Behaviour Research and Therapy 49 (2011) 815e820

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Behaviour Research and Therapy

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Shorter communication

Treatment manuals: Use in the treatment of bulimia nervosa

Laurel M. Wallace, Kristin M. von Ranson*
Department of Psychology, University of Calgary, 2500 University Drive N.W., Calgary, Alberta T2N 1N4, Canada

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 19 July 2011
Received in revised form
28 August 2011
Accepted 8 September 2011

As psychology has moved toward emphasizing evidence-based practice, use of treatment manuals has
extended from research trials into clinical practice. Minimal research has directly evaluated use of
manuals in clinical practice. This survey of international eating disorder professionals examined use of
manuals with 259 clinicians most recent client with bulimia nervosa. Although evidence-based manuals
for bulimia nervosa exist, only 35.9% of clinicians reported using a manual. Clinicians were more likely to
use a manual if they were younger; were treating an adult client; were clinical psychologists; were
involved in research related to eating disorders; and endorsed a cognitive-behavioral orientation.
Clinicians were less likely to use a manual if they provided eclectic psychotherapy that incorporated
multiple psychotherapeutic approaches. We conclude that psychotherapy provided in clinical practice
often does not align with the specic form validated in research trials, and eclecticism is at odds with
efforts to disseminate manuals into clinical practice.
2011 Elsevier Ltd. All rights reserved.

Keywords:
Bulimia nervosa
Evidence-based practice
Psychological treatments
Psychotherapeutic techniques
Therapists attitudes
Technology transfer

Across health disciplines, the movement toward evidence-based

practice has become increasingly evident in recent years (McHugh
& Barlow, 2010). In the eld of psychology, this has included a major
shift in the design of psychotherapy outcome research toward
imitating the design of clinical trials in drug efcacy research,
including incorporating specic, systematic treatment manuals in
psychotherapy outcome studies. Over time, pressure to use treatment manuals has extended beyond controlled research trials to
clinical practice (Wilson, 1996).
The use of treatment manuals addresses growing concerns
regarding the internal validity of psychotherapy research, and
provides a step toward meeting growing demands to provide treatments that have validated outcomes. Within psychotherapy research
trials, use of treatment manuals facilitates measurement of treatment
delity; replication of research methods; and objective identication
and comparison of effective treatments, among other advantages
(Dobson & Shaw, 1988). According to criteria developed by the
American Psychological Association to dene empirically-supported
treatments (ESTs; i.e., clearly specied psychological treatments
shown to be efcacious in controlled research with a delineated
population; Chambless & Hollon, 1998, p. 7), use of a manual within
a research trial evaluating a psychotherapy is necessary for that
psychotherapy to be deemed empirically-supported.

* Corresponding author. Tel.: 1 (403) 220 7085; fax: 1 (403) 282 8249.
E-mail addresses: lmwallac@ucalgary.ca (L.M. Wallace), kvonrans@ucalgary.ca
(K.M. von Ranson).
0005-7967/$ e see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.brat.2011.09.002

The benets of using treatment manuals in clinical practice

include facilitating training; broadening clinicians treatment skills;
and providing a structured, focused approach (Wilson, 1996).
Perhaps most importantly, manuals can increase treatment delity.
Notably, only a minority of clinicians who provide ESTs without use
of a manual may be able to do so with adequate delity. For
example, Santa Ana et al. (2008) observed interventions provided
in the treatment-as-usual arm of two multisite randomized effectiveness trials (wherein use of a manual was not required), and
found that techniques provided largely did not align with the
theoretical orientation clinicians claimed to follow or the treatments site directors claimed were used. Thus, current training and
dissemination methods for ESTs may not guarantee treatment
delity in the absence of manual use, emphasizing the importance
of increasing the use of manuals in clinical settings.
Research has provided strong evidence supporting the use of
manuals in clinical practice. For example, improved client
outcomes were observed and maintained over a ten-year period
following a transition to the use of manual-based treatments in
a clinical psychology graduate training clinic (Cukrowicz et al.,
2011). However, use of manuals in clinical practice remains unenthusiastically received by many clinicians. Manuals are oftcriticized for impeding clinicians clinical judgment; preventing
modications of treatment to idiographic case formulations;
undermining clinical artistry and innovation; impairing the therapeutic relationship; and promoting particular schools of therapy
(Addis, Wade, & Hatgis, 1999; Wilson, 1996). In addition, critics
have claimed that treatment efcacy demonstrated in randomized

