Cognitive Behavioral Therapy For The Eating Disorder

Annual Review of Clinical Psychology
Cognitive Behavioral Therapy

for the Eating Disorders
W. Stewart Agras and Cara Bohon
Annu. Rev. Clin. Psychol. 2021.17:417-438. Downloaded from www.annualreviews.org
Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford,

California 94305, USA; email: sagras@stanford.edu, cbohon@stanford.edu
Access provided by 112.120.250.18 on 12/04/23. For personal use only.
Annu. Rev. Clin. Psychol. 2021. 17:417–38 Keywords

The Annual Review of Clinical Psychology is online at
cognitive behavioral psychotherapy, eating disorders, bulimia nervosa, BN,
clinpsy.annualreviews.org
binge eating disorder, anorexia nervosa, dissemination
https://doi.org/10.1146/annurev-clinpsy-081219-
110907 Abstract
Copyright © 2021 by Annual Reviews.
Research findings strongly suggest that cognitive behavioral therapy for the
All rights reserved
eating disorders (CBT-ED) is more effective than other treatments for bu-
limia nervosa (BN) and for binge eating disorder (BED), although interper-
sonal psychotherapy appears to be equally effective for BED. Evidence for
the effectiveness of CBT-ED for the persistent (adult) form of anorexia ner-
vosa (AN) is insufficient at present and is essentially absent for AN in adoles-
cents except for some evidence from uncontrolled trials. This article begins
with an overview of the early studies in the development of CBT-ED that
showed a similar effectiveness of other symptom-focused psychotherapies—
a finding that was neglected at the time. Later developments are then
considered, including comparisons of CBT-ED with other psychotherapies,
efforts to develop Internet-based training and treatment, and electronic
applications for treatment. Finally, implications of the findings for future
short- and long-term research and for clinical practice are considered.
417
Contents
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418
EFFECTIVENESS OF COGNITIVE BEHAVIORAL THERAPY . . . . . . . . . . . . . . . . 419
Early Controlled Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419
Later Controlled Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Comparisons of Cognitive Behavioral Therapy for the Eating Disorders
with Other Psychotherapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
PREDICTORS, MODERATORS, AND MEDIATORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
Predictors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
Moderators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
Mediators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
BROADENING THE DELIVERY OF COGNITIVE BEHAVIORAL

THERAPY FOR THE EATING DISORDERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Teletherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Therapist Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430
Electronically Delivered Psychotherapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
IMPLICATIONS FOR RESEARCH AND TREATMENT . . . . . . . . . . . . . . . . . . . . . . . . 433
Implications for Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
Implications for Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
INTRODUCTION
Cognitive behavioral therapy for the eating disorders (CBT-ED) is widely recognized as the treat-
ment of choice for bulimia nervosa (BN) and binge eating disorder (BED) by several national
guidelines, such as those of the National Institute for Health and Care Excellence (NICE 2017)
in the United Kingdom. This article critically evaluates the development and present status of
CBT-ED and examines present and future applications of both CBT-ED and its modifications.
Comparisons of CBT-ED with other psychotherapies are examined in detail.
The development of CBT-ED was closely linked to the emerging clinical awareness of BN
and to the efficacy of cognitive behavioral therapy (CBT) in depression and the anxiety disorders
( Jarrett & Vittengl 2016). During the 1970s, the number of treatment-seeking individuals with
BN began to increase; as a result, the disorder was recognized in the third edition of the Diag-
nostic and Statistical Manual of Mental Disorders (DSM-III) (Am. Psychiatr. Assoc. 1980) as bulimia
and in DSM-III-R (Am. Psychiatr. Assoc. 1987) as bulimia nervosa. Fairburn (1981) published the
first paper on the use of CBT-ED, which described an outpatient study of 11 patients with BN.
The theoretical framework for CBT-ED is largely based on clinical observation, and the ther-
apeutic procedures are based on social learning theory. It is hypothesized that low self-esteem
and/or persistent negative affect promotes dissatisfaction with weight and shape, which gives rise
to restricted food intake. Eventually this leads to loss of control of eating behaviors and binge
eating with or without compensatory behaviors such as self-induced vomiting, excessive exercise,
and use of laxatives and diuretics. Interpersonal problems and other life stressors often trigger
episodes of binge eating. Fairburn (1981) described the treatment as having two parts: The first
was aimed at helping patients control their restricted food intake; the second had a broader scope
of helping patients modify their abnormal attitudes about food, shape, and weight and increase
their problem-solving skills to enhance maintenance of improvement. Many of the procedures
418 Agras • Bohon

used were adapted from Beck’s (1976) CBT manual for the treatment of depression. In the first
phase of treatment, restricted eating was approached with self-monitoring of food intake; eating
meals at regular times (usually three meals and two snacks), thus reducing intervals between eat-
ing and lessening the urge to binge; and weekly weighing. Fairburn (1981) noted that the first
phase of treatment usually took about 8 weeks. In the second phase, self-monitoring continued,
and the patients were encouraged to gradually introduce feared foods into their meals, hence ex-
posing them to avoided foods. Triggers for binge eating were also explored. Shape and weight
concerns were addressed in this phase by challenging abnormal attitudes and addressing rituals
such as frequent checking of shape and weight. Treatment outcomes appeared promising: 9 of the
11 patients ceased binge eating and purging. Follow-up 12 months after treatment, which found
that 8 patients were abstinent (73%), suggested that the treatment was effective and had enduring
effects.
EFFECTIVENESS OF COGNITIVE BEHAVIORAL THERAPY

Early Controlled Studies

It is important to review the early studies involving CBT-ED because they, and their interpreta-
tion, set the direction for future research. In interpreting the results of these studies, it is important
to remember that at the time they were conducted, there was no agreement on assessments or on
what to use as a primary outcome. Commonly used measures of outcome were percent reduction
in binge eating and purging, change in the rates of binge eating and purging, and abstinence from
both binge eating and purging. Percent reduction is somewhat misleading because large percent
reductions can be associated with low abstinence rates. In this review, we report abstinence as a
primary outcome where available because it is a more direct measure of clinical outcome. It is
also important to note that the time frames used for assessment of binge eating and purging vary
between studies.
In a study comparing CBT-ED with nondirective psychotherapy (ND) (16 weeks of group
treatment in both conditions), 28 women with BN were randomly allocated to the two treatments
(Kirkley et al. 1985). The principal difference between the two psychotherapies was that in the
ND group, no behavior-change procedures focused on eating disorders were used; rather, the
emphasis was on self-discovery, understanding one’s bulimia, and self-disclosure. Hence, ND was
not a symptom-focused psychotherapy. During treatment, there was one dropout from CBT-ED
compared with five from ND. At the end of treatment, participants in the CBT-ED group had sig-
nificantly reduced their self-reported rates of binge eating and vomiting compared with the ND
group. Interestingly, there were no significant differences between groups on secondary variables
such as anxiety, depression, and eating disorder cognitions; both groups had significant reductions
in these variables. Additionally, there were no statistically significant differences between treat-
ment groups at the 3-month follow-up, although five (38%) participants who received CBT-ED
were abstinent compared with one (7%) in the ND group—a result suggesting that the sample
size was too small to allow for adequate statistical analysis. The authors concluded that “CBT-ED
focusing on specific behavior changes yields results superior to a less directive approach” (Kirkley
et al. 1985, p. 46).
Fairburn et al. (1986) reported the results of a comparison between CBT-ED and short-term
focal psychotherapy. The rationale given to patients for focal psychotherapy was that BN was a
maladaptive solution for other problems in the patient’s life, and the aim of therapy was to identify
and remediate these problems. Particular attention was paid to thoughts and feelings antecedent
to binge eating. Hence, the therapy focused on the eating problem but contained none of the
therapeutic procedures used in CBT-ED except for self-monitoring. Twenty-four participants
www.annualreviews.org • CBT for the Eating Disorders 419

