BABCP guidance for the remote delivery of evidence-based CBT for eating disorders
These guidelines have been developed in response to the impact of the
Coronavirus pandemic. While CBT has been delivered via telehealth for many
years, its results have not been impressive in working with eating
disorders (e.g., Loucas et al., 2014), possibly because there are many
elements in evidence-based CBT for eating disorders (CBT-ED) that have been
developed around face-to-face delivery. That is no longer possible, in days
where social isolation is vital.
The guidelines reflect the fact that many of us are now working at home,
and having to either transfer patients to online treatment or run the whole
therapy by telephone or online. It is important not to start with negative
expectations of this approach (e.g., “It cannot work” or “The alliance is
going to fall to pieces”), as such expectations can very easily lead us to
drift, creating a self-fulfilling prophecy. This document reflects recent
changes in practice that we have been finding useful. Those changes have
ensured that we can deliver CBT-ED remotely without losing sight of the
evidence-based principles and practice. We have considered ways of using
technology and used our experience to shape them to allow us to achieve key
Of course, we start by recommending that CBT-ED clinicians should employ
evidence-based CBT-ED protocols, as always (see below). We have already
been seeing some very positive outcomes by staying on protocol despite the
move to telehealth, and there is no reason that this should not work for
all of us.
Basics of treatment
There are a number of general competences and metacompetences that we
should always attend to, and these are just as important as ever when
working via telehealth:
- Advise the patient to remain safe and socially isolated, as directed.
- Monitor and respond to physical and suicide risk, directing patients to
appropriate medical resources if necessary. It is important to make sure
that you ask these questions each time, either directly or as part of a
routine assessment tool.
- Work with the patient to address any therapy-interfering behaviours or
situations (e.g., using online shopping to ensure food is available; keep
to regular time slots).
- Maintain professional and ethical boundaries.
- Work within your professional and employment requirements.
- Address patient and therapist concerns about telehealth from early on,
discussing this as ‘business as usual under unusual circumstances’. To
date, we have found that it tends to be the therapists who can have more
concern about this working.
- If the patient is worried about the shift to a different format, then
suggest that it is worth trying it as an experiment, rather than waiting
for the resumption of ‘normal service’.
- Monitor progress as well as outcomes, and do not let the remote method of
working stop you from pressing the patient to make early behavioural change
(as this is the best predictor of outcome, regardless of the setting).
Practical issues in telehealth
Telehealth can seem daunting or it might seem like an extension of how you
interact with many other people already. Either way, make sure that you
consider the following technical issues:
- Pick an appropriate, secure platform, with video linkage if possible.
Follow local guidance on appropriate technology to use, but be aware that
some platforms are currently more secure (e.g., Google Meet; VSee) than
others (e.g., Skype; Zoom). Use recording facilities where they exist.
Remember that these platforms drain batteries, so avoid the stress of
worrying about whether your battery will last by plugging in.
- Turn off any assistant devices (e.g., Alexa; Google Assistant; Siri), as
these can be recording your conversations for external scrutiny.
- If having to use a phone, use a work phone or block your outgoing number
when calling a patient.
- Turn off your phone ringer, alerts, etc., as these can be distracting.
- Treat this as a work situation – dress as you would for a face-to-face
session; be on time; work to an agenda.
- Clarify and agree session conditions with the patient – encouraging
minimal opportunity for interruption, turning off other forms of
communication, being on time etc,
- Make sure that interruptions are minimised, or that you warn the patient
if it is likely to happen. We have found that patients are very
understanding, and will often need to break off to deal with issues at home
- Communicating key material that is normally presented on paper can
usually be done electronically, especially if the patient keeps their food
diary on their phone, uses an online food diary system, emails in photos of
a paper record, uses scanning apps for diagrams, etc. Some platforms allow
you to share screens and to demonstrate material via ‘whiteboards’.
- Routine pdfs and fillable versions of eating and other questionnaire
measures are available in a number of places (particularly from the Centre
for Clinical Interventions -
, and can be sent by email to the clinician.
- More tips on remote therapy provision are available at
Staying on target
A key element of evidence-based practice is that it requires us to work to
the protocols, to avoid drifting off course and thus running the risk that
we make treatment more protracted and less effective. However, as with all
protocols, remember to apply them flexibly, according to the needs of the
individual (Wilson, 1996). Therefore, we recommend the following:
- Ensure that you use evidence-based protocols (e.g., Fairburn, 2008;
Fairburn et al., 1993; Gowers & Green, 2007; Thomas & Eddy, 2019;
Waller et al., 2007, 2019), rather than letting yourself ‘drift’. Remember
that these protocols require us to be flexible for the individual patient –
just flex without losing track.