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L.M. Wallace, K.M. von Ranson / Behaviour Research and Therapy 49 (2011) 815e820

controlled trials (RCTs) may not generalize to non-research settings

and clients who present with greater comorbidity than those seen
in research trials (Ruscio & Holohan, 2006). As most manuals are
disorder-specic, comorbidity may also be perceived to complicate
selection of the appropriately targeted manual.
It is possible that perceptions and use of manual-based treatments are changing, although differences in samples and methodology employed across studies make trends unclear. In 1998,
a survey of American practicing psychologists (N 891) showed
widely varying attitudes toward treatment manuals, with less than
50% reporting a relatively clear perception of what manuals were
(Addis & Krasnow, 2000). In contrast, a survey of 47 cognitivebehavioral clinicians attending a national cognitive-behavioral
conference indicated an extremely positive view of manuals,
without nearly any of the oft-cited criticisms of manuals endorsed
(Najavits, Weiss, Shaw, & Dierberger, 2000). More recently, Barry
et al. (2008) surveyed substance use clinicians (N 40) and found
overall favorable attitudes toward treatment manuals, with
minimal differences in reported perceptions and use of manuals
across research- and community-based clinicians. Findings from
selected samples may not generalize to other populations,
however.
Most research to date has examined perceptions of treatment
manuals without directly evaluating use of treatment manuals.
Although perceptions of manuals likely inuence the use of
a manual, a causal association cannot be assumed. In the area of
eating disorders (EDs), two studies have specically examined use
of treatment manuals. Tobin, Banker, Weisberg, and Bowers (2007)
surveyed 265 clinicians recruited online and at meetings for ED
professionals, and reported that 79% of clinicians used treatment
manuals when treating EDs. However, only 6% indicated that they
adhered closely to manuals, with 73% indicating that they were
exible in how they applied manuals. Simmons, Milnes, and
Anderson (2008) surveyed 268 members of the Academy for
Eating Disorders, and reported that only a minority of clinicians
(38%) used manual-based psychotherapies for EDs. Further analyses suggested that clinicians who used manual-based treatments,
as compared to those who did not, had spent fewer years in clinical
practice; had treated a greater portion of clients with EDs; and were
less likely to be clinical psychologists or medical doctors.
These previous studies have explored a general tendency to use
manuals, which may distort actual rates of manual use through
recall and reporting biases. For example, responses from clinicians
who use manuals with some clients but not others may be
misleading. In the present study, we sought more objective
responses regarding manual use by examining manual use with
a specic client e i.e., clinicians most recent client with bulimia
nervosa (BN), to whom he/she had provided psychotherapy in the
past 12 months. Furthermore, we examined characteristics of the
clinician that may be associated with manual use as well as characteristics of the client and of the treatment approach itself, which
have received relatively little research attention to date. This study
is the rst to examine the association between use of a treatment
manual and provision of eclectic treatment. Eclectic psychotherapy
approaches appear to be common in clinical practice (e.g., Hepner,
Greenwood, Azocar, Miranda, & Burnam, 2010; von Ranson &
Robinson, 2006), but may be inconsistent with manual use
because eclectic therapy tends to involve melding of different
techniques and approaches, whereas manual use usually involves
delity to a single treatment. In sum, we sought to examine manual
use within the evolving climate of evidence-based practice, and to
improve upon previous research via more objective methodology
and an expanded focus on factors associated with the likelihood of
using a manual. Identifying such factors may be critical to designing
and focusing efforts to disseminate manuals into clinical practice.

