, Psychotherapy Research, DOI:
10.1080/10503307.2018.1425931

To link to this article: https://doi.org/10.1080/10503307.2018.1425931

Published online: 19 Jan 2018.

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Psychotherapy Research, 2018
https://doi.org/10.1080/10503307.2018.1425931

EMPIRICAL PAPER

Patient baseline interpersonal problems as moderators of outcome in

two psychotherapies for bulimia nervosa

JUAN MARTIN GOMEZ PENEDO1, MICHAEL J. CONSTANTINO2, ALICE E. COYNE2,

SAMANTHA L. BERNECKER 2∗ , & LOTTE SMITH-HANSEN3
1
CONICET & Department of Psychology, Universidad de Buenos Aires, Buenos Aires, Argentina; 2Department of
Psychological and Brain Sciences, University of Massachusetts Amherst, Amherst, MA, USA & 3Department of Psychology,
Suffolk University, Boston, MA, USA
(Received 21 July 2017; revised 2 January 2018; accepted 3 January 2018)

Abstract
Objective: We tested an aptitude by treatment interaction; namely, whether patients’ baseline interpersonal problems
moderated the comparative efficacy of cognitive-behavioral therapy (CBT) vs. interpersonal psychotherapy (IPT) for
bulimia nervosa (BN). Method: Data derived from a randomized-controlled trial. Patients reported on their interpersonal
problems at baseline; purge frequency at baseline, midtreatment, and posttreatment; and global eating disorder severity at
baseline and posttreatment. We estimated the rate of change in purge frequency across therapy, and the likelihood of
attaining clinically meaningful improvement (recovery) in global eating disorder severity by posttreatment. We then tested
the interpersonal problem by treatment interactions as predictors of both outcomes. Results: Patients with more baseline
overly communal/friendly problems showed steeper reduction in likelihood of purging when treated with CBT vs. IPT.
Patients with more problems of being under communal/cold had similar reductions in likelihood of purging across both
treatments. Patients with more baseline problems of being overly agentic were more likely to recover when treated with
IPT vs. CBT, whereas patients with more problems of being under agentic were more likely to recover when treated with
CBT vs. IPT. Conclusions: Interpersonal problems related to communion and agency may inform treatment fit among
two empirically supported therapies for BN.

Keywords: interpersonal problems; moderators; cognitive-behavioral therapy (CBT); interpersonal psychotherapy (IPT);
bulimia nervosa

Clinical or methodological significance of this article: Patients with bulimia nervosa (BN) who presented with more
problems of an overly communal/friendly and/or under agentic/submissive nature showed greater improvement in
cognitive-behavioral therapy (CBT) vs. interpersonal psychotherapy (IPT). Patients with more problems of being overly
agentic/domineering were more likely to recover when treated with IPT vs. CBT, whereas patients with more problems of
being under communal/cold had a similar outcome in the two treatments. These aptitudes (trait) by treatment interactions
suggest that it is important to assess baseline interpersonal problems to help establish which of these two empirically
supported therapies would, on average, be a better fit for patients with BN.
Both cognitive-behavioral therapy (CBT) and inter- Brenner et al., 2016). It is possible that such residual
personal psychotherapy (IPT) have demonstrated symptoms, or lack of clinically significant response
general efficacy in treating bulimia nervosa (BN; altogether, could stem, at least partially, from patients
Hay & Claudino, 2010; Wilson & Shafran, 2005). being poorly suited for CBT or IPT—two vastly
However, a substantial proportion of bulimic patients different approaches for treating BN.
receiving these treatments continue to experience On the one hand, CBT focuses explicitly on BN
symptoms after therapy ends (Agras, Walsh, Fair- symptoms. The model assumes that dysfunctional
burn, Wilson, & Kraemer, 2000; Thompson- (rigid and unrealistic) beliefs about food, eating

Correspondence concerning this article should be addressed to Juan Martin Gomez Penedo CONICET & Department of Psychology, Uni-
versidad de Buenos Aires, 2353 Lavalle St., Ciudad de Buenos Aires, Argentina. Email: juanmartin.gomez@comunidad.ub.edu.ar
∗
Present address: Department of Psychology, Harvard University, Cambridge, MA, USA.

