When Quick Therapy Works: New Insights on Brief Treatment for Eating Disorders
Researchers explore what makes some people succeed faster in 10-session eating disorder therapy
When Sarah walked into her first therapy session for bulimia, she wasn't sure what to expect. She'd been on a waiting list for over a year and had tried various approaches before. But within just four sessions of a brief, 10-session cognitive behavioral therapy program, her eating disorder symptoms had significantly improved. Meanwhile, another patient in the same program struggled to make changes in the same timeframe.
What makes the difference between early success and slower progress in eating disorder treatment? A groundbreaking new study from an NHS eating disorder service in the UK sought to answer this question by examining what predicts early improvement in brief therapy for nonunderweight eating disorders.
The Rise of Brief Therapy
Traditional eating disorder treatment often involves 20 or more therapy sessions, but longer treatments don't necessarily produce better outcomes. With long waiting lists and limited resources in healthcare systems worldwide, researchers have developed shorter, more intensive approaches.
CBT-T (10-session cognitive behavioral therapy) was designed specifically for people with nonunderweight eating disorders, including binge eating disorder, bulimia nervosa, and atypical anorexia nervosa. These conditions affect between 1% and 10% of women during their lifetime and are associated with serious physical and psychological health problems.
The treatment is highly structured and moves quickly. It includes food monitoring, weekly weighing, education about nutrition, behavioral experiments, and cognitive restructuring. Crucially, the approach requires people to start making changes immediately rather than spending time building motivation or exploring underlying issues.
"It's a 'doing therapy' in which service users 'get out what they put in,'" explained one of the clinicians interviewed for the study.
Understanding Early Change
Early change in eating disorder symptoms has emerged as the strongest predictor of treatment success. In CBT-T, therapists review progress after four sessions. If someone hasn't made substantial changes by then, continuing with the remaining sessions is unlikely to be beneficial, and they're encouraged to return when they're more ready to engage.
This approach makes identifying predictors of early change crucial. Understanding who is likely to succeed quickly could help clinicians make better treatment decisions, ensure resources are used effectively, and help patients avoid the stress of unsuccessful therapy attempts.
What Therapists Think Matters
The researchers first interviewed eight therapists who deliver CBT-T to understand their perspectives on what influences early success. The clinicians identified several key factors they believed made a difference:
Motivation and Readiness: Therapists emphasized that people need to be highly motivated and ready to "give up" their eating disorder when starting treatment. Since CBT-T doesn't spend time building motivation, people need to arrive ready to make immediate changes.
"The people who are not very attached to their eating disorder and are really motivated... they're not contemplating change. They would do it right now if someone just told them what to do," explained one clinician.
Ability to Push Through Anxiety: The changes required in CBT-T are anxiety-provoking. Therapists noticed that people who understood the rationale for changes and could "push through" their fears tended to do better, especially if they "dived into" dietary changes rather than making gradual adjustments.
Diagnosis Type: All eight therapists felt the treatment worked better for binge eating disorders (bulimia nervosa and binge eating disorder) than for restrictive presentations like atypical anorexia nervosa. They found the manual was designed with binge eating in mind and harder to adapt for restrictive cases.
Life Circumstances: External stressors, mental health conditions like depression and anxiety, and unprocessed trauma were all seen as potential barriers to making early changes.
Therapeutic Relationship: Despite the manual's de-emphasis on building rapport, all therapists believed a strong therapeutic alliance was essential for helping people feel safe enough to make difficult changes.
Wait Times: Long waits for treatment were viewed as harmful, with therapists believing that people's symptoms worsened and expectations became unclear during extended waiting periods.
Testing the Theory
The researchers then examined data from 107 people who had received CBT-T to see if the therapists' beliefs held up statistically. They looked at five factors that could be measured from routine clinical data: diagnosis type, wait time, therapeutic alliance, and baseline levels of depression and anxiety.
The results were surprising: none of these factors significantly predicted early improvement in eating disorder symptoms.
