Enhanced Cognitive Behaviour Therapy for Eating Disorders: Research Recommendations to Improve Future Studies

 

Introduction

Enhanced Cognitive Behaviour Therapy (CBT-E) is a transdiagnostic approach designed to treat the core psychopathology underlying eating disorders, rather than focusing on any specific DSM diagnostic category [1, 2]. It is based on the transdiagnostic theory of eating disorders, which identifies the key maintaining mechanisms that therapy aims to target [1]. CBT-E was initially developed as an individualized outpatient treatment for adults of any gender with clinically significant eating disorders. Over time, it has been adapted for younger individuals [3] and for those with binge eating and higher weight [4] as well as for application in more intensive treatment contexts—such as intensive outpatient, day-patient, and inpatient programs [5, 6].

CBT-E has been evaluated across the entire spectrum of eating disorders. Although the studies report some variation in treatment outcomes, this may reflect differences in patient characteristics as well as in the quality of CBT-E delivery. Notably, the most favourable results were obtained in trials where CBT-E was implemented with high fidelity—specifically those carried out in Oxford and Leicester (UK) [7], Copenhagen (Denmark) [8], and Verona (Italy) [9].

As matters currently stand, research findings may be summarised as follows. CBT-E has been demonstrated to be effective across all forms of eating disorders observed in adults [7, 10]. This breadth of applicability has not been reported for any other treatment currently available. Specifically, the evidence suggests that among adult patients who are not significantly underweight, the drop-out rate is about 22% and approximately two/third of those who completed the treatment achieve full recovery at 60-week follow-up [7]. In contrast, among patients who are substantially underweight, the dropout rate is less than 30%, and around 60% of the total sample achieve a healthy weight at 12-month follow-up [10].

CBT-E has also been shown to be effective in the treatment of younger patients, positioning it as a potential alternative to Family-Based Therapy (FBT) for this population [11].

In direct comparisons with other psychological treatments for adults, CBT-E has been found to be more effective than Interpersonal Psychotherapy (IPT) among patients who are not underweight [12]. It has also demonstrated superior outcomes compared with 100 sessions of psychoanalytic psychotherapy delivered over a two-year period for non-underweight patients [8]. Additionally, in the treatment of anorexia nervosa, CBT-E has yielded outcomes comparable to those of other evidence-based psychological interventions [10]. To date, no alternative psychological treatment for eating disorders has demonstrated superior efficacy to CBT-E.

The above findings have informed the most recent United Kingdom national guidelines, which recommend Eating Disorder–Focused Cognitive Behavioural Therapy (CBT-ED) as the first-line treatment for eating disorders [13]. Within this framework, CBT-E is recognised as one of the most prominent and extensively implemented approaches. CBT-E has now been disseminated internationally, and thousands of clinicians have been trained in its delivery [14].

Despite this, recent randomized controlled trials have exhibited poor internal validity due to inadequate therapist training, lack of supervision, and failure to assess treatment fidelity. In some cases, CBT-E was inaccurately described or implemented, diverging substantially from the manualized protocol. Interventions often resembled hybrid treatments, incorporating elements not included in CBT-E or combining CBT-E with other therapies without clear theoretical rationale and small sample size.

Recent meta-analyses of CBT-ED have reported mixed results regarding its relative efficacy [15]. While CBT-ED produces meaningful clinical improvements, its superiority over other active treatments remains uncertain, largely reflecting the methodological heterogeneity and fidelity issues noted above. It should be noted that these meta-analyses included not only studies where CBT-E was well implemented but also a broader range of interventions within the CBT-ED framework, which share some similarities yet differ in key aspects.

This variability underscores the urgent need to improve the methodological rigor and internal validity of CBT-E research. Drawing upon extensive clinical and research experience with CBT-E, the present paper outlines key recommendations to strengthen the design, conduct, and interpretation of future trials. By addressing these limitations, future research can more accurately determine the effectiveness of CBT-E and enhance its application across diverse clinical populations and settings.