© 2018 Society for Psychotherapy Research

2 J. M. Gomez Penedo et al.
behaviors, and perceptions of body weight/shape
underlie the development and maintenance of the
disorder (Spangler, 1999). Consequently, the CBT
clinician uses multiple directive strategies to increase
adaptive eating, and to challenge distorted thought
processes about food, weight, and shape. On the
other hand, IPT centers not on BN symptoms expli-
citly, but rather on interpersonal difficulties that
implicitly connect to the manifest pathology (Apple,
1999). The model assumes that interpersonal pro-
blems, such as role disputes or unresolved grief, pre-
cipitate BN problems. Thus, the IPT clinician uses
multiple active, yet nondirective, strategies to
implement adaptive interpersonal change, increase
social support, and reduce relational distress, all of
which are purported to facilitate long-term
reductions in disordered eating symptoms, without
ever discussing such symptoms directly.
Given that CBT and IPT represent two clearly dis-
tinct approaches to treating BN, it seems important
to identify factors that might optimize bulimic
patients’ match to one of these evidence-based thera-
pies. One class of factors that might influence differ-
ential treatment response is the theoretically relevant
individual characteristics with which BN patients
present; that is, aptitude by treatment interactions
(ATIs; Accurso et al., 2016). Many BN theories
posit that maladaptive interpersonal functioning is
implicated in the genesis and maintenance of the dis-
order. From this pathoplasticity perspective
(Hopwood, Clarke, & Perez, 2007), individuals
with BN have evidenced a variety of elevated social
problems compared to healthy controls (Tanofsky-
Kraff & Wilfley, 2010), and several types of interper-
sonal difficulties have been associated with greater
severity of BN symptomatology (e.g., Ansell, Grilo,
& White, 2012).
To more precisely characterize prototypic interper-
sonal difficulties in persons with BN, some research-
ers have drawn on the Inventory of Interpersonal
Problems-Circumplex version (IIP-C; Horowitz,
Alden, Wiggins, & Pincus, 2000), a measure of inter-
personal excesses and inhibitions distributed in circu-
lar fashion around the two relational dimensions of
agency (ranging from problematic submissive to pro-
blematic domineering behaviors) and communion
(ranging from problematic hostile/cold to proble-
matic friendly/nurturing behaviors; Horowitz et al.,
2000). Two-dimensional combinations of agency
and communion create eight specific problem
vectors that reflect being too domineering, intrusive,
self-sacrificing, overly accommodating, nonassertive,
socially inhibited, cold, and/or vindictive.
Across three relevant IIP-C studies with clinical
BN samples, individuals reported significantly more
overall distress (total score) from interpersonal
problems than non-clinical control participants;
however, supporting the notion that interpersonal
problems in BN individuals are heterogeneous, one
study found problems to be primarily of the overly
submissive type (Hartmann, Zeeck, & Barrett,
2010), whereas the others (e.g., Hopwood et al.,
2007) found problem profiles evenly distributed
across the IIP-C vectors. In a study examining the
association between interpersonal problems and
bulimic episodes in a non-clinical sample, the
researchers found an indirect effect; higher levels of
overall interpersonal problems were related to
greater negative affect, which, in turn, was related
to a higher probability of having an objective
bulimic episode (Ansell et al., 2012). Additionally,
several specific types of interpersonal problems
related to bulimic episodes either directly or
indirectly. First, individuals with more problems
related to being overly friendly/nurturant (i.e., one
extreme end of the communion dimension) were
more likely to have bulimic episodes. Second,
patients with more problems related to being overly
hostile/cold (i.e., the other extreme end of the com-
munion dimension) reported more negative affect
that, in turn, related to a higher probability of
bulimic episodes.
Based on the literature, interpersonal problems
appear to be candidate aptitudes (or more precisely,
in this case, traits) that may moderate patient
response to CBT and IPT for BN, which, as noted,
are the current individual psychotherapies with the
most empirical support. To date, though, research
on these approaches has largely focused on their
general efficacy (Agras et al., 2000). We are unaware
of studies that have examined interpersonal ATIs,
despite the promise such a focus holds for empirically
responsive treatment selection (Constantino,
Boswell, Bernecker, & Castonguay, 2013). To this
end, the present study focused on this interpersonal
trait × treatment question. Given that previous
research has generally failed to isolate specific prototy-
pic IIP-C vectors that characterize BN, and/or has
implicated the foundational IIP-C dimensions of
agency and communion in BN symptom severity,
we reasoned that these dimensions would be most
likely to inform treatment suitability. Regarding
agency, it may be that BN patients with an interperso-
nal style of, and need for, being overly domineering
toward others may have difficulty deferring to and fol-
lowing the CBT therapist’s directive style centered on
reducing disordered eating cognitions and behaviors
(Fairburn, Cooper, & Shafran, 2003). Rather,
patients with a more domineering problem style
may be better suited for IPT given its focus on the
interpersonal difficulties that underlie eating pro-
blems. To the extent that a pattern of problematic