BN is a disorder for which there is ample evidence for an efcacious, manual-based treatment (National Institute for Health and
Clinical Excellence, 2011) e i.e., cognitive-behavioral therapy (CBT;
Fairburn, Marcus, & Wilson, 1993). Manual-based treatment for BN
also exists for interpersonal psychotherapy (IPT; Klerman &
Weissman, 1993), dialectical behavior therapy (DBT; Safer, Telch,
& Chen, 2009), family-based therapy (FBT; Le Grange & Lock,
2007), and motivational enhancement therapy (MET; see Dunn,
Neighbors, & Larimer, 2006). However, it may take longer with
IPT to attain similar improvement as CBT (Fairburn, Jones, Peveler,
Hope, & OConnor, 1993), and the efcacy of DBT (Safer, Telch, &
Agras, 2001), FBT (Le Grange, Crosby, Rathouz, & Leventhal,
2007), and MET (Dunn et al., 2006) is less well established. The
majority of these manuals have been designed for and evaluated
with adults, not adolescents, with the exception of FBT (Le Grange
et al., 2007; Schmidt et al., 2007) and CBT guided self-care (Schmidt
et al., 2007).
Method
Participants
Potential participants were identied through the member
directories of two international organizations for ED research,
treatment, and prevention: the Academy for Eating Disorders (AED)
and the Eating Disorders Research Society (EDRS). Both the AED
and EDRS are primarily English-language organizations. To be
eligible to participate in the present study, members must have
provided multiple sessions of psychotherapy to at least one individual with BN in the past 12 months.
Measures
An online survey was created, with a section that instructed
participants to recall the most recent client with BN to whom
psychotherapy had been provided across multiple sessions in the
past 12 months. The term client was noted to refer to an individual seen in clinical practice, not a research participant. This
distinction was made because research protocol often dictates
exactly how treatment is provided in research settings, unlike in
clinical practice.
The target survey item asked participants, Did you use
a manual when providing this psychotherapy? Other items
explored characteristics of the clinician (i.e., the participant), the
client, and the treatment approach used.
Procedure
Ethics approval was obtained from the institutional research
ethics board prior to contacting potential participants. Potential
participants were sent a personalized email message that invited
participation in the study, contained an electronic link to an online
survey, and detailed the opportunity to enter a draw for a prize.
Two reminder emails were distributed 7 and 17 days after the initial
email to non-respondents. All participants indicated their consent
to participate prior to beginning the survey, and all identifying
information was deleted from all records once data collection was
complete.
Coding
An open-ended item that asked participants to indicate the
psychotherapeutic approach(es) provided to his/her most recent
client with BN was coded independently by three coders (a clinical
psychologist and researcher [KMvR], a masters student in clinical
psychology [LMW], and a clinical psychology doctoral student, all

L.M. Wallace, K.M. von Ranson / Behaviour Research and Therapy 49 (2011) 815e820

specializing in ED research) to determine the number and type of

separate psychotherapeutic approaches used by each participant.
The nal coding was determined by consensus of the three coders.

817

Table 2
Characteristics of the clinician, client, and treatment approach associated with use of
a manual when providing psychotherapy for bulimia nervosa (N 259).
Characteristic

Manual c2
used

119
124
187
59
91
50
105
109
137
139
120

43.7%
31.5%
35.8%
40.7%
31.9%
28.0%
45.7%
45.0%
30.7%
49.6%
20.0%

Results
An email message describing the study was sent to 1297 individuals who had their name and email address listed in the
member directory of AED and/or EDRS. Sixty-seven of these
messages were undeliverable. Of the 1230 potential participants
whose emails did not bounce back, 36.3% (n 446) responded. Of
the respondents, 2.7% (n 12) declined participation, 36.3%
(n 162) were ineligible to participate (i.e., had not provided
psychotherapy to a client with BN in the past 12 months), and 61.0%
(n 272) were eligible and participated (i.e., 22.1% of 1230 potential
participants). As 4.8% of the 272 eligible participants did not answer
the target item regarding manual use, data from these participants
were discarded. Therefore, the following results present data from
259 participants. Percentages reported have been calculated from
the total number of valid responses for each respective item.
Manual use
See Table 1 for demographic characteristics of the sample.
Participants could indicate use of multiple manuals with multiple
psychotherapeutic approaches. Only 35.9% (n 93) of participants
indicated that they had used a manual when providing psychotherapy to their most recent client with BN. Of these participants,
84.9% (n 79) were able to report the author of the manual, or
otherwise specify the manual (e.g., indicate the title). The most
common psychotherapeutic approach for which participants had
used a manual was CBT (66.7%, n 62), followed by DBT (18.3%,
n 17).
Factors inuencing manual use
We used Pearsons chi-square analyses to examine associations
between use of a manual and characteristics of the clinician,
treatment approach, and client treated. See Table 2 for results.
Relatedly, we used an independent samples t-test to compare the
number of years participants had been providing psychotherapy to
clients with EDs across participants who did and did not use
a manual. No signicant difference was found.