Interpreting conclusions of meta-analyses of CBT-ED with caution

Several meta-analyses have examined the efficacy of CBT-ED in the last few years [16–20]. A recent commentary synthesizing four meta-analyses published between 2024 and 2025 [15] concluded that evidence for the effectiveness of CBT-ED remains mixed and limited—particularly for anorexia nervosa, where high-quality randomized controlled trials are scarce. Across studies, CBT-ED demonstrates moderate to large effects when compared with waitlist controls (not used for anorexia); however, it does not appear significantly more effective than treatment as usual or other active psychotherapies. Both controlled and naturalistic studies report comparable within-group improvements, with effect sizes of approximately 1.20 after an average of twenty-seven sessions—similar to those achieved in shorter, ten-session CBT protocols (ES = 1.49). Treatment outcomes also appear consistent across individual, group, and guided self-help formats. Despite these uncertainties, CBT-ED reliably produces clinically meaningful improvement for a substantial proportion of individuals, with roughly 36% achieving abstinence from disordered eating behaviours compared with about 10% in control conditions.

Although meta-analyses can integrate findings across numerous individual studies and offer a quantitative overview, they may also overlook critical methodological nuances, sometimes leading to distorted or overly confident conclusions [21]. The validity of a conclusion is influenced by the quality of the studies synthesized, and those studies inevitably vary in susceptibility to bias in various forms [22]. A range of complex—often inadvertent or unnoticed—biases can shape both primary research and the reviews or meta-analyses that synthesize it.

Numerous authors have described the many limitations and potential hazards associated with meta-analytic methods [22, 23].

In many of the studies included in meta-analyses, CBT-ED was delivered by clinicians or researchers with limited training and experience in CBT-E, often within highly controlled research environments that constrain external validity. Moreover, the meta-analyses incorporated both studies in which CBT-E was well implemented and others evaluating broader CBT-ED interventions that differ in key conceptual and procedural aspects from CBT-E. Additional methodological issues—including heterogeneous study designs, inconsistent diagnostic criteria, small sample size, and variable internal validity—further limit the reliability of aggregated effect estimates and may contribute to inflated or misleading conclusions regarding efficacy.

Given the methodological limitations in CBT-E meta-analysis, we suggest being cautious in drawing conclusions related to the efficacy and effectiveness of the treatment, and to focus attention on methodologically well-conducted trials [7–10].

Future research efforts would be more productively directed toward enhancing the internal and external validity of studies on CBT-E, as well as refining and empirically evaluating strategies designed to improve its effectiveness. Such advances have the potential to optimize outcomes for the diverse range of individuals who engage collaboratively with therapists in the treatment of eating disorders.

Use of an adeguate sample size

The use of an adequate sample sizes in psychotherapy studies remains a crucial issue. When comparing randomized controlled trials (RCTs) in psychotherapy and pharmacotherapy, a substantial discrepancy in sample sizes clearly emerges in favor of pharmacotherapy trials. This issue is particularly evident in eating disorders research, where difficulties in recruiting individuals affected by these conditions often result in small sample sizes.

In an insightful analysis, Nelson and colleagues [23] argue that psychologists have long been aware of two seemingly contradictory problems in the published literature. On the one hand, the vast majority of published findings are statistically significant. On the other hand, the overwhelming majority of published studies are underpowered and therefore, in theory, unlikely to yield statistically significant results. Based on sample size considerations alone, most studies should have failed to achieve significance, yet the published record suggests an almost uniform success. Despite long-standing evidence that many clinical studies are severely underpowered and repeated calls to increase sample sizes, research practices have not substantially changed.

A small sample size in a clinical trial is particularly problematic because it reduces statistical power and increases the risk of both Type I errors (detecting effects that are not real) and Type II errors (failing to detect real effects).

Use of an appropriate intervention as a comparator treatment

The use of waiting list (WL) control groups is widespread in clinical trials addressing eating disorders. Nonetheless, their frequent inclusion has prompted debate regarding the actual efficacy of psychological interventions. Evidence from meta-analyses consistently shows that therapeutic approaches often yield greater effect sizes when compared with WL controls than with alternative conditions such as treatment-as-usual (TAU) [24]. The mechanisms underlying this apparent inflation of effect sizes in WL designs remain uncertain. One possible explanation is that individuals assigned to a WL may postpone improvement until treatment begins, thereby exhibiting lower spontaneous recovery rates. Another potential factor involves expectancy effects, as participants in WL groups might anticipate greater improvement compared to those in alternative control conditions [25]. Finally, passive control conditions, such as clinical monitoring or waiting list, may control for the natural time course of recovery for some mental health problems, but not for the participants’ investment of time and energy in treatment, or for their expectation that the investment will lead to improvement [22].