dominance emerges in the interpersonal assessment,
treatment can help patients more effectively navigate
self and other needs for agency in relationships
(Wilson, 1996). With such interpersonal gains may
come less risk for disordered eating behavior (even
in the absence of specific work on eating-relevant
cognitions and actions).
On the contrary, patients with an interpersonal
style of, and need for, being overly submissive to
others may find the CBT therapist’s directive,
symptom-focused approach suitable to their typical
way of relating. With this complementary pattern of
therapist influence and patient deference, it is poss-
ible that CBT strategies would work well for these
patients, at least with regard to improving eating
symptoms in the short-term. However, with excessive
submissiveness often manifesting as treatment com-
pliance (Muran, Segal, Samstag, & Crawford,
1994), it is possible that the interpersonal focus of
IPT might overlook this behavior as problematic.
Thus, the IPT therapist’s focus on other interperso-
nal contents (and not specific eating symptoms, as
is proscribed in IPT), may miss the mark on a likely
interpersonal risk factor of limited effective assertive-
ness. Consequently, these patients may do less well in
this time-limited treatment.
Regarding communion, BN patients with an inter-
personal style of, and need for, being overly cold and
distant from others might have difficulty working with
a CBT therapist who tends toward an expert stance
and active working relationship. In other words, the
CBT therapist’s bid for active collaboration may
prove too threatening to the person motivated to
keep hostile distance from others (albeit to maladap-
tive consequence). With such threat could come
heightened reactance or resistance, which could
undermine adaptive therapeutic process and gain
(e.g., Beutler, Harwood, Michelson, Song, &
Holman, 2011). Rather, patients with a colder
problem style may be better suited for IPT, where
the therapist might be able to target the hostility/cold-
ness (as a factor that underlies the BN) with a more
nondirective stance less likely to promote negative
process.
On the contrary, patients with an interpersonal
style of being overly communal/friendly toward
others may find the CBT therapist’s directive,
symptom-focused approach suitable and effective in
that it never challenges this pattern as problematic
(rather, it may capitalize on the need for communion,
which will likely enhance the active collaboration that
is presumably central to CBT efficacy). However, if
the IPT therapist targets the patient’s need for com-
munion and close connection as problematic, the
patient who may fail to see this behavior as proble-
matic could resist this direction (thereby
Psychotherapy Research 3
undermining IPT’s central focus that purportedly
drives its efficacy).
Of course, these moderator ideas require testing,
which was our aim in this study drawing on a large
sample of women with BN who were treated with
individual CBT or IPT in the context of a random-
ized-controlled trial (RCT; Agras et al., 2000). We
hypothesized that patients both with more baseline
problems of being overly submissive and overly
friendly would demonstrate more improvement in
CBT vs. IPT, whereas patients with more baseline
problems of being overly domineering and overly
cold/hostile would demonstrate more improvement
in IPT vs. CBT. Improvement was operationalized
as (i) a continuous measure of purge frequency over
the course of treatment and (ii) a dichotomous
measure of clinically meaningful improvement from
baseline to posttreatment on a global index of
eating disorder symptoms.
Method
Data derived from the aforementioned RCT that
compared CBT and IPT for BN across two sites:
Stanford University and Columbia University (see
Agras et al., 2000, for additional design and
primary outcome details). At posttreatment, CBT
significantly outperformed IPT in terms of the pro-
portion of patients recovered, remitted, and
meeting community norms on eating behaviors and
attitudes; however, across three follow-up occasions
(4, 8, and 12 months), there were no significant
differences between CBT and IPT. There was less
attrition in IPT (19.1%) than CBT (30.0%), with
the difference approaching significance.
Participants
Patients were 220 women (110 at each site; by design,
no men were recruited) meeting Diagnostic and Stat-
istical Manual of Mental Disorders (third edition,
revised; DSM-III-R; American Psychiatric Associ-
ation, 1987) criteria for BN. Patients were excluded
if they had a severe physical or psychiatric (e.g., psy-
chotic) disorder, were diagnosed with anorexia
nervosa (AN), were already in a psychosocial treat-
ment, were on psychotropic medications, were preg-
nant, and/or had engaged in a prior adequate dose of
CBT or IPT. Patients averaged 28.1 years of age (SD
= 7.2 years), and the majority were Caucasian
(77.0%) and either single, divorced, or widowed
(80.4%). The sample averaged 11.4 years (SD = 7.5
years) of bingeing and 9.8 years (SD = 6.8 years) of
purging. Twenty-two percent of patients also met cri-
teria for current major depressive disorder, and 37%
4 J. M. Gomez Penedo et al.
for a current personality disorder. Across the two
treatment conditions, patients were largely equivalent
on baseline demographic and eating symptom vari-
ables; however, CBT patients had significantly
more purge episodes and eating concerns than IPT
patients. Several significant site differences also
emerged; patients treated at Stanford were older
and more likely to have been diagnosed with lifetime
substance abuse or dependence, whereas Columbia
patients had a longer purging duration, were less
likely to have a history of AN, had fewer concerns
about eating and shape, and reported fewer global
symptoms.
Therapists were seven doctoral-level psychologists
and one psychiatrist who each treated similar
numbers of patients in both CBT and IPT. Although
data on therapists’ primary orientation and allegiance
upon entering the trial are unavailable, all therapists
were experienced in treating eating disorders,
received extensive training in the treatment proto-
cols, were closely supervised throughout the trial,
and delivered the treatments with adequate fidelity
and competency (see Agras et al., 2000). Loeb et al.
(2005) reported high levels of observer-rated thera-
pist adherence to both treatment manuals (on a
scale from 1 to 7, mean adherence was 5.52 in
CBT and 5.03 in IPT). Furthermore, in a selected
subsample of cases, the independent raters (blind to
the treatment) were able to identify correctly the
treatment being conducted (Loeb et al., 2005).
Treatments
Both treatments were manual-driven and involved 19
individual outpatient sessions conducted over 20
weeks. The 50-minute sessions were administered
twice weekly for the first two weeks, weekly for the
next 12 weeks, and biweekly thereafter. Therapists
delivered CBT according to the Fairburn, Marcus,
and Wilson (1993) manual, which directly targets
the main symptomatic features of BN (i.e., bingeing,
purging, and shape and weight distortions) through
psychoeducation, behavior monitoring, strategies to
reduce dietary restraint and irregular eating, strat-
egies for challenging distorted thoughts and assump-
tions, implementation of adaptive coping responses
to binge-eating triggers, and relapse prevention.
Therapists delivered IPT according to the
Klerman, Weismann, Rounsaville, and Chevron
(1984) manual adapted for BN (Fairburn, 1997).
The IPT therapist initially draws a connection
between patients’ interpersonal difficulties (e.g.,
role disputes, role transitions, interpersonal deficits,
unresolved grief) and their BN symptoms. Sub-
sequently, this connection is only implied, as the
therapist helps patients implement interpersonal
changes, monitor treatment gains, process feelings
about treatment termination, and plan for coping
with future interpersonal distress. IPT for BN pro-
scribes explicit attention to eating patterns, compen-
satory behaviors, or body shape and weight attitudes;
it also does not include self-monitoring of food intake
or specific behavioral instruction.
Measures
Interpersonal problems. To assess the modera-
tor variable of interpersonal problems, patients com-
pleted the original, 127-item version of the IIP
(Horowitz, Rosenberg, Baer, Ureño, & Villaseñor,
1988). For the current study, variables were derived
from the 64 items that comprise the IIP-C (Horowitz
et al., 2000). The IIP-C is a widely used instrument
assessing interpersonal inhibitions and excesses,
with each item in this trial rated on a 5-point scale
ranging from 0 to 4. Higher total scores indicate
more interpersonal problems. As previously
described, the IIP-C has eight subscales that com-
prise a circumplex of problematic interpersonal be-
havior around the interpersonal dimensions of
agency and communion. The IIP-C has evidenced
good psychometric properties (Horowitz et al.,
2000), and the internal consistency alpha coefficients
in the current study were .94 for the total score and
ranged from .71 to .89 for the subscales.
As noted, we focused on two IIP-C indices that
were computed based on the formulas that Ruiz
et al. (2004) presented. We calculated an interpersonal
communion index by using data from six subscales
weighted based on their proximity to the horizontal
communion axis. The formula is Communion = .25
[nurturant – cold + .71 (intrusive – vindictive –
socially inhibited + exploitable)]. Thus, the commu-
nion index represents interpersonal problems
ranging from being overly cold and distant on one
end of the axis to being overly warm and self-sacrifi-
cing on the other. Note that domineering and nonas-
sertive interpersonal problems are not included in
this formula because they are neutral in terms of com-
munion. The theoretical range for this index is
−19.36 (colder and more distant) to 19.36 (warmer
and more self-sacrificing). We also calculated an
interpersonal agency index by using data from six sub-
scales weighted based on their proximity to the verti-
cal agency axis. The formula is: Agency = .25
[domineering – nonassertive + .71 (intrusive + vin-
dictive – socially inhibited – exploitable)]. Thus, the
agency index represents interpersonal problems
ranging from overly submissive behavior on one end
of the axis to overly domineering behavior on the
other. In this case, nurturant and cold interpersonal
problems are not included in the formula because