with BN were randomly allocated to one of the two treatments. At both the end of treatment
and 1-year follow-up, there was no difference between the two treatments in reducing the rates
of binge eating or purging, as assessed during a 4-week period by interview, nor were there any
differences in general psychopathology. However, at 8-month follow-up, reduction in episodes of
vomiting was significantly superior in the CBT-ED group. There were also differences favoring
CBT-ED in global clinical state and patients’ own ratings of improvement. As the authors noted,
“Undoubtedly the most striking finding of the study is that both groups improved substantially in
response to these relatively brief forms of treatment” (Fairburn et al. 1986, p. 639). The improve-
ment was evident in all aspects of the patients’ functioning, including their specific and general
psychopathology and their levels of social adjustment. It is important to recognize that this study
had a small sample size that may have masked the true outcome, as was the case for all the early
studies.
In another study (Garner et al. 1993), which compared CBT-ED with supportive-expressive
therapy (SET), 60 patients with BN were randomly allocated to 18 sessions of either CBT-ED or
SET. Both treatments were manualized, and different therapists were used for each treatment. The
rationale for SET was that “the eating disorder served a functional role by disguising underlying
interpersonal problems” (Garner et al. 1993, p. 40). Therapists gave no advice; rather, the emphasis
was on the patients’ problem-solving skills. At the end of treatment, there were no statistically
significant differences between the two treatment groups in reducing the rate of either binge
eating or purging. The abstinence rate was 36% for CBT-ED and 12% for SET, a nonsignificant
difference. However, CBT-ED was more effective in reducing eating disorder psychopathology,
such as preoccupation with food and binge eating, dietary restraint, and shape and weight concerns.
In a study that examined whether adding the cognitive elements of CBT-ED to the behavioral
elements improved outcomes (Freeman et al. 1988), 92 women with BN were randomly allocated
to one of three groups: CBT-ED (n = 32), behavior therapy (BT, n = 30), and group psychother-
apy (n = 30) with 15 weekly sessions of treatment. BT focused on establishing a normal eating
pattern of three meals and two snacks each day through the use of self-monitoring and alternative
coping strategies, such as relaxation. CBT-ED added a focus on changing dysfunctional beliefs
about food, weight, and shape. Group psychotherapy was largely supportive and educational with
weekly structured sessions. A further waiting-list group of 20 women was added to the three treat-
ment groups. Some 29% of participants dropped out of treatment (there were no differences in
dropout rate between treatment groups). All treatment groups showed highly significant changes
in the rates of binge eating and purging (assessed from weekly self-monitoring) from pre- to post-
treatment; there were, however, no differences between treatment groups. The authors concluded
that there were no differences between BT and CBT-ED outcomes, suggesting that cognitive pro-
cedures did not add to BT. The authors also noted that the results for CBT-ED may have been
improved by using Fairburn’s more intensive treatment, although such treatment was difficult to
deliver within the constraints of the United Kingdom’s National Health Service (NHS). They
also noted that group psychotherapy might be the most useful treatment because it was the most
cost-effective.
In a further study to determine whether adding cognitive elements to the behavioral elements
of CBT-ED improved outcomes, Fairburn et al. (1991) compared CBT-ED, BT, and interper-
sonal psychotherapy (IPT) among 75 women with BN who were randomly allocated to one of
the three groups. IPT was chosen as a credible control for CBT-ED because many women with
BN have disturbed interpersonal relationships. There were 19 sessions of manualized treatment
for 18 weeks. Attrition rates were 24% for BT, 16% for CBT-ED, and 12% for IPT. A completer
analysis was used to compare outcomes rather than intent-to-treat analysis. There were no statis-
tically significant differences between groups at the end of treatment for reduction in binge eating
420 Agras • Bohon

or purging rates; ITT abstinence rates were 60% for CBT-ED, 44% for BT, and 52% for IPT,
with no statistically significant difference between groups. In planned comparisons, IPT was less
effective than BT or CBT-ED in reducing vomiting, with no difference between CBT-ED and
BT. There were, however, differences between groups in eating disorder psychopathology. For
reductions in dietary restraint, CBT-ED was more effective than the other treatments, and for re-
ductions in weight and shape concerns, CBT-ED was superior to BT but not to IPT. There were
no differences among treatment groups for reductions in general psychopathology. The authors
concluded that CBT-ED was superior to both BT and IPT and suggested that CBT-ED oper-
ates through a specific mechanism. However, in an important 12-month follow-up of this study
(Fairburn et al. 1993), the abstinence rate for CBT-ED was 36% (compared with 44% for IPT
and 20% for BT), with CBT-ED superior to BT and no significant difference between CBT-ED
and IPT. In addition, CBT-ED and IPT had similar effects on both specific ED psychopathology
and general psychopathology, and greater effects than BT. This result suggests that addressing the
cognitive features of BN adds to the maintenance of treatment effects. IPT takes longer to achieve
its full effects but is then equivalent to CBT-ED; this fact suggests that the two therapies work via
different mechanisms. Given that in this study, IPT strictly avoided addressing eating behaviors
and shape and weight concerns directly, this is a very interesting finding.
Overall, the results of these early studies suggest that there may be little difference between
CBT-ED and other focused psychotherapies in reducing the principal symptoms of BN: binge
eating and purging rates and (where assessed) abstinence from binge eating and purging. However,
CBT-ED appears superior in reducing dietary restriction and shape and weight concerns, both
of which have been hypothesized to lead to relapse if not adequately addressed. There were, of
course, several deficiencies in the design of these early studies: small sample size, in many cases
no treatment manuals, no attempt to assess the fidelity of treatments, few standard measures, and,
in many studies, the use of completer analyses rather than intent-to-treat. However, given the
lack of difference, it is interesting that the research field continued to focus on CBT-ED when
it might have been expected to widen research on other focused psychotherapeutic treatments
for BN. A likely explanation is that CBT was the dominant therapy for a variety of conditions
and was regarded by its proponents as having a scientific approach in contrast to psychoanalysis
and therapies derived from it. This was a case where lack of research was confounded with lack
of evidence and where enthusiasm for BT helped researchers overlook the therapeutic effects of
other types of therapy.
Later Controlled Studies

Several developments influenced the next phase of research. The first was the identification of
BED, which was recognized as a disorder for further study in DSM-IV (Am. Psychiatr. Assoc.
1994) and as a full disorder in DSM-5 (Am. Psychiatr. Assoc. 2013). BED is characterized by re-
peated episodes of binge eating without compensatory behaviors such as vomiting and laxative
and/or diuretic use, but with similar eating disorder and general psychopathology to BN. More-
over, the comorbid overweight/obesity is often associated with cardiovascular disease and diabetes
(Sarwer & Polonsky 2016, Upadhyay et al. 2018).
A further development was the formulation of a transdiagnostic theory concerning mainte-
nance of the eating disorders (Fairburn et al. 2003), which suggests that BN, BED, and anorexia
nervosa (AN) share identical mechanisms facilitating maintenance of the disorder. Moreover, as
Fairburn et al. (2003) noted, the eating disorders tend to cross diagnostic boundaries (Agras et al.
2009). The transdiagnostic theory was introduced in part to address the fact that less than 50% of
patients with BN are remitted at the end of treatment. Hence, the theory proposes four additional