Moreover, prior evidence shows that participants frequently experience disappointment upon being allocated to control groups. Nevertheless, this reaction may be less intense among WL participants, who are aware they will eventually receive the intervention [24]. These methodological and psychological dynamics may artificially exaggerate treatment effects by suppressing change within the control condition. Consequently, several scholars have recommended minimizing or avoiding the use of WL control groups in randomized trials [24] or limiting their use to small pilot or feasibility studies [15].

Developing an active comparison condition that controls for common therapeutic factors while excluding the core components of CBT remains challenging [15]. Nonetheless, in the treatment of adolescents with eating disorders, an opportunity is to directly compare FBT and CBT-E. These two interventions differ not only in their theoretical understanding of eating disorder psychopathology but also in their therapeutic strategies, procedures, and proposed mechanisms of change. Ongoing comparisons, such as those conducted in the Norwegian CogFam randomized controlled trial (RCT), have the potential to yield valuable insights into moderators that may inform patient–treatment matching and mediators that could guide future refinements to enhance the efficacy of both CBT-E and FBT [26].

Employment of innovative clinical trials

Recent discussions highlight the need for more personalized approaches in CBT research [15]. Innovative trial design—such as individual or cluster randomization, non-inferiority trials, and adaptive designs that tailor treatment according to patients’ intermediate responses—are increasingly recommended [27]. Given the considerable variability in CBT treatment response across individuals [19], these adaptive designs might offer a way to adjust interventions for slower responders, thereby enhancing overall treatment effectiveness [15]. These methods might be particularly valuable for research on CBT in anorexia nervosa, where recruitment and retention in randomized controlled trials remain especially challenging.

However, it is important to consider that innovative clinical trial designs, which have been primarily developed for drug research, are not well-suited to evaluating psychological treatments for eating disorders. Indeed, control conditions pose ethical and practical barriers for people with anorexia nervosa, while crossover designs conflict with the long-term, enduring changes targeted by treatment and may disrupt therapeutic relationship and progress.

More broadly, future CBT-E trials will need to face challenges related to patient engagement, ethical concerns surrounding randomization, and reluctance from clinicians and services to adopt methods that are misaligned with routine clinical practice. For these reasons, the next step should be to actively involve both patients and clinicians in designing trials that can be feasibly delivered within real-world clinical settings. Our current experience supervising a trial delivered in real-world settings highlights several practical obstacles that must be addressed, including therapist absences (e.g., due to holidays), staff turnover, the heavy clinical workload limiting attention to research protocols, clinician scepticism about randomization, and reluctance to adhere to fixed treatment durations. These challenges underscore the need for trial designs that are flexible, pragmatic, and responsive to the realities of routine clinical practice.

Evaluation of a more flexible implementation of CBT-E

Traditionally, CBT-E has been delivered with a fixed number of sessions—typically 20 weeks for patients who are not significantly underweight and 40 weeks for those requiring weight restoration. Recently, several trials have been initiated to assess the efficacy of shorter forms of CBT for eating disorders, such as the 10-session protocol proposed by CBT-T (with T denoting “ten”) for individuals who are not underweight [28], and its derivative, CBT-AN-20, a 20-session adaptation for patients with anorexia nervosa [29]. Although CBT-T, which is conceptually distinct from CBT-E, has yielded some promising preliminary findings, it is important to move beyond considerations of feasibility, acceptability, and cost reduction alone. Rather than pursuing a form of psychotherapeutic reductionism—reducing treatment duration primarily for pragmatic or economic reasons—extensive clinical experience with CBT-E in real-world settings supports a personalized and flexible approach to treatment duration. Some patients achieve remission of their eating-disorder psychopathology within only a few sessions (sometimes fewer than ten), whereas others require a considerably longer course than the 40 sessions recommended in the standard CBT-E protocol. However, extending the duration of CBT-E should be considered only when the patient remains engaged, actively participates in the treatment, and continues to make progress. Moreover, the need for such an extension should be formally evaluated at regular intervals during review sessions, and treatment should conclude following the procedures outlined in the final phase of CBT-E.