Table 1
Demographic characteristics of the sample (N 246e259).
Variable

% or M (SD)

Sex

Female
Male

81.1%
18.9%

Age

<45 Years
45 Years

49.0%
51.0%

Highest degree obtained

Below masters degree

Masters degree
M.D.
Ph.D. or Psy.D.

4.9%
32.1%
20.3%
42.7%

Field of highest degree

Clinical psychology
Medicine/psychiatry
Applied/counseling psychology
Social work
Other

48.0%
16.2%
12.7%
11.3%
11.8%

Current student

Yes
No

14.7%
85.3%

Clinical experience with

eating disorders

Years (including training)

14.53 (9.69)

Clinician
Age
Country of work/school
Highest degree obtained

Field of highest degree

Involvement in eating
disorder research
in the past 12 months
Client
Age
Comorbid disorder
Treatment approach
Primary psychotherapeutic
orientation
Number of psychotherapies
used with client

Under 45 years of age

45 Years of age or older
North America
Outside North Americaa
Masters degree or lower
M.D.
Ph.D./Psy.D.
Clinical psychology
Other
Yes
No

Adolescent (14e19 years) 72 26.4%

Adults (20 years or older) 187 39.5%
Present
174 35.6%
Absent
82 36.5%
Cognitive-behavioral
Other
One
Multiple

132
83
125
132

47.0%
24.1%
47.0%
24.8%

3.87*
.45
6.19*b

5.32*
24.59***

3.93*
.02

11.30**
13.67***

a
Other countries include countries in Europe, Australia, southeast Asia, South
America, and southern Africa.
b
Follow-up analyses indicated that participants with a Ph.D. or Psy.D. were more
likely to use a manual than participants with an M.D. (c2(1) 4.43, p < .05) and
participants with a masters degree or lower (c2(1) 3.92, p < .05). *p < .05,
**p < .01, ***p < .001.

Cognitive-behavioral orientation
Although participants who endorsed a cognitive-behavioral
theoretical orientation were more likely than those who did not to
have used a manual, still only 47% of these participants reported
having used a manual. To identify potential predictors of the use of
manuals by CBT providers, we conducted a Pearsons chi-square
analysis to determine whether use of a manual among cognitivebehaviorally oriented participants was associated with clinician
characteristics associated with manual use in the larger sample: the
level and eld of education they had received. Results were
signicant: cognitive-behaviorally oriented participants with
a Ph.D. or Psy.D. in clinical psychology were more likely to have
used a manual than cognitive-behaviorally oriented participants
with either a Ph.D./Psy.D. from an alternative eld or no Ph.D./
Psy.D. (68.9% vs. 35.6%; c2(1) 13.17, p < .001).
Discussion
This study surveying use of manuals in psychotherapy provision
for BN provides information relevant to the current movement
toward evidence-based practice in mental health. Overall, the data
suggested a low rate of manual use for psychotherapy provision:
only approximately one-third of participants indicated that they
had used a manual when treating their most recent client with BN.
Analysis of variables describing the clinician, client, and treatment
approach provided insight into factors associated with the likelihood that a manual was used.
With respect to clinician characteristics, education was associated with the decision to use a manual: participants were more
likely to use a manual if they had obtained a Ph.D. or Psy.D., and/or
if they received their highest degree in clinical psychology. Thus,
targeting efforts for manual dissemination at clinicians without

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L.M. Wallace, K.M. von Ranson / Behaviour Research and Therapy 49 (2011) 815e820