maintaining factors that may be responsible for inadequate clinical outcomes: (a) clinical perfec-
tionism, defined as overvaluation of efforts to meet personally demanding standards; (b) core low
self-esteem, defined as a global negative view of the person, beyond the low self-esteem seen in
most individuals with eating disorders; (c) mood intolerance, defined as an inability to cope with
certain emotional states, again beyond what is seen in most individuals in whom negative emotions
trigger binge eating; and (d) interpersonal difficulties, defined as long-term difficulties in inter-
personal relationships beyond the triggering effect seen in most individuals with eating disorders.
This revised theory led to the development of enhanced CBT (CBT-E), which addresses the new
maintaining factors when needed. The treatment has two forms: focused and broad. The focused
version is similar to the original CBT-ED but involves a revised approach to weight and shape
concerns and a treatment module for mood intolerance as a trigger for binge eating and/or purg-
ing. The broad form addresses comorbid elements believed to maintain the eating disorder, such
as perfectionism, intense mood states, and interpersonal difficulties. Forty (rather than 20) ses-
sions are recommended for low-weight patients, who most often meet criteria for AN. A second
consequence of the transdiagnostic approach was that many subsequent studies enrolled binge
eaters irrespective of diagnosis (usually excepting AN). This is important because recovery rates
are lower for BN than for BED. A meta-analysis involving 27 studies carried out in routine clinical
practice found an average abstinence rate of 37.4% for BN and 50.2% for BED (Linardon et al.
2018). If transdiagnostic treatment studies differ from one another in the proportions of BN and
BED enrolled, then their outcomes may not be comparable.
Comparing cognitive behavioral therapy for the eating disorders and enhanced cognitive
behavioral therapy. There are two reasons to compare CBT-ED and CBT-E. First, it was hy-
pothesized that adding treatment modules to CBT-ED would result in improved outcomes across
the eating disorders (Fairburn et al. 2003). Hence, the theory stands or falls on the comparison.
Second, it is necessary to know whether CBT-E is superior to CBT-ED for clinical reasons and
whether it is superior for all individuals with eating disorders or for subgroups of individuals. How-
ever, in more than 15 years since the transdiagnostic theory was proposed, there have been only
two controlled studies comparing the two therapies, and both studies compared the focused form
(CBT-Ef ) with the broad form (CBT-Eb) rather than with the original CBT (Atwood & Friedman
2020). However, CBT-Ef is similar to CBT-ED, and CBT-Eb contains the additional components
hypothesized to improve outcomes. In the first study (Fairburn et al. 2009), 154 participants with
any eating disorder (38% BN, 62% eating disorder not otherwise specified) were randomized to
one of three groups: waiting list, CBT-Ef, and CBT-Eb. The primary outcome was global Eating
Disorders Examination (EDE) score. At 8 and 60 weeks, both active treatments were superior
to the waiting-list condition, and there was no difference between the two active conditions on
any measure. Overall, 22% of those treated dropped out, and 48% were abstinent at both assess-
ment points. However, a post hoc analysis showed that participants with psychopathologic features
matching those targeted by CBT-Eb improved more with that treatment. In the second study,
Thompson-Brenner et al. (2016) randomized 50 participants with BN and borderline personality
disorder, a group with poor treatment outcomes, to the two forms of CBT-E. Twenty percent of
those treated dropped out of treatment (with no difference in dropout rate between treatment
groups), and there were no differences in remission either at the end of treatment (CBT-Ef, 44%;
CBT-Eb, 40%) or follow-up. However, a moderator analysis found that participants with higher
affective/interpersonal problem scores improved more with CBT-Eb. Overall, these two studies
suggested that the focused and broad forms of CBT-E do not differ in reducing the symptoms
of eating disorders either at the end of treatment or at follow-up (the broad form may be more
useful for those with higher levels of comorbid psychopathology, although this finding requires
422 Agras • Bohon

META-ANALYSIS
Meta-analysis has become useful as a method to review and assimilate the results of multiple studies. Meta-analyses
are important because they may inform clinical practice, resulting in improved treatments for many patients. How-
ever, there are several problematic features of this analytic method. Studies selected in meta-analyses may carry
the same name, but treatment protocols may differ in important ways; nonetheless, such studies are often lumped
together as though they were the same treatment. Treatment length, number of treatment sessions, and timing
of assessments often vary between studies, yet again such variation is often overlooked in a meta-analysis. Partici-
pant variables such as age (adolescent or adult populations) and differences in gender proportions may be ignored.
Studies with faulty design or insufficient power are often included in meta-analyses. Kraemer & Thiemann (1987,
p. 172) pointed out that “for an 80% power using a 5% significance level and a one-tailed t-test requires a minimum
of 50 per group.” In a critique of a meta-analysis, Lock et al. (2019) pointed out that of 35 studies included in the
study, only 7 met this threshold. These are only some of the variables that meta-analyses may overlook, yet by doing
so they lose specificity and wrongly depict the status of a field.
replication in further studies). This conclusion was supported by a recent meta-analysis reviewing
the 10 existing controlled studies of CBT-E, although the authors pointed out that no study had
yet compared CBT-E with CBT, the most critical comparison (Atwood & Friedman 2020).
Effectiveness of cognitive behavioral therapy for the eating disorders for bulimia nervosa
and binge eating disorder. Linardon et al. (2017b) conducted a meta-analysis addressing treat-
ments for BN and BED. For BN, therapist-led CBT-ED was more effective posttreatment than
were waiting list, treatment as usual, and other psychotherapies for abstinence, binge/purge fre-
quencies, and cognitive symptoms (see the sidebar titled Meta-Analysis). An interesting finding
was that therapist-led CBT-ED was superior to other psychotherapies only when the full manu-
alized versions of CBT-ED or CBT-E were used. At follow-up, CBT-ED was superior to active
control groups, mostly psychotherapy, in reducing binge eating and purging but not for cognitive
change. For BED, CBT-ED was significantly more effective than inactive comparison conditions
(waiting list, treatment as usual) on remission rates and binge frequencies, with large effect sizes
(0.79–0.98), although when compared with active conditions (largely psychotherapy), the differ-
ences in reducing binge eating (effect size: 0.19) and eating disorder cognitions (effect size: 0.26)
were small. Moreover, CBT-E was not more effective than active conditions for remission. Other
meta-analyses have come to similar conclusions (Slade et al. 2018, Spielmans et al. 2013).
Hilbert et al. (2019) examined 81 randomized trials for BED with over 7,500 participants
treated with psychotherapy (including CBT-ED, brief CBT, IPT, and psychodynamic therapy;
CBT-ED formed the majority of the studies). Compared with inactive control groups (waiting
list, no treatment, treatment as usual), CBT-ED showed large effect sizes for binge eating and
abstinence, followed by structured self-help treatment, largely based on CBT-ED, with small to
medium effects. Moreover, CBT-ED showed a superior effect on binge eating but not abstinence
when compared with other psychotherapies. Full psychotherapy (including CBT-ED) was supe-
rior to structured self-help in its effects on binge eating and abstinence. In comparisons with other
psychotherapies, CBT-ED was more effective than humanistic and psychodynamic psychothera-
pies, with small effect sizes, although it should be noted that very few trials have compared CBT-
ED with humanistic and psychodynamic psychotherapies, and thus these findings are tentative.
Shortening cognitive behavioral therapy for the eating disorders. Although CBT-ED has
been shown to be effective in a number of community settings (Linardon et al. 2018), a criticism