they are neutral in terms of agency. The theoretical
range for this index is again −19.36 (more submiss-
ive) to 19.36 (more domineering).
Purge frequency. To assess the continuous
outcome variable, patients reported on their 1-week
purge frequency. This variable was used similarly in
previous studies drawing on the present trial data
(e.g., Loeb et al., 2005). This variable was not only
measured on multiple occasions (allowing for a
more reliable assessment of change than simply pre-
posttreatment), but also possesses fewer assessment
liabilities than other symptoms of eating pathology
given that purge recall is less ambiguous than idiosyn-
cratic definitions of bingeing and weight/shape con-
cerns (Wilson, 1993). Further, researchers have
argued that such brief self-report assessments can
be used effectively for repeated measurement in
trials after a BN diagnosis has been established with
rigorous interview methods (Loeb, Pike, Walsh, &
Wilson, 1994). In this sample, the purge frequency
presented an adequate test–retest reliability (two-
way mixed, average measure’s Intraclass Correlation
Coefficient [ICC] = .92).
Severity of global eating disorder
symptomatology. To assess the dichotomous
outcome of clinically meaningful change, we drew
on Eating Disorder Examination (EDE; Cooper &
Fairburn, 1987) data. The EDE is a comprehensive
and well-validated structured interview that measures
multiple dimensions of eating disorder symptomatol-
ogy over the previous 28 days. For the present study,
we created a global index of eating disorder severity
(our main interest for capturing clinically meaningful
change on a broader scale of BN problems) by
summing the scores of four EDE subscales of
dietary restraint, shape concerns, weight concerns,
and eating concerns (Fairburn, Cooper, &
O’Connor, 2008) and then dividing these results by
four. Thus, the global EDE index had a theoretical
range from 0 to 6. The four indices have shown ade-
quate internal consistency (α ranging from .67 to
.78), inter-rater reliability (Spearman’s Rho coeffi-
cients ranging from .90 to .99), and test–retest
reliability (Spearman’s Rho coefficients ranging
from .71 to .76; Rizvi, Peterson, Crow, & Agras,
2000). In the current sample, the global index had
an alpha coefficient of .84.1
To create our binary variable of clinically meaning-
ful improvement on the global EDE index, we first
used the Edwards–Nunnally (EN) method to calcu-
late an index of reliable change (Speer, 1992).2 This
method defines reliable change as having surpassed
the lower limit of a confidence interval (based on
Psychotherapy Research 5
±2 standard errors of measurement) around each
patient’s estimated true score at baseline. A true
score is estimated as the product of the patient’s base-
line deviation score (i.e., the difference between a
given patient’s actual score at baseline and the
sample mean) and test–retest reliability, plus the
baseline sample mean (Speer, 1992). However, in
the present study, we also followed Lambert and
Ogles (2009) suggestion to use internal consistency
rather than test–retest reliability as the measure of
reliability. After calculating each patient’s true score
at baseline, we next calculated the standard error of
measurement (SE = 0.45), which is equal to the
product of the sample SD at baseline (1.12) and the
root mean square of measurement error (i.e., 1
minus the internal consistency of the measure; α
= .84). To be classified as having reliably changed,
patients needed to have a posttreatment score at
least two SE (i.e., 0.90) below their estimated true
score at baseline.
To also contribute to our binary variable of clini-
cally meaningful change on the global EDE index,
we next created an index of clinically significant
response using Jacobson and Truax’s (1991) Cutoff
C criteria, as this method is considered the current
best practice (Lambert & Ogles, 2009). To calculate
Cutoff C, or the point at which a person’s score is
closer to the normal than the clinical range, we
used normative data from a non-clinical, commu-
nity-sample, which reported a mean global EDE
index of 0.93 (SD = 0.81; Fairburn et al., 2008), as
well as the means and standard deviation of the
study sample at baseline, which represents a patho-
logical BN population with a mean EDE index of
3.31 (SD = 1.12). Based on this analysis, the cutoff
point for clinically significant response was 2.32
points on the global EDE index.
Combing the EN assessment of reliable change and
the Cutoff C assessment of clinically significant
response on the global index, a patient was classified
as recovered (i.e., yes on clinically meaningful change)
when they passed both criteria, and not recovered (i.e.,
no on clinically meaningful change) when they did
not. For descriptive purposes, we also present percen-
tages for the following classifications: improved (when
patients passed only the EN confidence interval cri-
terion in the positive direction), unchanged (when
they did not pass the EN confidence interval cri-
terion), or deteriorated (when they passed the EN con-
fidence interval criterion in the negative direction).
Procedure
Potential trial patients were initially phone screened for
eligibility. Those who were not ruled out with this
screen were scheduled for an in-person baseline clinical
6 J. M. Gomez Penedo et al.
assessment with a trained research assistant. After
obtaining consent, research assistants administered
the EDE and the Structured Clinical Interview for
the DSM-III-R (SCID; Spitzer, Williams, Gibbon, &
First, 1989). If they remained eligible, participants
completed a baseline battery of self-report measures,
including the IIP. Patient purge frequency was
recorded at week 1, midtreatment (week 10), and post-
treatment. The EDE was administered again at post-
treatment. The present analyses were conducted on
completely de-identified, archival trial data.
Results
Sample descriptives
We present in Online Supplemental Table 1 the
descriptive statistics of baseline interpersonal pro-
blems, purge frequency, and EDE scores across the
total sample and by each treatment condition.
There were no significant differences between CBT
and IPT patients’ IIP-C total score, IIP-C agency
index, or IIP-C communion index. At baseline,
across both treatments, agency and communion
had a small, but significant negative correlation, r =
−.19, p = .005, with one index explaining less than
4% of the variance in the other. Despite this corre-
lation, there were no evidences of problematic colli-
nearity between these two interpersonal indexes
(Tolerance = .97, VIF = 1.04).
Regarding outcome measures, there were no signifi-
cant differences between the two conditions on base-
line global EDE score. However, IPT patients
reported greater purge frequency at baseline than
CBT patients. Given this difference, we controlled
for baseline differences in purge frequency, as assessed
with the EDE, in all analyses with purge frequency as
the outcome variable. Additionally, because Agras
et al. (2000) reported an effect of site on patient
eating disorder symptomatology, we also included
site as a control variable in all of our primary analyses.
Regarding clinically meaningful improvement percen-
tages at posttreatment, 42.7% of the sample were
recovered (CBT = 45.5%, IPT = 40.0%), 5.5%
improved (CBT = 5.5%, IPT = 5.5%), 50.9%
unchanged (CBT = 48.2%, IPT = 53.6%), and 0.9%
deteriorated (CBT = 0.9%, IPT = 0.9%).3
Primary Outcome: Purge Frequency
To test the two IIP dimensions (i.e., communion and
agency) as moderators of treatment efficacy on the
primary purge frequency outcome, we used hierarch-
ical linear modeling (HLM; Raudenbush & Bryk,
2002), which addresses dependency in repeated
measures data and is robust to handling missing
within-patient data, such that HLM mimicked an
intent-to-treat (ITT) sample by retaining all partici-
pants who completed at least one purge frequency
rating. Thus, although some patients were missing
purge frequency data at week 1 (3%), midtreatment
(26%), and posttreatment (30%), we still retained
216 of the 220 trial patients (98%) in the analyses.
Given that multiple patients were nested within
therapists, we first conducted 3-level models to test
for possible therapist effects on the weekly rate of
change and in posttreatment level of purge frequency.
The intraclass correlations calculated from these
models suggested that therapists accounted for <1%
of the variability in both outcomes. Given this lack
of between-therapist variability, we fit 2-level
models for our primary analyses.
Unconditional model. We first fit a 2-level
unconditional model with time expressed in weeks
and centered at posttreatment as the only predictor.
Given that purge frequency is a count variable and
it had a positively skewed distribution across all
measurement occasions (as is typical for count vari-
ables), we used a Poisson (constant exposure) distri-
bution for the outcome variable (the equation for this
model is described in the Online Supplement).
Results of this unconditional model indicated that
the average likelihood of purging at posttreatment
was significantly different from 0 (γ00 = 0.33, SE =
0.17, p = .05). For ease of interpretation, we expo-
nentiated the coefficient to represent a rate ratio
(RR), which indicated that the average posttreatment
likelihood of another purge episode was 1.39. Also,
the average weekly reduction in the likelihood of
purging significantly differed from 0 (γ00 = −0.10,
SE = 0.008, p < .001; RR = 0.90). In this case, the
RR of 0.90 indicated that patients experienced a
10% reduction in purge likelihood per week, on
average. Random effects indicated that there was sig-
nificant between-patient variability in both the
average likelihood of purging at posttreatment (τ0 =
3.05, p < .001) and the average weekly change in
this likelihood (τ1 = 0.005, p < .001) that could be
explained by the addition of predictors.
Conditional models. First, for comparison pur-
poses, we ran a main effects and covariates model
with treatment condition (IPT = 0, CBT = 1), the rel-
evant interpersonal problem dimension (commu-
nion, agency), site (Stanford = −0.5, Columbia =
0.5), and baseline purge frequency as the level-2 pre-
dictors. Second, we ran two separate interaction
models, each of which added an interpersonal
problem dimension by treatment interaction as a