People made similar progress whether they had binge eating or restrictive diagnoses, whether they waited weeks or months for treatment, whether they had strong or weak therapeutic relationships, and regardless of their initial levels of depression and anxiety.
The Treatment Still Works
Despite the inability to predict who would improve quickly, the overall results for CBT-T were encouraging. After just four sessions:
- Eating disorder symptoms significantly decreased across the group
- 44% of people scored below the threshold for clinical concern (up from 26% at the start)
- 22% showed reliable improvement
- 8% showed clinically significant change
- Less than 1% of people got worse
These improvements continued beyond the initial four sessions, supporting the effectiveness of the brief treatment approach.
When Therapist Intuition Meets Data
The disconnect between what therapists believed mattered and what the data showed highlights an important phenomenon in healthcare: clinical intuition doesn't always align with statistical reality.
Research has consistently shown that healthcare providers are often poor at predicting which patients will do well in treatment. This can be due to cognitive biases, limited feedback on the accuracy of predictions, and the tendency to remember unusual cases more vividly than typical ones.
For example, therapists strongly emphasized the importance of the therapeutic relationship, but data showed no connection between alliance strength and early symptom improvement. This mirrors previous research suggesting that in eating disorder treatment, early symptom change actually predicts later therapeutic alliance, not the other way around.
What This Means for Treatment
The findings have several important implications:
Don't Judge Too Quickly: The inability to predict early success suggests that more people might benefit from CBT-T than therapists initially think. Factors that seem like barriers (such as having a restrictive eating disorder or experiencing depression and anxiety) didn't actually prevent improvement.
Focus on Action, Not Relationship Building: While therapeutic relationships matter for the overall treatment experience, the data supports the CBT-T approach of prioritizing behavioral change over alliance building in the early sessions.
Brief Can Be Better: The effectiveness of the 10-session approach supports using shorter treatments, which can help more people access care and reduce waiting lists.
Keep Testing Assumptions: The study demonstrates the importance of testing clinical beliefs with data rather than relying solely on professional intuition.
The Bigger Picture
About 16% of people ended treatment before completing all 10 sessions, and this was more likely to happen for people with higher baseline depression and anxiety scores. However, among those who stayed in treatment, these mental health symptoms didn't prevent improvement.
This suggests that while some mental health conditions might make it harder to engage with treatment initially, they don't necessarily limit the ability to benefit once someone is actively participating.
Identified Factors
The researchers identified several factors from their interviews that couldn't be tested with available data but might be important predictors of success:
- Self-efficacy and belief in one's ability to change
- Commitment to treatment and willingness to prioritize it
- Having adequate social support
- Trauma history and how it's managed
- Specific attitudes toward change and recovery
Future research could explore these factors more systematically to better understand what drives early improvement in brief eating disorder treatment.
Encouraging News - CBT Offers Improvement
This research offers encouraging news for people with eating disorders and their families. It suggests that meaningful improvement can happen quickly when the right treatment approach is used, regardless of many factors that might seem like barriers.
The study also supports the value of brief, intensive treatments that get people making changes immediately rather than spending months building up to action. For healthcare systems struggling with long waiting lists and limited resources, effective brief treatments could help more people access care sooner.
Perhaps most importantly, the research challenges assumptions about who can benefit from treatment. Rather than lengthy assessments to determine "readiness," the findings suggest that offering treatment and reviewing progress after a few sessions might be more effective.
For Sarah and others like her, this research validates what they experienced: sometimes, when the right approach meets the right moment, recovery can begin surprisingly quickly. And for those who don't improve in the first few sessions, the data suggests this isn't a failure but valuable information that can guide decisions about alternative approaches.
The key insight is that we still have much to learn about what drives successful eating disorder treatment, but brief, action-focused approaches show real promise for helping people recover more efficiently than ever before.
Gatley, D., Millar‐Sarahs, V., Brown, A., Brooks, C. P., & Matcham, F. (2025). Understanding Early Treatment Response in Brief CBT for Nonunderweight Eating Disorders: A Mixed Methods Study. International Journal of Eating Disorders, 58(3), 518-530.