of evidence-based psychotherapies is that they are not easily adaptable to community clinical use.
Many community clinics cannot offer the requisite number of sessions required of an evidence-
based treatment or cannot afford the cost and time required for the training of therapists. To
address this shortcoming, an abbreviated form of CBT-ED was developed using a therapist-guided
format (CBTgsh) (Fairburn 1995). Although the number of sessions of treatment in guided self-
help varies, as well as the amount of support provided, in its original form eight 30-min weekly
sessions were used with therapists who often did not have doctoral-level training. Because of these
features, CBTgsh should be less expensive than full CBT-ED. The therapist’s role is to coach
patients to follow a book and to answer relevant questions.
A meta-regression compared CBTgsh with various control conditions (waiting lists, delayed
treatment, active conditions such as CBT and IPT) (Traviss-Turner et al. 2017). For abstinence
from binge eating and/or purging, CBTgsh was more effective than control conditions, with a
small effect size (0.20). For eating disorder psychopathology, CBTgsh was again significantly more
effective, with a medium effect size (0.46). Few moderators of outcome were identified. A diagnosis
of BED moderated abstinence with a small but significant effect suggesting that CBTgsh is more
effective for BED than for BN. Another meta-analysis (Ghaderi et al. 2018) compared CBTgsh
with no treatment and active treatments such as IPT or behavioral weight loss (BWL) for BED,
although the amount of therapist support for guided self-help varied between studies from a single
telephone call to nineteen 30-min sessions. For abstinence from binge eating and reduction in
eating disorder psychopathology in four studies that provided a “reasonable amount of support”
(n = 4), CBTgsh was superior to waiting list with a small to medium effect. There were similar
findings for depression.
There have been few direct comparisons of CBT-ED and CBTgsh, and all have had some
form of experimental confound. For example, de Zwaan et al. (2017) compared Internet-based
guided self-help with face-to-face full CBT-ED, confounding (for our purpose) mode of deliv-
ery. Similarly, Bailer et al. (2004) compared group CBT-ED with individual sessions of CBTgsh,
confounding (again, for our purpose) mode of delivery.
In summary, at the end of treatment CBT-ED appears superior to inactive conditions, such
as no treatment, with large effect sizes for both BN and BED. CBT-ED is also superior to other
psychotherapies at the end of treatment for BN, with small effect sizes between groups. Compared
with other psychotherapies for BED, CBT-ED was found to be superior on some measures, such
as reduction of binge eating, but not on more strict criteria, such as abstinence. CBTgsh is a
useful treatment for BED when full treatment with CBT-ED is not available or, in a stepped-
care approach, as a first-level treatment followed by CBT-ED if the CBTgsh is not effective.
Interestingly, those treated with CBTgsh who show improvement by the fourth week have a high
chance of recovery with further CBTgsh (Chen et al. 2017), allowing an early step to full CBT-ED
for those who fail to respond.
Comparisons of Cognitive Behavioral Therapy for the Eating Disorders

with Other Psychotherapies
Because other psychotherapies are often lumped together for comparison with CBT-ED in meta-
analyses, the following sections review studies and meta-analyses that have directly compared spe-
cific psychotherapies with CBT-ED.
Interpersonal psychotherapy. Interest in IPT as a treatment for BN and BED was sparked in
part by the comparison of CBT-ED with focal psychotherapy described above (see the section
titled Early Controlled Studies), which showed no difference between CBT-ED and focal
424 Agras • Bohon

psychotherapy for binge eating, purging, and general psychopathology (Fairburn et al. 1986).
Larger-scale studies (Agras et al. 2000, Fairburn et al. 2015, Wilfley et al. 2002) found that for
BN, CBT-ED was significantly superior to IPT at the end of treatment but not at follow-up, and
for BED, the two treatments were equivalent at all time points. Using a transdiagnostic sample of
eating disorders, Fairburn et al. (2015) entered 130 participants with any form of eating disorder
and randomly assigned them to CBT-E or IPT. However, the weight entry criteria excluded
participants with current AN (body mass index <17.5) or extreme obesity (body mass index >40).
Hence, the sample was composed of participants with BN (40.8%), BED (6.2%), and other eating
disorders (53.1%). At the end of treatment, the rate of remission as defined by a global EDE
community norm score below 1.74 was 65.5% in the CBT-ED group and 33.3% in the IPT
group; at 60-week follow-up, remission rates were 69.4% (CBT-ED) and 49% (IPT). Hence,
at both time points CBT-ED was significantly superior by this measure. However, if abstinence
from binge eating and/or purging was used as the outcome measure (for those that showed these
symptoms at baseline), the results were different: At the end of treatment, remission rates were
41.5% for CBT-ED and 13.5% for IPT—clearly a significant difference. At follow-up, however,
remission rates were 40% for CBT-ED and 39% for IPT, as had been found in previous studies
(Agras et al. 2000, Fairburn et al. 2015, Wilfley et al. 2002). This finding suggests, again, that the
two treatments may work through different mechanisms, with IPT slower to achieve its effects.
Nonetheless, CBT-ED is in this case the more efficient psychotherapy and, hence, the first choice
of treatment for transdiagnostic samples and for BN, but not for BED.
Dietary treatments. The clinical observation that when overweight patients with BED lost
weight with weight loss therapy (BWL), they also reduced binge eating—whereas those treated
with CBT-ED lost little weight—suggested that BWL may be a useful approach to BED (Telch &
Agras 1993). Because BWL is widely used, its implementation typically requires less training than
CBT does, a distinct advantage over CBT-ED. Grilo et al. (2011) randomized 125 obese patients
with BED to CBT-ED, BWL, and CBT-ED followed by BWL. Dropout rates were not signif-
icantly different between groups. At the end of treatment, there was no significant difference in
remission rates between the three groups: 44.4% for CBT-ED, 37.8% for BWL, and 48.6% for
combined treatment, with similar results at 6- and 12-month follow-up. Weight was significantly
improved with BWL but not with CBT-ED. Hence, it might be argued that BWL is the preferred
treatment for BED because of the significant effects on both binge eating and weight, unlike CBT-
ED. However, Wilson et al. (2010) examined the longer-term outcomes of BWL in a clinical trial
comparing it with CBTgsh and IPT. Two hundred five participants who met the full DSM criteria
for BED were randomly allocated to one of the three treatments. Participants received 20 sessions
of either BWL or IPT or 10 sessions of CBTgsh for 6 months. At the end of treatment, there was
no between-group difference for remission of binge eating for the three treatments, nor were
there any differences for eating disorder or general psychopathology. At 2-year follow-up, both
IPT and CBTgsh were more effective in producing remission than BWL, with large odds ratios,
and a moderator analysis suggested that IPT was superior to the other treatments for patients with
low self-esteem and high eating disorder psychopathology. This study suggested that the effects
of BWL on binge eating are not long-lasting and that CBTgsh may be the preferred treatment
because of its lower cost; specialty treatments such as full CBT-ED and IPT could be reserved for
patients with higher levels of eating disorder psychopathology.
Psychoanalytic psychotherapy. It might have been expected that the early research finding that
psychotherapies other than CBT-ED were often equivalent in reducing primary eating disorder
symptoms would have led to investigations of the mechanisms and active components of both

treatments. The primary alternative psychotherapies to CBT then and now, which are still widely
practiced, are variants of psychodynamic psychotherapy. The few studies comparing CBT-ED
with psychotherapies based on psychoanalytic procedures for the eating disorders are reviewed
below.
Poulsen et al. (2014) compared 5 months of CBT-E treatment with 2 years of psychoanalytic
psychotherapy (PP) specifically developed for BN. Seventy participants who met the full criteria
for BN were enrolled in the trial. The study was carried out at a site with therapists who were
expert in PP. Both treatments were manualized and supervised by the developers of each treat-
ment. PP was based on the hypothesis that bulimic symptoms are rooted in a need to ward off
inner feeling states and desires and in difficulties acknowledging and regulating such inner states.
The treatment was nondirective, and bulimic symptoms were not discussed at every session, al-
though the patients were encouraged to link symptoms with underlying feelings. Hence, this was
a strict test of the comparative efficacy of the two treatments, and any therapist bias was directed
toward PP and against CBT-ED. For the primary outcome—abstinence from binge eating and
purging after 5 months of treatment—42% of those treated with CBT-E were abstinent com-
pared with 6% of those treated with PP (odds ratio: 13.4). At 24 months, after completion of PP,
42% had recovered with CBT-E compared with 15% for PP (odds ratio: 4.34). Cognitive be-
havioral psychotherapy also produced significantly greater improvements in eating disorder and
general psychopathology at the 5-month assessment, but these differences were not sustained at
the 24-month follow-up. Hence, CBT-E was faster and more effective, and because fewer treat-
ment sessions were used than in PP, it would be less costly. Tasca et al. (2014) suggested that one
reason for the better response to CBT-E may have been the therapists’ focus on eating disordered
behaviors in CBT-E compared with less focus on such behaviors in PP.
This hypothesis was subsequently tested by Stefini et al. (2017), who compared a symptom-
focused form of psychodynamic psychotherapy with CBT-ED to determine whether CBT-ED
would prove superior to psychodynamic psychotherapy. Eighty-one adolescent females (mean age
18.7 years) who met the criteria for full or partial BN were randomized to up to 60 sessions
of either treatment across a 12-month period (far more than the usual 20 sessions of treatment
with CBT-ED). There was no significant difference in dropouts during treatment or in remission
rates (CBT-ED, 33%; PP, 31%) at the end of treatment or at 12-month follow-up. There were
minor differences in some secondary measures in favor of one treatment or the other. However, it
appears that CBT-ED and psychodynamic psychotherapy were equally effective in the treatment
of adolescent and young adult BN when a symptom focus consistent with the rationale for therapy
was used.
When considered together with the earlier comparisons of CBT-ED and some form of
symptom-focused psychotherapy, the results suggest that the difference in outcomes between
these two types of treatment is not large. However, the fact that the treatments differ in proce-
dures raises two important questions: Through what mechanisms does psychotherapy work, and
what are the active ingredients? One possibility is that all treatments work through a common
mechanism despite differences in therapeutic procedures. A second possibility is that different
psychotherapies have different active components and work through different mechanisms.
In a study of AN in adult patients, Zipfel et al. (2014) randomized 242 participants to CBT-
E, focal psychodynamic therapy, or enhanced treatment as usual. The latter treatment included
supervision by the patient’s family physician, with weight monitoring and necessary blood tests
and referral to a psychotherapist with experience treating AN for supportive psychotherapy. The
investigators hypothesized that both CBT-E and focal psychodynamic therapy would be more
effective than treatment as usual in weight regain at both the end of treatment and 12-month
follow-up. Treatment dropout rates were low (22%); the dropout rate was significantly larger
426 Agras • Bohon