level-2 predictor (the equations for these models are
described in the Online Supplement).4
Results of both the main effect and interaction
models for each interpersonal problem index are pre-
sented in Table I. The interactive effect of treatment
by agency did not significantly predict the posttreat-
ment purge likelihood or weekly change in purge like-
lihood across treatment. However, the interactive
effect of treatment by communion significantly pre-
dicted both the likelihood of purging at posttreat-
ment, γ04 = −0.16, SE = 0.07, CI95 [−0.29, −0.03],
t(210) = −2.361, p = .02, pseudo R 2 = 0.07, and
weekly change in the likelihood of purging, γ13 =
−0.01, SE = 0.003, CI95 [−0.02, −0.004], t(210) =
−3.139, p = .002, pseudo R 2 = 0.11.5 Overly commu-
nal patients experienced lower overall likelihood of
purging at posttreatment and a steeper weekly
reduction in purge likelihood when treated with
CBT vs. IPT. Under communal patients had lower
likelihood of purging at posttreatment when treated
with CBT vs. IPT, though these patients had
similar reductions in likelihood of purging across
both treatments (see Figure 1).
To probe further the interactive effects, we gener-
ated conditional slopes representing the effect of
treatment on weekly purge reduction at high (1 SD
above the mean) versus low levels (1 SD below the
mean) of communion. We generated these slopes
by first re-centering the relevant IIP-C index at ± 1
SD from the mean and then creating new interaction
terms using each of these re-centered indices. The re-
Figure 1. Evolution of the likelihood of purging during treatment in
overly and under communal patients, comparing CBT vs. IPT.
Overly and under communal were defined as ±1 SD (3.72) from
the mean (1.66) of the communion dimension subscale in the
sample. Note. OV COM = overly communal; UN COM = under
communal; CBT = cognitive-behavioral therapy; IPT = interperso-
nal psychotherapy. ∗ Conditional slopes analysis showed a signifi-
cant treatment effect in overly communal patients (p < .05), but
not in under communal patients.
Psychotherapy Research 7
centered main effects and newly generated inter-
action terms were then entered as predictors in two
additional HLM models (one for high communion
and one for low communion).6 The results indicated
that for overly communal patients, there was a signifi-
cant difference between the two treatments in
purging rates at posttreatment (γ01 = −1.85, p
< .001) and in the weekly rate of change in purging
rates (γ11 = −0.10, p < .001); expressed in terms of
RRs, when treated with CBT, overly communal/
friendly patients’ rates of purging at posttreatment
were .16 times as likely (i.e., 84% less likely), and
the weekly rate of change in that likelihood was
0.90 times steeper (i.e., a 10% greater weekly
reduction in purge likelihood) than for IPT patients.
In other words, the advantage of CBT vs. IPT was
more pronounced for over communal patients than
for patients with an average level of communion.
For under communal/cold patients, there was no sig-
nificant difference between the two treatments in
likelihood of purging at posttreatment (γ01 = −0.65,
p = .08), or in the weekly change in purge likelihood
(γ11 = −0.02, p = .30). In other words, the advantage
of CBT vs. IPT was reduced to non-significance for
under communal patients. Thus, although there
was a comparative advantage of CBT vs. IPT for
patients who had either average or high levels of com-
munion at baseline, the two treatments were rela-
tively equivalent for under communal patients.
Secondary Outcome: Clinically Meaningful
Improvement
We next used SPSS 23 to conduct separate logistic
regression models examining the interactive effect of
each interpersonal problem index by treatment con-
dition on the likelihood of achieving clinically mean-
ingful improvement on the global EDE index. To
address missing values in the global EDE index at
posttreatment (26%), we used an ITT approach in
which patients’ baseline EDE global index scores
were carried forward to replace missing data at post-
treatment. We also included site as a covariate,
because we could not residualize out the effect of site
from the clinically meaningful improvement variable
(due to its binary nature). The results of these
models are presented in Online Supplemental Table 2.
There was no significant interactive effect of treat-
ment by communion on the likelihood of having clini-
cally meaningful improvement, β = 0.123, SE = 0.08,
Wald(1) = 2.539, p = .11. However, there was a signifi-
cant interactive effect of treatment by agency on clini-
cally meaningful improvement, β = −0.165, SE = 0.07,
Wald(1) = 6.157, p = .01, odds ratio (OR) = .85. In
IPT patients, a 1-unit increase in agency was associ-
ated with a 1.07 times greater odds of achieving
8 J. M. Gomez Penedo et al.
Table I. Unconditional and conditional models analyzing the main and moderating effects of interpersonal problems on the likelihood of
purging.