a Ph.D./Psy.D. and clinicians trained outside of clinical psychology

programs may be particularly fruitful. In addition, participants
younger than 45 years of age were more likely to have used
a manual than older participants, although amount of clinical
experience treating clients with EDs was not associated with
manual use, suggesting a possible cohort effect. Participants who
reported involvement in ED-related research in the past 12 months
were more likely to have used a manual than clinicians not involved
in such research, suggesting that research involvement may make
clinicians more inclined to use a manual in their own practice. This
nding may be due to an emphasis on manualized treatment in
clinical research settings, which researchers then may extend to
their own clinical practice. However, not all research pertains
directly to treatment. Among other possibilities, researchers may
be more familiar with manual-based treatments or the evidence in
favor of such treatments; may place greater value on the importance of research evidence in selecting treatments; and may feel
greater allegiance to the concept of evidence-based practice.
Some ndings from the present study conict with previous
research that has examined clinician characteristics associated with
manual use. For example, Simmons et al. (2008) reported that ED
clinicians whose highest educational degree was in clinical
psychology were less likely to use a manual, as compared to clinicians with a degree in counseling, medicine/psychiatry, etc., and
that clinicians with more clinical experience were less likely to use
a manual. Barry et al. (2008) similarly indicated that substance
abuse clinicians with more clinical experience held less favorable
attitudes toward treatment manuals, which was not accounted for
by age. Possibly, our conicting nding that clinical experience was
not associated with manual use occurred because we only examined clinical experience specic to EDs, unlike these other studies.
In further contrast to our ndings, Barry et al.s research indicated
few differences between research- and community-based
substance abuse clinicians in regards to patterns of manuals read,
used, and perceived as most useful. Thus, while Barry et al.s data
appear to suggest that the research-practice gap concerning
manual use may be narrowing among substance use clinicians, data
from the present study seemingly suggest that this gap remains
wide among ED clinicians. It seems likely that these discrepancies
are due to differences in samples, and possibly differences across
forms of psychopathology (e.g., substance use vs. EDs), as well as
clinicians perceptions of the evidence supporting the use of
treatment manuals for particular disorders. It is possible that the
present studys methodology, wherein participants were specically asked to report on treatment with their most recent client,
yielded more objective responding than questions inviting generalizations about clinical choices. Finally, considering that Barry et al.
(2008) and Simmons et al. (2008) both surveyed participants prior
to 2007, whereas the present data were collected from November
2010 to January 2011, it is possible that trends in treatment provision and manual use have changed over the past several years.
In regards to client characteristics, fewer participants used
a manual if the client being treated was an adolescent rather than an
adult. Few treatment manuals for BN specic to adolescents are
available, and research evaluating the efcacy of manual-based
treatments for BN is less developed with adolescent than adult
populations, which could impact a clinicians decision to use
a manual. Alternatively, clinicians may perceive existing manuals for
adolescents to be less effective, to be developmentally inappropriate,
or to be more difcult to employ. Further research to understand the
infrequency of manual use with younger populations is needed.
In contrast, client comorbidity was not associated with manual
use. This nding contradicts frequently-cited concerns that
manuals do not allow comorbidity to be adequately addressed
(Ruscio & Holohan, 2006; Westen, Novotny, & Thompson-Brenner,

2004). Recent evidence suggests that comorbidity may not impede

the outcome of manual-based treatment (Fairburn et al., 2009;
Kendall, Brady, & Verduin, 2001). Perhaps clinicians are taking
note of such research and shifting their perceptions concerning
comorbidity. Alternatively, this concern may simply not be inuencing practice.
Findings further indicated that participants were more likely to
have used a manual if they endorsed a cognitive-behavioral theoretical orientation. This association may exist because CBT is
particularly amenable to manual use (e.g., through a structured,
time-limited focus, and use of specic techniques; Westen et al.,
2004), because of the prevalence and accessibility of various CBT
manuals specic to BN (e.g., Fairburn, 2008; Fairburn, Marcus, et al.,
1993), or both. However, manual-based treatments are not limited
to psychotherapies that are cognitive-behaviorally oriented.
Recently, psychotherapies formerly perceived as less amenable
than CBT to manualization, such as psychoanalytic and psychodynamic psychotherapy, have been manualized and evaluated in
several RCTs for various disorders (e.g., Dare, Eisler, Russell,
Treasure, & Dodge, 2001; Leichsenring et al., 2009).
Notably, despite a cognitive-behavioral orientation being associated with increased manual use, it was still associated with a low
rate of use (47%). However, two-thirds of the subgroup of cognitivebehaviorally oriented participants who had obtained a Ph.D./Psy.D.
in clinical psychology reported having used a manual.
A novel nding with important implications was that eclectic
psychotherapeutic approaches were associated with a decreased
likelihood of using a manual. This nding may suggest that the use
of eclectic psychotherapy, as currently practiced, may be perceived
as inconsistent with use of manuals. One interpretation is that
researchers should take steps toward creating and evaluating
manuals that are compatible with an eclectic approach, such as by
indicating principles for how specic techniques from other
psychotherapeutic approaches can be integrated into the manualized psychotherapy. Currently, essential mechanisms of change
in many treatments are largely unknown (Kazdin, 2009), which
challenges specication of essential techniques of a treatment
necessary to include in an eclectic approach. However, if use of
eclectic therapeutic approaches conicts with the use of manualbased treatment e as the present ndings suggest e it appears
vital to ask: Is integrating an existing, standalone manual into an
eclectic approach more effective than not using a manual at all?
Fairburn et al.s (2009) evaluation of enhanced CBT, wherein
condensed IPT is integrated into CBT for a subset of clients with EDs,
suggests that combining certain psychotherapies can be efcacious.
Furthermore, this treatment demonstrates that manualization of
such integrated treatment is possible (Fairburn, 2008), and that use
of such treatment in clinical settings can be effective (Byrne,
Fursland, Allen, & Watson, 2011).
The recent growth of modular treatment approaches may strike
a balance between conicting demands of eclectic treatment vs.
specic manual-based treatment. Modular treatment approaches
allow exible application of core strategies that are selected based
on idiographic client proles, at times including exibility in the
order or inclusion of modules. However, they maintain much of the
structure inherent in treatment manuals (McHugh, Murray, &
Barlow, 2009). Perhaps such modular treatments provide a means
to empirically combine techniques from multiple theoretical
approaches. At present, however, the efcacy of modular treatments has only been established among treatments that maintain
delity to a single theoretical orientation. Furthermore, ensuring
that techniques from multiple approaches are conceptually
compatible could pose a challenge.
The present study provides several strengths, including a large,
international sample that included clinicians with varying levels of