for treatment as usual after treatment and at follow-up. At both assessment points, there were
no differences between the three treatment groups on the primary outcome of weight gain, with
small effect sizes for between-group comparisons, although all three groups showed weight gain
across the trial period. Patients treated with CBT-E gained weight more rapidly than the other
two groups. Overall, there were no statistically significant outcome differences between the three
treatments, and Zipfel et al. (2014, p. 135) concluded that optimized treatment as usual formed a
“solid baseline treatment” for adult AN.
Similar findings were made in a further study (Byrne et al. 2017) in which 120 adult partici-
pants with AN were randomly allocated to three groups: CBT-E, clinical management consisting
of medical follow-up combined with supportive psychotherapy, and the Maudsley Model Anorexia
Treatment (MANTRA). The latter treatment is individualized and targets three maintaining fac-
tors: the person’s thinking and emotional style, close others’ responses to the illness, and beliefs
about the utility of AN in the life of the patient (Schmidt et al. 2014). Up to 40 sessions of treatment
were offered to participants, and the dropout rate was equivalent among treatments. Participant
weights increased similarly for all three groups, and there were no differences in remission rates
between treatments (mean 28.3%) in eating disorder psychopathology or general psychopathol-

ogy at both the end of treatment and follow-up. These results provide further evidence that there
are similar outcomes between CBT-ED and focal psychotherapy.
Third-wave psychotherapies. These newer psychotherapies move beyond the earlier waves.
The first wave focused primarily on behaviors and used therapies derived from learning theory,
such as reinforcement learning. The second wave added a focus on cognitive processes—hence,
cognitive behavioral therapy. The third wave is characterized by the targeting of response-focused
emotional regulation (as opposed to CBT-ED’s targeting of antecedent emotional response).
Third-wave psychotherapies often use components of CBT-ED, such as self-monitoring and
exposure to feared foods, in addition to the focus on emotional regulation. Unfortunately, there
have been few adequate randomized comparisons of third-wave therapies with CBT-ED, and with
the exception of dialectical behavior therapy, few third-wave therapies have sufficient evidence
to be regarded as potentially effective for the eating disorders (Linardon et al. 2017b). One
controlled study of integrative cognitive affective therapy (I-CAT)—a treatment characterized by
many of the same components as CBT-ED, such as self-monitoring, meal planning, interpersonal
problems, and relapse prevention, but adding attention to response-based emotional/cognitive
reactions—compared I-CAT with CBT-Ef (Wonderlich et al. 2014). Eighty participants with BN
were randomized to one of two groups for 21 treatment sessions. Dropout rates were 25% for
CBT-Ef and 15% for I-CAT—a nonsignificant difference. There were no significant differences
on any outcome measure, including abstinence from binge eating and purging at the end of
treatment (CBT-ED, 22.5%; I-CAT, 37.5%) or at 4-month follow-up (CBT-ED, 22.5%; I-CAT,
32.5%). There were also no differences in measures of general psychopathology. The similar
results between treatments may have been due to the incorporation of elements of CBT-E within
I-CAT. Hence, at this point there is no evidence that any third-wave psychotherapy is superior
to CBT-ED or IPT for the treatment of eating disorders, although more studies are needed—in
particular, studies comparing dialectical behavior therapy with CBT-ED or IPT.
Family-based treatment. Two studies compared CBT-ED with family-based treatment (FBT)
for adolescents with BN. In the first study, CBTgsh was compared with FBT for BN (Schmidt
et al. 2007). FBT, which was originally developed to treat AN, involves all family members; its pri-
mary aim is to enable the family to establish a normal feeding pattern for their child. Eighty-five
participants with either BN or BED were randomly allocated to one of two treatments (13 sessions

for each treatment condition). Both treatments were supervised by experts. At the 6-month assess-
ment, guided self-help was significantly superior to FBT in abstinence from binge eating, but at
12 months there was no difference between the two treatments. For abstinence from binge eating
and purging, there was no significant difference between treatments: 12.5% and 41.4% for FBT at
6 and 12 months, respectively, compared with 19.4% and 36% for CBTgsh at the same time points.
The second, larger study compared full CBT-ED with FBT (Le Grange et al. 2015). One
hundred thirty adolescents who met the criteria for BN entered the study and were treated with
18 sessions of either CBT-ED or FBT. At the end of treatment, FBT (39.4%) was statistically
superior to CBT-ED (19.7%) for percent abstinence from binge eating and purging; however, at
12 months there was no significant difference between groups for abstinence (FBT, 48.5%; CBT-
ED, 32%). There was also no difference in measures of eating disorder psychopathology between
the two treatments, although depression was lowered significantly more in the CBT-ED group at
the end of treatment but not at follow-up. These two studies offer conflicting results. In one study,
CBTgsh was equivalent to FBT in terms of abstinence, whereas in the other, full CBT was not
as effective as FBT. It is possible that these disparate results were due to differences in therapist
expertise in using one or the other of the treatments.
PREDICTORS, MODERATORS, AND MEDIATORS

Two questions are often asked about a given treatment: Who will benefit, and how does it work?
Predictors and moderators can be helpful in answering the first question, and mediators of out-
come can be of use in answering the second.
Predictors
The most consistent and powerful predictor of outcome for CBT-ED is a rapid improvement in
key symptoms (e.g., binge eating or purging for BN and BED; weight for AN) early in treatment
(Wilson & Vitousek 1999). This holds true not only for the treatment of eating disorders but
also for depression, anxiety, and other disorders. However, not all treatments share this marker
of outcome. For example, Hilbert et al. (2015) examined early response in a study that compared
BWL, CBTgsh, and IPT for the treatment of participants with BED and obesity (Wilson et al.
2010). Those treated with CBTgsh showed a predictive early response, but those treated with
BWL or IPT did not. In a systematic review, Linardon et al. (2017a) found no other consistent
predictors of response to treatment, although some treatment studies have suggested that more
severe eating disorder psychopathology and low self-esteem are likely predictors of outcome.
Moderators
Despite many studies of CBT-ED for BED in particular as well as some for BN, no consistent
moderators of treatment outcome have been found that differentiate between CBT-ED and an-
other treatment. Hence, it is not possible to answer the question, For whom is CBT-ED most
suitable?
Mediators
Dietary restriction and concerns about body shape are hypothesized to be important factors main-
taining eating disorders (Fairburn 1981). Hence, it would be expected that CBT-ED would exert
its effects by reducing dietary restraint and concerns about body shape. In a mediator analysis of
a multicenter comparison of CBT-ED and IPT for BN, Wilson et al. (2002) found that change in
428 Agras • Bohon

dietary restraint at 4 weeks mediated outcomes for the combination of binge eating and purging
together with shape and weight concerns. Another study found that dietary restraint, but not shape
and weight concerns, mediated decreases in vomiting in patients with BN (Spangler et al. 2004).
Hence, early attention to reduce dietary restraint largely through self-monitoring combined with
dietary education could be an important mechanism in the treatment of BN with CBT-ED.
BROADENING THE DELIVERY OF COGNITIVE BEHAVIORAL