- Beware of the temptation to ‘add on’ a few more sessions due to COVID-19,
as this is likely to mean that you give yourself an excuse to drift from
- Always start with an agenda. Where the patient wants to talk about
COVID-19 and nothing else, build time for this topic into the agenda so you
can acknowledge the difficulties at this time, but limit the time so that
the CBT-ED itself can be addressed. You may find it useful to refer the
patient to resources such as the BABCP podcast on anxiety around
coronavirus, or other resources on the covid-19 resources page:
- When delivering treatment by telephone, acknowledge that sometimes you
might interrupt each other or talk over one another, as you can’t see each
other’s non-verbal cues. Acknowledge that it is okay, and does not mean you
cannot do meaningful work together. Similarly, therapists might have to
give permission for there to be periods of silence on the telephone (e.g.,
“I’ll just give you a minute to think about that”), so that patients feel
okay with the process of reflection during telephone/online sessions
- Use supervision to keep you on track (see the associated BABCP guidance
for supervision under COVID-19 conditions:
- Maintain focus on patient progress and outcomes during that supervision.
- Maintain the frequency of supervision, to ensure that you keep on track
(and to allow the supervisor to check on your own experience of isolation
and remote working).
- Group supervision can still be employed with video platforms, but avoid
using the phone for this, as conference phone calls can be slow and
- A brief email from the clinician at the end of the session can help the
patient to understand and deliver on the treatment plans. It is also useful
in some cases to get the patient to take responsibility for this summary,
and how and when they will send it before the next session.
- Use the following resources to consider ways of implementing CBT-ED
effectively under COVID-19 conditions:
Specific CBT-ED competences
Clinicians have expressed concerns about how they and their patients will
be able to implement specific CBT-ED skills under these conditions of
social isolation. However, each of these is manageable when using
appropriate levels of flexibility in delivering the techniques. In some
cases, patients might say that they cannot implement the techniques due to
the situation at home. In that case, you can stress the ‘If not now, then
when…?’ approach, stressing that trying it now means the possibility of
recovery sooner, while waiting until normal is reinstated is unlikely to
enhance outcomes, but will definitely mean longer with the eating disorder
and associated comorbid mood, risk, etc.
Another issue to consider is whether the patient would benefit from
involving family members in the delivery of CBT-ED. If the patient is
living in social isolation with their family, we recommend asking the
patient to consider involving them in the treatment, including being on the
calls for part or all of the session if appropriate. This might be
particularly helpful for underweight patients working on weight regain
(e.g., monitoring weight each week).
is a key element of CBT-ED, as well as being inherent to exposure therapy
for the eating disorders (see below). Therefore, food requires some
Of course, the context that we are working in needs to be considered at all
times. For example, under normal circumstances, we might recommend that the
patient tries eating somewhere new or mixing with other people. Therefore,
we need to consider using the resources that the patient has (e.g., making
social links by phone or online).
In contrast, other CBT-ED techniques can be delivered pretty much as
normal. We just have to remember to use them at the appropriate point, and
in the appropriate way. These methods include:
Most psychoeducation (apart from that relating directly to
COVID-19). Psychoeducation materials are readily available, e.g.:
Most cognitive restructuring techniques.
- Working with emotional triggers to behaviours.
Core belief work
, including imagery rescripting and chairwork (possibly building in
some self-soothing work, as you will not be present when the patient is
processing some of the experience).
(which patients seem to find very positive). We recommend asking the
patients to self-weigh and report on their weight and their behaviours
immediately before the group. This allows us to continue the helpful
practice of talking with the group about overall group progress rather
than discussing individual cases in front of the group.
Impact upon therapists
While CBT-ED by telehealth can be as effective as routine, face-to-face
CBT, it is important to acknowledge this as a significant change in the way
many clinicians are working. It should also be remembered that this change
is coupled with the stressors that those clinicians (along with everyone
else) are facing at the moment (e.g., home schooling, separation from loved
ones, illness). Therefore, do not be surprised if delivering sessions
remotely is more tiring, especially due to the increased concentration
required to adapt, to read non-verbal communication, and to work with the
limitations of the technology (e.g., audio visual delays). All these
stressors may be occurring while access to our normal coping strategies is
limited. Alongside routine advice about clinicians taking regular breaks,
timing sessions appropriately, it is essential to reflect upon these
challenges and use supervision, in order to ensure we remain healthy and
able to deliver effective therapy.
It is beyond doubt that these are strange times, where routine,
face-to-face delivery of CBT-ED is not possible in the great majority of
cases. However, strange times can make us consider whether our normal
pattern of delivery is the only one. In the past, telehealth methods have
not been as effective as one might have hoped in the field of eating
disorders, often because they involved a watered-down version of the
therapy. However, the drive now is to get CBT-ED back on track when we
cannot meet, rather than to deliver a less expensive version of the
We have found that it is perfectly possible to engage patients in
evidence-based CBT-ED via telehealth, as long as we adhere to the core
principles of that therapy and think flexibly about its delivery. The
result is that we are all developing new skills. What is important now is
to monitor how effective this new approach is, as early indications have
been positive. Indeed, if one good thing comes out of the whole COVID-19
lockdown, it might be that we get more effective at delivering therapies
via telehealth, and that it will become a much more viable option in the
Glenn Waller, Matthew Pugh, Madeleine Tatham, Jane Evans, Victoria A.
Mountford, and Hannah Turner