L.M. Wallace, K.M. von Ranson / Behaviour Research and Therapy 49 (2011) 815e820

educational backgrounds and research involvement. In addition,

the studys methodology that involved specication of manual use
with a specic, recent client may have provided more objective
results than previous studies.
Despite the strengths of this study, several limitations exist.
Notably, the moderate (36.3%) response rate may limit the generalizability of the results. However, this response rate is comparable
to studies examining similar samples (e.g., Simmons et al., 2008).
Furthermore, as we cannot determine whether emails to nonrespondents were received, or whether non-respondents were
eligible to participate in the study, this rate reported is likely
conservative.
Another limitation is that members of the AED and/or EDRS
may not represent clinicians who do not belong to either organization. Many clients with EDs likely receive treatment from
a clinician who does not specialize in EDs. Both organizations
promote and encourage research, which may have led to more
favorable views of manual-based treatment than would have been
endorsed by clinicians who were not members of either organization. Reliance on self-report data is another limitation. However,
the large majority (84.9%) of participants who indicated using
a manual were able to describe a specic manual that they had
used, supporting the validity of their reports. In addition, the
wording of the item regarding manual use limits our understanding as to how manuals were being used by participants, as
use is an inclusive if somewhat vague descriptor. However, more
precise terminology might have created small cell sizes that
reduced power to detect effects. Nonetheless, future research
could specify varying levels of manual use to provide further
clarication as to how manuals are used.
In sum, results of this study suggest that psychotherapy for BN
provided in clinical practice is typically not provided with the use of
a manual, in contrast to psychotherapy provided e and validated e
in controlled research trials. Perhaps clinicians are able to imitate
treatment provided in research trials without use of the manuals
used in the trials, or are able to provide their own forms of
psychotherapy that can be equally, or more, effective as the forms of
psychotherapy validated in research trials. However, without
evidence to support this assertion we cannot simply assume this is
the case. Considering the prevalent use of eclectic treatment
approaches, and our nding that incorporating multiple
approaches in the treatment of BN is associated with lower probability of use of a manual, it is imperative to determine the content
and outcome of the various forms of treatment that are currently
being provided in clinical care.
Acknowledgments
This manuscript is based on a portion of the masters thesis
research of Laurel M. Wallace, which was completed under the
supervision of Kristin M. von Ranson and supported in part by
a Social Sciences and Humanities Research Council of Canada
Masters Scholarship. We thank Dr. Susann Laverty, Dr. Keith Dobson, and Dr. Jean Wallace for their assistance with study design, and
Phil Masson for his assistance with data coding. Finally, we express
sincere gratitude to those who volunteered their time to participate
in this study.
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