Future research should also examine the effectiveness of more intensive treatment models for individuals who are engaged but do not respond to standard outpatient CBT-E. These include intensive outpatient programs, day-hospital CBT-E, and residential CBT-E, which are delivered by multidisciplinary teams comprising psychologists, dietitians, and physicians trained in CBT-E. Such programs appear to benefit a substantial proportion of patients who fail to achieve adequate improvement with outpatient CBT-E [9, 30–33].

These observations align with the growing emphasis on personalized and stepped-care models in the treatment of eating disorders. Rather than adhering to fixed treatment durations, these frameworks advocate for tailoring the intensity and length of therapy to each patient’s clinical presentation, treatment response, and individual needs. Such an approach recognizes the heterogeneity of eating disorders, not only in symptom severity and its duration, but also in psychological mechanisms and comorbid features, and seeks to optimize outcomes by allocating therapeutic resources where they are most needed. Implementing flexible-duration CBT-E within a stepped-care model may therefore enhance both clinical effectiveness and cost-efficiency, while preserving the comprehensive and transdiagnostic principles that underpin CBT-E.

Use of standardized definition of eating disorder recovery

Although there is general agreement that recovery from eating disorders is multidimensional, the field still lacks standardized criteria, which limits comparability across studies—including those assessing CBT-E. Recovery from an eating disorder should be understood through an integrated lens encompassing physical, behavioural, and cognitive domains [34]. Research suggests that addressing all three dimensions enhances the stability of recovery and decreases the risk of relapse [35], both of which are central goals of treatment. Given the empirical support for this multidimensional model [36], adopting comprehensive and standardized recovery criteria is essential to accurately reflect the complex and multifaceted nature of the recovery process.

Several operational definitions of eating disorder recovery have been proposed that encompass physical, behavioural, and cognitive criteria [37]. These include frameworks developed for specific eating disorders [38, 39] as well as those adopting a transdiagnostic perspective [40]. The latter aligns with the transdiagnostic approach of CBT-E and is recommended as the most suitable framework for evaluating treatment outcomes in CBT-E studies. Moreover, this framework has demonstrated stronger associations with quality of life compared with other definitions of recovery [41].

Within this operationalization, physical recovery is defined as achieving a body mass index (BMI) of ≥ 18.5 or ≥ 19 kg/m²; behavioural recovery as the absence of eating disorder behaviours (i.e., objective binge eating, self-induced vomiting, laxative misuse, and fasting) over the preceding three months; and cognitive recovery as all subscale scores on the Eating Disorder Examination–Questionnaire (EDE-Q) [42–44] falling within one standard deviation of age- and gender-matched norms [34, 40]. Although reliance on the EDE-Q global score may obscure elevations within specific cognitive domains, its use—defined as falling within one standard deviation of age- and gender-matched norms—can be considered a reasonable alternative approach, given that the four-factor structure of the EDE-Q has not been consistently validated [45] and no alternative structure has demonstrated robust empirical support. Notably, a recent study reported that when the EDE-Q global score is applied alongside the same physical (i.e., BMI ≥ 18.5) and behavioural criteria, the proportion of individuals classified as fully recovered is slightly higher when using the global score (22.4%) compared with the subscale criteria (16.6%) [34].

Using this operationalization, individuals with a history of an eating disorder can be classified as follows [34]: (1) fully recovered—no current eating disorder diagnosis and evidence of recovery across all three domains (physical, behavioural, and cognitive); (2) partially recovered—no current eating disorder diagnosis but recovery achieved in exactly two domains (e.g., physical and behavioural, but not cognitive); and (3) currently ill—presence of a current ED diagnosis, or absence of a diagnosis but recovery attained in only one or none of the domains.

Maintain a high internal validity

Research on CBT-E for eating disorders demonstrates generally high internal validity. RCTs [7–10] have employed rigorous designs with random allocation, manualized treatment protocols, and standardized outcome measures such as the Eating Disorder Examination Interview [46, 47]. These features enhance causal inference by reducing confounding variables and ensuring treatment fidelity. Therapist training and blinded assessors further strengthen validity, although limitations remain—particularly therapist allegiance effects, participant non-blinding, and attrition bias, which are common in eating disorder populations. Overall, the methodological rigor of CBT-E trials supports a strong causal link between treatment and symptom improvement, though future studies should continue to address potential biases to further consolidate internal validity. However, some recent RCTs, which compared CBT-E for eating disorders with other psychological treatments or with the combination of CBT-E with other psychological treatment lacked good internal validity. This problem was related to two main factors.