THERAPY FOR THE EATING DISORDERS
Many patients with eating disorders are not treated with evidence-based psychotherapies such
as CBT-ED because they either use other treatments, many of which are not evidence-based, or
report using only some of the evidence-based procedures (Brown & Perry 2018, Mussell et al.
2000). Therapist self-report, of course, may not reflect actual use. In a recent implementation
study (Wilfley et al. 2020), 184 counselors at 24 student health centers were audiotaped during the
baseline condition. Although 23.4% of the therapists reported attending an IPT workshop and
38% reported using IPT in the previous year, a review of audiotaped treatment sessions found
no evidence of the use of IPT and only a handful of instances when some other evidence-based
treatment was used. Moreover, many individuals with an eating disorder do not receive any treat-
ment. One systematic review found that only a quarter of individuals with an eating disorder in
the United States received some form of treatment (Hart et al. 2011). There are many reasons
for this state of affairs in the United States. Many individuals with eating disorders live in rural
areas with little access to specialist treatments. Many clinics, because of fiscal restraints, cannot
afford the training or treatment time to offer evidence-based treatment. A fee-for-service system
based largely on private and governmental insurance does not afford adequate time for contin-
ued training in evidence-based psychotherapies, and treatment is inaccessible to many potential
patients because of cost. Therapist training in evidence-based psychotherapies does not appear to
be adequate either in graduate school or thereafter. Therapists tend to drift from evidence-based
procedures and often incorporate evidence-based features into an eclectic psychotherapy, thus di-
luting the treatment (Waller et al. 2012). Apart from a major reform of health services, what can
be done to broaden access to evidence-based treatments?
Teletherapy
Teletherapy—the provision of mental health services at a distance using various communication
devices—has been catalyzed by the coronavirus disease 2019 (COVID-19) pandemic and sub-
sequent shutdown of face-to-face services together with the availability of online conferencing
services. Teletherapy has a more than 50-year history, although development has been slow—
partly because costs were high until relatively recently. To date, the main role of teletherapy has
been to provide access to specialized treatments to people in rural areas distant from psychological
services. Whether its role will change post-COVID-19—for example, to save patient travel time
to clinics—remains to be seen. In the last 20 years, controlled studies have shown that teletherapy
is in most cases equivalent to in-person assessment and treatment of mental illness across a variety
of diagnostic entities (Chakrabarti 2015). In one controlled study that is pertinent to this review
(Mitchell et al. 2008), 128 individuals with BN were randomly assigned to either teletherapy or
face-to-face therapy. Both groups received manualized CBT-ED treatment (fidelity was assessed
by auditing therapy tapes). The study was carried out in rural communities in northwestern
Minnesota and eastern North Dakota. The primary outcome, abstinence from binge eating and

purging, did not differ significantly between treatment groups: 28.2% for face-to-face therapy
and 22.6% for teletherapy. Secondary measures, including eating disorder psychopathology and
depression, were significantly reduced in both groups. Therapist fidelity to CBT-ED did not
differ between the two groups. Hence, this study followed the general trend for such comparisons,
which suggests that teletherapy is as effective as face-to-face therapy in the treatment of BN.
Therapist Training
One way to enhance the delivery of evidence-based psychotherapies is to provide training for ther-
apists in practice. Within the NHS, psychologists and other mental health professionals are being
trained and deployed in a governmental program to provide evidence-based psychotherapies for
anxiety and depression (Clark 2018). To date, 10,500 psychologists and other mental health pro-
fessionals have been trained, over half a million patients have been treated each year, and clinical
outcome data have been collected on 98% of the patients treated by these trainees. This is evi-
dently a highly successful program and appears to provide cost savings within the NHS. However,
therapists attend training 2 days/week for a year, which includes lectures, workshops, and case
supervision; such a level of training would likely be difficult to provide outside a country-wide
health service.
Another way to scale therapist training is to use technology, such as online training tools.
Fairburn et al. (2017) evaluated the effectiveness of a web-based training program for CBT-E.
The authors described two distinguishing features of the program. First, the training was en-
tirely program-led, and second, it could be delivered to large numbers of geographically dispersed
trainees. One hundred thirty-nine therapists volunteered for training. Therapist competence in
implementing CBT-E was assessed by a 22-item multiple-choice questionnaire. Scores on this
questionnaire were related to performance in implementing CBT-E, and there was a cut point
for good competence. Of the 86 trainees who completed the pre- and postassessments, 34 scored
above the competence cut point—24.4% (34/139) of those who had volunteered for the training.
A study from the same group of researchers addressed the question of whether support provided
to the trainee by a nonclinician would be superior to no support in web-based training for CBT-E
(Cooper et al. 2017). Assessment of competence was the same as in the previous study. There was
no difference between groups for program completion or assessment of competence either post-
training or at 6-month follow-up. Fifty percent of trainees completed the follow-up assessment,
and 51% of this group was judged competent—about one-quarter of the original sample. A fur-
ther, multinational study that enrolled over 800 participants confirmed the results of the previous
studies (O’Connor et al. 2018).
These studies demonstrated that it is feasible to train therapists to use CBT-E competently
via a web-based program and that simple support makes no difference in any outcome. Both
studies showed that only about one-quarter of those trained completed the posttraining test and
were judged competent. Because the training program is cost-effective, it may not matter that
the majority of those enrolled in the course either did not complete it or were judged not com-
petent. It is possible, however, that patients may not know whether to trust a therapist trained
online if most who are trained do not reach competence. Further research is needed to find cost-
effective methods to enhance the present results. Moreover, assessment of exactly what therapists
do in practice is difficult to determine. The gold standard is to record therapy sessions with pa-
tients, but this is difficult in practice because of privacy concerns. Questionnaires offer an alter-
native method, but it is unclear whether they provide an accurate account of therapist–patient
behavior.
430 Agras • Bohon

Electronically Delivered Psychotherapies
Another solution to broadening the reach of evidence-based psychotherapies is to provide treat-
ment with less therapist input via the Internet or the use of mobile applications. These are reviewed
in the next two sections.
Internet-based treatments. The Internet allows psychotherapies to be disseminated widely and,

depending on the amount of therapist support available to patients, is likely to be more cost-
effective than conventional, office-based treatment. However, research into the effectiveness of
Internet-based psychotherapies for the eating disorders is still in its infancy. In a previous review
of the literature (Agras et al. 2017), seven studies pertinent to this article were reviewed. Because it
is easier to recruit participants for an Internet study, sample sizes are often fairly large; five of the
seven studies had more than 50 participants per treatment condition. In four of these studies, the
comparison groups for Internet-based CBT-ED (iCBT-ED) comprised participants on a waiting