Unconditional
model Main effect models Interactive effect models

Fixed model effects β SE β SE β SE

Likelihood of purging at posttreatment

Communion IP
Intercept 0.33∗ 0.17 1.03∗∗∗ 0.17 0.99∗∗∗ 0.17
Treatment −1.34∗∗∗ 0.26 −1.25∗∗∗ 0.25
IP −0.03 0.03 0.04 0.04
Site −0.23 0.03 −0.30 0.25
Baseline purge frequency 0.02∗∗∗ 0.003 0.02∗∗∗ 0.003
IP × treatment −0.16∗∗ 0.07
Pseudo R 2 = .07
Agency IP
Intercept 0.33∗ 0.17 1.00∗∗∗ 0.18 1.02∗∗∗ 0.10
Treatment −1.32∗∗∗ 0.26 −1.31∗∗∗ 0.26
IP 0.009 0.03 −0.02 0.04
Site −0.25 0.26 −0.27 0.26
Baseline purge frequency 0.02∗∗∗ 0.003 0.02 0.003
IP × treatment 0.05 0.06
Pseudo R 2 = .02
Weekly change on likelihood of purging
Communion IP
Intercept −0.10∗∗∗ 0.008 −0.07∗∗∗ 0.009 −0.07∗∗∗ 0.008
Treatment −0.06∗∗∗ 0.01 −0.06∗∗∗ 0.01
IP −0.002 0.002 0.002 0.002
Site −0.004 0.01 −0.008 0.01
Baseline purge frequency 0.0004∗∗ 0.0001 0.0004∗∗ 0.0001
IP × treatment −0.01∗∗ 0.003
Pseudo R 2 = .11
Agency IP
Intercept −0.10∗∗∗ 0.008 −0.07∗∗∗ 0.009 −0.07∗∗∗ 0.009
Treatment −0.06∗∗∗ 0.01 −0.06∗∗∗ 0.01
IP 0.0009 0.001 −0.0004 0.002
Site −0.005 0.01 −0.006 0.01
Baseline purge frequency 0.0004∗∗ 0.0001 0.0004∗∗ 0.0001
IP × treatment 0.003 0.003
Pseudo R 2 = .02
Model comparison for communion IP χ (8) = 177.90, p < .001 χ 2(2) = 12.94, p = .002
2

Model comparison for agency IP χ 2(8) = 176.96, p < .001 χ 2(2) = 0.95, p > .50

Note: IP = interpersonal problems; Pseudo R 2 = effect size measure based on the variance explained by the interactive effect.
∗∗∗
p < .001.
∗∗
p < .05.
∗
p = .05.

clinically meaningful improvement, whereas in CBT
patients that increase in agency was related to a 0.91
times lower odds of clinically meaningful improve-
ment. In other words, overly agentic patients were
more likely to achieve clinically meaningful improve-
ment in IPT vs. CBT, whereas under agentic patients
were more likely to achieve clinically meaningful
improvement in CBT vs. IPT (see Figure 2).7
Discussion
We examined two dimensions of patient baseline
interpersonal problems (communion and agency) as
potential moderators of the comparative posttreat-
ment efficacy of CBT and IPT for BN. In the
trial from which the data derived, CBT, on
average, significantly outperformed IPT at post-
treatment on indices of recovery, remittance, and
meeting community norms on eating behaviors
and attitudes (Agras et al., 2000). These results,
though, said nothing of specific patient-treatment
fit, which prompted the present ATI analyses. As
hypothesized, there was an interactive effect of
interpersonal communion problems by treatment
on the purge frequency outcomes. This effect was
largely driven by patients with more baseline