First, CBT-E is a complex treatment to learn and implement, requiring intensive, certified training and ongoing supervision by an expert in CBT-E. This was not the case in some studies [48–50]. Indeed, the CBT-E protocol has been poor implemented in some studies, and the way some authors described CBT-E suggests only a superficial understanding of the approach, differing substantially from the recommended protocol. In general, the intervention delivered did not correspond to CBT-E but rather resembled a hybrid treatment. For example, one study described nine modules, whereas CBT-E for adults with eating disorders is structured into four stages, with only the third stage of the focused form including five optional modules. Moreover, CBT-E does not include modules on “motivation,” “nutrition,” or “creating a formulation.” Cognitive restructuring is also not part of CBT-E, and the “self-esteem” module (referred to in CBT-E as “core low self-esteem”) is applied only to a specific subgroup of patients within the broad form [49]. Another study included an unspecified initial day-hospital phase, followed by an eclectic combination of nutritional and psychiatric interventions alongside some CBT-E procedures [50]. In yet another study involving patients with eating disorders who were not underweight, participants met with a dietitian to co-construct a nutritional plan that was subsequently reviewed during therapy [48]—an approach that contradicts the anti-diet principle of CBT-E. To ensure strong internal validity, we recommended for future trial to:

1. Obtain formal training in CBT-E accredited by the CBT-E Training Group, such as the CBT-E Web Training https://www.cbte.co/for-professionals/web-based-training/ or training certificated by CREDO.
2. Receive ongoing supervision from a member formally recognized by the CBT-E Training Group https://www.cbte.co.
3. Evaluate the fidelity of the treatment delivered through external assessment of recorded therapy sessions, and use of the Therapist Self-Rated CBT-E Components Checklist, a formative tool for therapists to assess, and improve as needed, their own adherence [51].

Second, the studies that compared CBT-E with CBT-E combined with other psychological treatments [48, 50] lacked a clear rationale explaining why the additional intervention—based on a different theoretical model—might enhance the outcomes of a standard evidence-based psychological treatment, or how two distinct psychotherapies could be effectively integrated. Furthermore, the small sample sizes of these studies did not account for the inherent complexity of such an approach. Indeed, demonstrating that an adjunctive intervention can improve upon the current gold standard requires sample sizes far larger than those typically achieved in clinical research to date. We recommend that rather than combining CBT-E with other psychological treatments remain many opportunities to enhance the effectiveness of CBT-E, in addition to the greater personalization. For example, we could develop strategies to make treatment more flexible, better engage patients in addressing the egosyntonic aspects of their disorders [52], target the influence of diet culture and the over-evaluation of shape and weight [14, 53], expand CBT-E to address additional comorbid psychopathology that contributes to maintenance and treatment resistance [54], and adapt interventions to meet the needs of specific populations (e.g., males, LGBTQ individuals, neurodivergent patients) [14, 55].

Conclusion

CBT-E remains one of the most empirically supported and conceptually comprehensive treatments for eating disorders, further refinement in both research design and clinical implementation is essential to fully establish its effectiveness across populations and settings. The evidence to date suggests that CBT-E is efficacious when delivered with high fidelity by well-trained and supervised clinicians; however, methodological limitations—such as inconsistent protocol adherence, inadequate therapist training, small sample sizes, and theoretically unjustified treatment combinations—continue to constrain the interpretability and generalizability of findings.

To advance the field, future research should prioritize methodological rigor, including the use of standardized definitions of recovery, careful selection of active comparator conditions, and trials conducted under conditions that maintain both internal and external validity. Collaborative efforts among researchers, clinicians, and patients will be crucial in developing innovative, flexible, and personalized adaptations of CBT-E that remain faithful to its theoretical foundations while addressing the heterogeneity of eating disorders. By strengthening the scientific and clinical foundations of CBT-E research, we can move closer to realizing its full potential as a globally effective, patient-cantered treatment for all forms of eating disorders.

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