list; two of the studies were comparisons with bibliotherapy, and one was a comparison with guided
self-help. All four studies with waiting-list comparison groups found iCBT-ED to be superior
(Aardoom et al. 2016, Carrard et al. 2011, Sanchez-Ortiz et al. 2011, ter Huurne et al. 2015). One
of the bibliotherapy studies found iCBT-ED superior (Ruwaard et al. 2013); however, the second
study using guided self-help (bibliotherapy) found that the two treatments had equivalent effects
(Wagner et al. 2016). A further study found iCBT-ED to be superior to guided self-help (Wagner
et al. 2013). Three studies that have appeared since the previous review are described below.
In the first study, a noninferiority design was used: iCBT-ED delivered via a therapeutic chat
group was compared with traditional face-to-face CBT-ED group therapy (Zerwas et al. 2017).
It was hypothesized that iCBT-ED would not be inferior to CBT-ED. One-hundred seventy-
nine adults were randomly allocated to one of the two treatments, and both groups received up
to 16 sessions led by a therapist. Participants were assessed in person with the EDE interview
before and after treatment and at 1-year follow-up. Dropout rates (including those who did not
receive treatment) were high—just over 50% in both groups. Abstinence rates were low in both
groups: for Internet-based psychotherapy, 14% after treatment and 30% at 1-year follow-up; for
face-to-face treatment, 21% after treatment and 26% at follow-up. The Internet-based treatment
was statistically inferior to face-to-face CBT-ED for abstinence at the end of treatment but not at
follow-up. On the basis of these findings, the cost of CBT-ED in each of the conditions was calcu-
lated in a second study, using intervention costs, health care costs outside the treatment protocol,
and gasoline and travel time costs (Watson et al. 2018). Social costs were not estimated. The mean
cost per abstinent patient after treatment was $7,757 and $11,870 for face-to-face and Internet-
based treatments, respectively, and, at 1-year follow-up, $16,777 for face-to-face and $21,028 for
Internet-based treatment, with no statistically significant difference between treatments at either
time point. This is a disappointing result because it is usually assumed that iCBT-ED will be
less costly than traditional, office-based treatment. However, if iCBT-ED is less effective than a
therapist-led treatment, it will increase costs.
The third study included 178 adult outpatients with full or subsyndromal BED (de Zwaan et al.
2017). Participants were randomly allocated to two treatment groups: (a) 20 sessions of face-to-
face CBT-ED or (b) iCBT-ED delivered in 11 modules with weekly email contact with a therapist
for a 4-month period. The trial used a noninferiority design. Dropout rates during treatment
were low at 6% for face-to-face versus 17% for iCBT-ED—a statistically significant difference in
favor of face-to-face treatment. iCBT-ED was found to be inferior to face-to-face CBT-ED at the
end of treatment (abstinence rates of 36% for iCBT-ED and 61% for CBT-ED) and at 6-month
follow-up (abstinence rates of 38% for iCBT-ED and 58% for CBT-ED).

Overall, iCBT-ED appears to be superior to no treatment and to unguided bibliotherapy, but
inferior to CBT-ED. Taking all studies into account, it appears that iCBT is likely to be more
effective for BED than for BN. However, at this point the role of iCBT for the treatment of eating
disorders is unclear. One possible use may be as a first treatment in a stepped-care paradigm in
which those who do not respond then receive traditional CBT-ED.
Mobile applications. Some 94% of people in the United States (271 million individuals) own
mobile phones, with uptake spanning all socioeconomic groups (Tregarthen et al. 2019). Hence,
mobile apps are likely to have an even greater reach into the community than iCBT-ED, and they
have therapeutic potential either as entirely automated versions or with therapist input. At this
point, there are few mobile apps for the treatment of eating disorders. Recovery Record is the
only stand-alone app with population-level reach that has been evaluated in a randomized con-
trolled trial (Tregarthen et al. 2019). In that study, a standard version of the app was compared with
a tailored version. The standard version comprises self-monitoring combined with psychoeduca-
tion teaching skills to reduce distress and overcome urges to binge or purge. The tailored version is
based on CBT-ED principles and provides personalized feedback, goal setting, skills training, and
a review of progress. Eating disorder outcomes were assessed with the EDE-Q, a questionnaire
based on the EDE (Fairburn & Cooper 1993). Eligible users were those who had downloaded the
free app to their cell phone, were located in the United States, and had recorded at least three
self-monitoring records. A total of 3,440 app users who met the eligibility criteria were invited to
participate in the study. One hundred forty-six individuals declined to participate, and 3,294 were
randomly allocated to the two versions of the app. Of those randomized, 779 (22.6%) completed
the 4-week assessment, and 577 (19.7%) completed the 8-week assessment. Completer analyses
revealed that just over half the participants attained clinically meaningful decreases in their symp-
toms compared with 46.2% in the standard condition at 4 weeks and slightly higher proportions
at the 8-week assessment, with no significant difference between groups. Hence, about 11.0% of
those entering the study reached a clinical level of change. Remission of eating disorder symp-
toms, defined as being within community norms, was achieved for 44.8% of treatment completers
with the tailored app compared with 31.1% of those using the standard app—a significant dif-
ference with a small effect size (0.22). At week 8 in subgroup analyses considering binge eating
and purging, 20% of the tailored group and 18% of the standard group had stopped binge eat-
ing. For purging, the percentages were similar for both groups (20% versus 18%). None of these
proportions was significantly different between groups. It should be noted that the self-reported
abstinence rates for binge eating did not exceed the mean placebo response for binge eating; this
result suggests that the app might act as a placebo. Moreover, nearly 80% of participants random-
ized were treatment or assessment dropouts, and only 11.0% met a clinical level of improvement.
However, the significant differences found suggest that the more sophisticated tailored app was
more effective than the standard app (again, perhaps just a better placebo).
A further study evaluated a mobile app (the Noom Monitor) designed to support CBT-ED
guided self-help (Hildebrandt et al. 2017). As discussed above, CBTgsh is more effective than
waiting-list conditions for both BN and BED and is generally considered to be a cost-effective first
treatment in a stepped-care treatment program; hence, it is reasonable to attempt to enhance its
effectiveness. The Noom Monitor provides a platform for self-monitoring of meals, snacks, binge
eating and purging, exercise, and body checking and also summarizes these activities graphically.
Data from the Noom Monitor are shared with the therapist’s computer so that both patient and
therapist can work from the same data. In Hildebrandt and colleagues’ (2017) transdiagnostic
study, 66 individuals who met the criteria for BN (44%) and BED (56%) were randomized to
CBTgsh with or without the Noom Monitor. At posttreatment, abstinence rates were 63% for
432 Agras • Bohon

the combined treatment group versus 41% for CBTgsh alone; however, at 6-month follow-up,
the two treatment conditions were not different from one another. Similarly, reductions in binge
eating were greater for the combined group at the end of treatment but not at follow-up. Hence,
this therapist-supported app appears to be an effective adjunct to treatment.
Safety of e-therapies. Although Internet-provided psychotherapy and mobile apps have a poten-
tially large reach, this benefit is associated with drawbacks. It is, for example, possible to provide
treatment without seeing the patient, as was the case in two of the early studies (Aardoom et al.
2016, ter Huurne et al. 2015) and with the Recovery Record app. Both BN and BED are often
associated with serious comorbid psychopathology, such as major depression, anxiety disorders,
obsessive-compulsive disorder, and addictive behaviors, as well as physical disorders consequent
on disordered eating behaviors, such as binge eating–purging and overweight. For BN, there are
complications that can lead to sometimes fatal electrolyte disturbances and require medical assess-
ment. Hence, in-person assessment of patients with eating disorders is essential for their safety.
Video conferencing platforms now allow assessment and therapist support if needed over long
distances. Thus, in the absence of face-to-face assessment of patients with eating disorders, video
conferencing should now become the standard for assessment, both in research and in clinical
work. Moreover, some form of continuing assessment throughout treatment is needed. Mobile
applications aimed at treatment pose particular difficulties in this regard. It is possible that only
therapist-assisted apps will be viable for the treatment of eating disorders.
IMPLICATIONS FOR RESEARCH AND TREATMENT