Figure 2. Likelihood of having a clinical significant change in
patients with low, average, and high agency levels, comparing
CBT vs. IPT. Low and high agency was defined as ±1 SD (4.32)
from the mean (−4.13) of agency in the sample. Likelihood was cal-
culated by the formula odds ratio/(1 + odds ratio).
Note: CS = clinical significant change.
problems of being overly communal/friendly
demonstrating lower purge rates at posttreatment
and a steeper reduction in those rates when
treated with CBT vs. IPT. Unexpectedly, this inter-
active finding did not hold for the outcome of clini-
cally meaningful improvement in eating disorder
symptoms more broadly. With regard to interperso-
nal agency, as expected, we found that patients with
more problems of being overly agentic did better in
IPT vs. CBT, whereas patients with more problems
of being under agentic did better in CBT vs. IPT
for the outcome of clinically meaningful improve-
ment in broadly defined eating disorder symptoms.
Unexpectedly, this interactive finding did not hold
for the purge frequency outcomes. Overall, the
results provided partial support for our hypotheses,
with no findings directly contradicting our expec-
tations. Rather, the specific interpersonal trait by
treatment interactions had different effect patterns
depending on the outcome variables examined,
and we offer several plausible explanations why.
Most simply, the fact that the hypothesized interac-
tive effects were only partially supported may have
resulted from low statistical power. Supporting this
view, all findings that failed to reach statistical signifi-
cance were in the expected direction, and indeed
often approached significance. Because the RCT
was not powered to test interactions (as is often the
case), it is challenging to detect such effects that are
often relatively small in size. It is possible that with
a larger sample, we may have found the predicted
interactive effects for both interpersonal problem
dimensions on both outcomes. That being said,
because our findings were not uniformly significant,
Psychotherapy Research 9
it is possible that the observed pattern is meaningful
beyond statistical power issues; thus, we speculate
next on what this pattern of results might mean
clinically.
Most predominantly, we draw on the reactance
and resistance literatures (e.g., Beutler et al., 2011).
Regarding communion, as we hypothesized, for
overly communal BN patients, CBT therapists may
be less likely to promote reactance or resistance
given that they are unlikely to target these patients’
interpersonal traits directly. Without challenging
this social exchange pattern as a problem underlying
the eating symptoms, the CBT therapist may actually
capitalize on the patient’s need for communion in the
form of close and active collaboration toward chan-
ging the specific behavior of purging. Indeed, pre-
vious research shows that patients who are more
accommodating (even if it is maladaptive for them)
are more likely to engage in collaborative, connected
relationships than people who are cold, inhibited,
and/or vindictive (Muran et al., 1994). In fact, in a
study also drawing on data from the current trial,
patients with overly communal problems reported
better therapeutic alliances in CBT (Constantino &
Smith-Hansen, 2008). As these authors noted, it
may be that the highly directive CBT relies, at least
partly, on patient communion/accommodation for
quality alliance development.
On other hand, the IPT therapist may hone in on
the patient’s need for communion and close connec-
tion (to the point of self-sacrifice and perhaps exploit-
ability) as problematic. Although the IPT therapist
may conceptualize this interpersonal pattern as
central to the cause and maintenance of the eating
disorder (e.g., constantly trying to please critical
others by attempting to maintain a perceived ideal
body shape), it may also threaten the patient who
fails to see attempts at close connection to others as
problematic. Such threat may prompt psychological
reactance and attempts to regain one’s sense of
autonomy (in this case, in how they interact with
others), or a more pointed resistance to the direction
of the IPT therapist, both of which can interfere with
treatment success (e.g., Aviram & Westra, 2011;
Beutler et al., 2011).
For under communal/cold patients, the CBT
therapist’s bid for close collaboration around actively
changing thoughts and behaviors may prove too
threatening to the person motivated to keep distance
from others. And, again, with such threat could come
heightened reactance or resistance, which could
undermine adaptive therapeutic process and gain in
this model. Moreover, cold/hostile interpersonal
traits have been negatively correlated with patient’s
desire to focus their therapeutic work on the specific
problems that bother them (CBT’s focus), and they
10 J. M. Gomez Penedo et al.
have been positively related to interpersonal concerns
during therapy (Gurtman & Balakrishnan, 1998);
again, these are things that could derail a treatment’s
efficacy. Such heightened reactance or resistance for
under communal patients may have resulted in
CBT being relatively less effective (compared to its
general efficacy for patients with an average or high
level of communality), rendering it equivalent to
IPT for under communal patients.
Alternatively, or complementarily, the relative
equivalence of the two treatments for reducing
purge frequency rates in under communal patients
could be driven by IPT therapists being better
equipped to assess such coldness and hostility as a
pattern central to eating pathology. And, without
needing to closely collaborate on strategies to
address explicitly eating pathology, the IPT thera-
pist can instead address hostility and coldness
within an interpersonal formulation that a patient
may be able to tolerate without imminent threat
likely to promote negative process. Without such
derailing negative processes, IPT could help
patients to develop new ways to deal with negative
affect, and to reduce the binge behaviors associated
with it (Iacovino, Gredysa, Altman, & Wilfley,
2012). Again, though, it is important to highlight
that IPT was relatively more effective for under
communal patients (relative to its general efficacy
for patients with an average or high level of com-
munality), but there was no evidence that it was
more effective than CBT for under communal
patients. Additionally, whether the comparable effi-
cacy of these two treatments for under communal
patients is due to CBT’s promotion of high reac-
tance rendering it less effective than usual, IPT’s
ability to address these interpersonal problems
directly without promoting resistance rendering it
more effective than usual, or a combination of these
patterns remain unknown.
Moreover, it bears repeating that the communion by
treatment interaction did not replicate for the clinically
meaningful change outcome. It is possible that this
pattern of results emerged because purge frequency
represents the type of outcome that is most targeted
by CBT; that is, behavioral change on the overt and
objective number of times someone purges. Consist-
ent with this view, even when overly communal
patients are well-matched (and receive CBT), it may
not confer an advantage for the broader outcome
that includes more subjective behavior. In other
words, CBT’s advantage for this subgroup may be
limited to the treatment’s most explicit target.
However, this notion requires testing, especially in
larger samples; as noted, is possible that the predicted
interactive effect for clinically meaningful change
would emerge with greater statistical power.
With regard to agency, as hypothesized, we found
that for overly domineering patients, IPT vs. CBT
is more likely to promote clinically meaningful
improvement in global eating disorder symptoms,
whereas for overly submissive patients, CBT vs.
IPT is more likely to promote such improvement.
As expected, it may be that for BN patients with an
interpersonal style of, and need for, being overly
domineering toward others, IPT may be the more
suitable treatment given that it may be less likely to
promote reactance or resistance than the more direc-
tive CBT; that is, perhaps IPT’s focus on the inter-
personal difficulties that underlie eating problems is
less threatening to overly domineering patients than
CBT’s explicit focus on changing disordered eating
cognitions and behaviors (Fairburn et al., 2003).
Moreover, IPT may be better situated to address
directly problematic dominance as an explicit treat-
ment target, which could allow IPT therapists to
help patients more effectively navigate self and other
needs for agency in relationships (Wilson, 1996).
With such interpersonal gains may come less risk
for disordered eating behavior. In contrast, for
overly domineering patients, direct attempts by the
CBT therapist to reduce disordered eating cognitions
and behavior may prompt patients to attempt to
regain their autonomy. Such attempts could take
the form of psychological reactance or even more
pointed resistance to the direction of the CBT thera-
pist, which can interfere with treatment success (e.g.,
Aviram & Westra, 2011; Beutler et al., 2011).
On the contrary, patients with an interpersonal
style of (and need for) being overly submissive to
others may find the directive CBT therapist’s
symptom-focused approach suitable to their typical
style of relating to others. Consistent with this
notion, these patients might be particularly likely to
trustingly engage with CBT techniques and strat-
egies, which has been associated with more positive
treatment outcomes in this approach (Kazantzis
et al., 2016). However, in IPT, such treatment com-
pliance may lead the IPT therapist to overlook exces-
sively submissive behaviors as problematic. Given the
interpersonal focus of IPT, this could result in a focus
on other interpersonal content, which may limit the
potential efficacy of treatment due to a lack of focus
on the patients’ primary interpersonal difficulty of
over submissiveness. This potential oversight could
result in poorer outcomes for overly submissive
patients in IPT.
However, these results should be interpreted with
some caution, as it is presently unknown why the
agency by treatment interaction did not replicate for
the purge frequency outcome. As noted, it is possible
that this could be due to power constraints. But, if
not, it will be important to understand what makes