Implications for Research
Behavior therapy emerged in the clinical research arena in the 1950s in the United States based
on Skinner’s (1938) operant conditioning. From the beginning, therapy was focused on symp-
tomatic behaviors and on directly changing those behaviors. Very much the newcomer, it was met
with considerable opposition from psychoanalytic psychotherapists, who considered it a superficial
therapy. Similarly, behavior therapists considered other psychotherapies unscientific and ineffec-
tive. For example, Eysenck (1952, 1966) concluded, on the basis of the best available evidence at
the time, that psychotherapy was no more effective than estimates of the effects of no treatment.
In the end, behavior therapy flourished largely because of its experimental approach to treatment
(i.e., the use of either single-case controlled designs or randomized between-group designs). In
the 1960s, Beck’s (1976, 2008) work on cognitive therapy led the way to the development of CBT
for depression. Because of the late recognition of BN as a clinical entity, and the even later recog-
nition of BED, eating disorder research did not begin until the 1980s, at which point CBT for
other disorders was already well established. Similar to behavior therapies for other conditions,
CBT-ED was research based and came to dominate psychotherapy research for the eating disor-
ders. For example, in a recent meta-analysis of psychodynamic controlled studies (Steinert et al.
2017), there were only 5 studies in which a psychodynamic treatment for eating disorder was used;
by comparison, another recent meta-analysis included 79 controlled trials in which CBT-ED was
used to treat an eating disorder (Linardon et al. 2017a).
There are three elephants in the room. First, despite being the evidence-based treatment of
choice for BN and BED, CBT-ED has not improved in clinical effectiveness in the last 15 years.
Second, CBT-ED results in an average remission rate of about 40% when placebo effects are taken
into account. Third, symptom-focused PP and other treatments may be nearly as effective as CBT-
ED for the eating disorders. IPT, a similarly symptom-focused treatment, is nearly as effective as

CBT-ED for BN and is as effective for BED. What are the implications of these problems for
research going forward?
One possibility is that the present search for a treatment that might augment CBT-ED or have
superior clinical effectiveness has just about played out. Certainly, the lack of progress over the
last 15 years would suggest so. From a long-term perspective, it may be time to widen the research
focus beyond CBT-ED to include all psychotherapies that have demonstrated effectiveness and
to develop a broad psychotherapy research field. A broadened viewpoint conceived as experimen-
tal psychotherapeutics would include both the basic and applied research needed to understand
the settings and mechanisms underlying behavioral, affective, and cognitive change for improved
mental health. This approach might tackle questions such as the following: Why do very different
psychotherapies have similar outcomes? How much of the outcome do specific symptom-focused
elements account for? What are the common and different mechanisms involved in different psy-
chotherapies? Can common factors be experimentally manipulated to discover setting variables
that might magnify their therapeutic effects? Is it possible to use dismantling studies to isolate the
most effective factors? Would it eventually be possible to combine known effective elements into
new, more effective therapies taking into account individual patient characteristics? This is a long-
term project and should include newer developments, such as Internet-based psychotherapies and
apps.
Efforts to bring psychotherapy for the eating disorders to more people still have a long way to
go. At this point, there are relatively few studies supporting the use of the Internet for training or
treatment or the use of apps for treatment. iCBT-ED has promise. It is expected that, for Internet-
based treatments as well as apps, the therapeutic modules will become more sophisticated, more
acceptable, and more effective.
The short-term research priorities for CBT-ED follow:
1. The search for mediators of outcome (mechanisms) and moderators of outcome (which
treatment is best for which individuals) should continue despite meager findings to date.
Larger studies may be beneficial for this aim.
2. To increase clinical efficiency and decrease cost, more research should be directed toward
stepped-care approaches to treatment.
3. Research to better understand rapid response to treatment, and to augment rapid response,
may help to improve treatment outcomes.
4. Research to implement evidence-based treatments in a variety of clinical situations should
be intensified. This will mean altering evidence-based treatments to fit the particular clin-
ical situation and working with others who will use these modified treatments to ensure
acceptability.
5. Continued efforts should be made to enhance the effectiveness of Internet-based treatments
and to determine their place in the management and treatment of eating disorders.
6. Further development and testing are needed for apps directed at the treatment of eating
disorders.
Implications for Treatment

The evidence from controlled clinical trials demonstrates that CBT-ED should be considered as
the first-line approach for BN and for BED and should be used by all those who treat eating disor-
ders. A stepped-care approach to both BN and BED may also be effective—that is, beginning with
CBTgsh followed by CBT-ED if progress is unsatisfactory after 4 weeks of treatment. However,
it is important to note that recovery rates for BN are around 40% (a further proportion of patients
434 Agras • Bohon

have improved symptoms but do not fully recover). For BED, recovery rates are higher, averaging
about 60%. Adding other treatments to CBT-ED does not improve outcomes. IPT can be con-
sidered as a secondary treatment for BN (because it is slower to attain full effects) and as a primary
treatment for BED, providing patients and therapists with a choice of treatments. Teletherapy ap-
pears to be a useful and acceptable mode of communication and may fit well into some practices.
Apps such as the Noom Monitor and others that provide self-monitoring assistance to the patient
and feedback to the therapist are likely to be useful therapeutic tools for many therapists. Such
apps extend psychotherapy beyond the office.
For the persistent form of AN present in adults, there is little difference between CBT-ED and
specialist clinical care comprising medical visits and supportive psychotherapy, and recovery rates
are low. For adolescents with AN, FBT is more effective than other treatments and is regarded as
the first-line treatment based on a number of controlled trials.
DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review.
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CP17_TOC ARjats.cls March 4, 2021 15:57
Annual Review of
Clinical Psychology
Volume 17, 2021
Contents
Smoking Treatment: A Report Card on Progress and Challenges
Timothy B. Baker and Danielle E. McCarthy p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
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Developmental Perspectives on the Study of Persons

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Cognitive Behavioral Therapy for the Eating Disorders
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Virtual Reality Therapy in Mental Health
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Resilience in Development and Psychopathology:
Multisystem Perspectives
Ann S. Masten, Cara M. Lucke, Kayla M. Nelson, and Isabella C. Stallworthy p p p p p p p p p 521
Designing Evidence-Based Preventive Interventions That Reach More
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Mary Jane Rotheram-Borus p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 551
Pathology in Relationships
Susan C. South p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 577
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Annual Review of Clinical Psychology

Cognitive Behavioral Therapy

Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford,

Annu. Rev. Clin. Psychol. 2021. 17:417–38 Keywords

BROADENING THE DELIVERY OF COGNITIVE BEHAVIORAL

418 Agras • Bohon

EFFECTIVENESS OF COGNITIVE BEHAVIORAL THERAPY

Early Controlled Studies

www.annualreviews.org • CBT for the Eating Disorders 419

420 Agras • Bohon

Later Controlled Studies

www.annualreviews.org • CBT for the Eating Disorders 421

422 Agras • Bohon

www.annualreviews.org • CBT for the Eating Disorders 423

Comparisons of Cognitive Behavioral Therapy for the Eating Disorders

424 Agras • Bohon

www.annualreviews.org • CBT for the Eating Disorders 425

426 Agras • Bohon

between treatments (mean 28.3%) in eating disorder psychopathology or general psychopathol-

www.annualreviews.org • CBT for the Eating Disorders 427

expertise in using one or the other of the treatments.

PREDICTORS, MODERATORS, AND MEDIATORS

428 Agras • Bohon

BROADENING THE DELIVERY OF COGNITIVE BEHAVIORAL

www.annualreviews.org • CBT for the Eating Disorders 429

430 Agras • Bohon

Internet-based treatments. The Internet allows psychotherapies to be disseminated widely and,

comparison groups for Internet-based CBT-ED (iCBT-ED) comprised participants on a waiting

www.annualreviews.org • CBT for the Eating Disorders 431

432 Agras • Bohon

IMPLICATIONS FOR RESEARCH AND TREATMENT

www.annualreviews.org • CBT for the Eating Disorders 433

Implications for Treatment

434 Agras • Bohon

www.annualreviews.org • CBT for the Eating Disorders 435

436 Agras • Bohon

Res. Ther. 46:581–92

www.annualreviews.org • CBT for the Eating Disorders 437

domized controlled trial. Int. J. Eat. Disord. 49:36–49

438 Agras • Bohon

Volume 17, 2021

Network Analysis of Psychopathology: Controversies and Challenges

Richard J. McNally p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p31

Intimate Relationships and Depression: Searching for Causation

Developmental Perspectives on the Study of Persons

with Intellectual Disability

An online log of corrections to Annual Review of Clinical Psychology articles may be

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