the problem of being overly communal a good match
with CBT for the very circumscribed issue of
purging, whereas being overly nonassertive in CBT
results in a greater effect across the board on ED
symptoms. Additionally, future research would
need to investigate whether the beneficial influence
of matching overly domineering patients to IPT also
extends to more specific behavioral outcomes such
as purge frequency. Although speculative, it is poss-
ible that the beneficial impact of IPT is most likely
to manifest as broad changes in eating disorder path-
ology, given its focus on addressing the underlying
interpersonal issues of BN rather than on changing
specific cognitive and behavioral targets.
Such future work could also start focusing on more
contemporary treatments, or iterations of CBT and
IPT, as the approaches in the present study are now
somewhat dated. In the period since the Agras et al.
(2000) trial, there were several new treatments devel-
oped for BN. For example, Wonderlich et al. (2014)
have created an integrative cognitive–affective
therapy (ICAT) for BN. In addition to more tra-
ditional cognitive strategies, ICAT also addresses
psychological variables that might maintain bulimic
behaviors, such as change ambivalence, emotional
dysregulation, coping problems, interpersonal diffi-
culties, self-oriented behaviors (e.g., excessive self-
control), and self-oriented cognitive patterns (e.g.,
self-discrepancy).
Regarding IPT for BN, we are aware of one new
development since the version used in the Agras
et al. (2000) trial. Murphy, Straebler, Basden,
Cooper, and Fairburn (2012) modified IPT to be a
transdiagnostic treatment for eating disorders in
general (IPT-ED). Therapists using this approach
are generally focused on patient’s current interperso-
nal relationships, rather than premorbid functioning,
and they attempt to anticipate eventual problems
related to inevitable role transitions. Whether CBT-
based, IPT-based, or different altogether, future
research should attempt to replicate the present find-
ings in these more contemporary approaches, both
for BN specifically and eating disorders in general.
Also with regard to future research, in addition to
replication, it seems important to understand the
specific mechanisms that may be responsible for
one treatment’s superiority over another under a
particular condition (e.g., for problems of interper-
sonal communion or agency). Although we con-
sidered that intrapsychic reactance, interpersonal
resistance, and/or alliance development might
explain the differential effects presented in CBT
vs. IPT based on communal and agentic interperso-
nal problems, in this particular study, we did not
examine the potential mediating effect of these
common treatment factors. Further mediated
Psychotherapy Research 11
moderation analyses might see if differences in
these putative mechanisms indeed account for why
traditional IPT and CBT perform better than the
other under certain conditions.
Several limitations characterize this study. First, as
noted, it is important to interpret the results with
caution given that the interactive effects of interperso-
nal problems by treatment were not uniform across
the two outcomes. Second, only self-report data
were available for assessing interpersonal functioning
outside of the therapy room. Third, we only analyzed
the differential symptomatic effects produced at post-
treatment. Fourth, the sample was restricted to
women. Although BN is much more prevalent
within women, 17% of diagnosed persons are men,
which is a meaningful subsample (Hudson, Hiripi,
Pope, & Kessler, 2007). Fifth, the therapists in the
study crossed conditions, and it is unknown if any
preexisting allegiance or other biases may have
affected treatment processes or outcomes. Finally,
the relatively low number of therapists in this study
may have limited our ability to detect therapist
effects on the outcomes.
Despite these limitations, to our knowledge, the
present findings are the first to point to potential pre-
scriptive variables indicating for whom (among BN
patients) CBT or IPT (in their traditional forms) is
most likely to be effective for different outcomes.
The results also contribute to the broader literature
on interpersonal factors that moderate the compara-
tive treatment efficacy (Gomez Penedo, Constantino,
Coyne, Westra, & & Antony, 2017). Such work
seems important given the growing perspective that
it is the match between-patient characteristics and
treatment type that may be primarily responsible for
promoting and maintaining improvement (Beutler
et al., 2011).
Notes
1
Note that to establish the internal consistency of the global EDE
index, we used the same strategy as Constantino, Arnow, Blasey
and Agras (2005) of calculating the alpha coefficient based on the
four subscales that combined to create the index.
2
Although Jacobson and Truax’s (1991) criteria are the most fre-
quently used method for this purpose, it does not account for
regression toward the mean when measuring change (Lambert
& Ogles, 2009; Speer & Greenbaum, 1995). Accounting for
such regression is particularly important in clinical trials, like
the present one, that requires patients’ baseline symptoms to
exceed an established threshold of severity for inclusion in the
trial (Johnson & Varghese, 1991).
3
For comparison, and following previous recommendations in the
literature, we also calculated clinically meaningful change using
fully the Jacobson and Truax (1991) method. Based on this
approach, 32.7% of the sample were recovered (CBT = 37.3%,
IPT = 28.2%), 6.8% improved (CBT = 6.4%, IPT = 7.27%),
60.0% unchanged (CBT = 56.4%, IPT = 63.6%), and 0.5%
deteriorated (CBT = 0.0%, IPT = 1.0%).
12 J. M. Gomez Penedo et al.
4
The interpersonal problems indices were grand mean centered
prior to the creation of the interaction terms.
5
As each interactive effect was tested in a separate model (one for
each interpersonal predictor), we replicated these findings in a
model including the main and interactive effects for both
agency and communion as predictors of purge frequency. In
this model, the interactive effect of communion by treatment
remained significant (when predicting both the intercept and
linear slope).
6
The result of this centering is that the main effect of treatment
represents the relation between treatment group and weekly
purge frequency change for patients with high and low values
of the relevant baseline IIP-C index. Note that in these models
only the main effects are impacted by the re-centering; the coef-
ficient for the interaction remains identical to the original model.
7
Given the relatively high proportion of missing data, we also
replicated our clinically meaningful change analyses using mul-
tiple imputation via the Markov Chain Monte Carlo (MCMC)
method in SPSS 23. First, we created 10 imputed datasets for
the global EDE index at posttreatment. Second, we calculated
the average of the global EDE index for each participant across
all imputed datasets. Third, we used that average to determine
whether patients met criteria for clinically meaningful change
(i.e., patients were classified as recovered or not recovered).
Finally, we conducted two separate logistic regressions using
this variable as the criterion. Results of these analyses replicate
those of the main analyses, with a significant interactive effect
of treatment by agency on clinically meaningful improvement,
B = −0.138, SE = 0.07, Wald(1) = 4.423, p = .04, OR = .871,
and no significant effect of treatment by communion on clinically
meaningful improvement, B = 0.113, SE = 0.08, Wald(1) =
2.040, p = .16.
Supplementary data
Supplemental data for this article can be accessed 10.
1080/10503307.2018.1425931.
Disclosure statement
The authors report no conflicts of interest.
Acknowledgement
The authors are grateful to W. S. Agras, T. Walsh,
C. G. Fairburn, and G. T. Wilson for allowing us
access to the data set.
ORCID
Samantha L. Bernecker http://orcid.org/0000-0002-
8803-3311
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