Exploring Therapists’ Approaches to Treating Eating Disorders to Inform User-Centric App Design: Web-Based Interview Study

Eating disorders are complex mental health conditions with substantial psychological and physical consequences, and many people with mild to moderate EDs do not receive help due to stigma, access barriers, and service constraints worsened post–COVID-19. Early intervention is important, yet those with milder presentations are often deprioritized. Apps may help overcome barriers to care, but therapists’ uptake is limited by concerns about safety, data privacy, personalization, and effectiveness. Many current ED apps closely mirror manual CBT or self-help materials and struggle with engagement and attrition. This study explores how therapists in community settings treat mild to moderate EDs, how they engage and motivate clients, and how an ED app might fit alongside care. It challenges the assumption that simply digitizing CBT is sufficient, by examining therapists’ deviations from standard CBT and identifying practice-based elements that could inform more acceptable, engaging app design.

Systematic reviews show digital interventions can reduce ED symptoms short-term and sometimes long-term, but evidence specifically for apps is limited and complicated by high dropout and engagement challenges. Qualitative research indicates potential users and clinicians see promise but have concerns regarding personalization, safety, and data privacy. Existing interventions often resemble written self-help or straightforward digital CBT translations, risking limited engagement. Prior work with German clinicians highlighted benefits (access, monitoring, adjunctive use) and concerns (loss of therapeutic relationship, data security, inadequate personalization), but offered limited guidance on acceptable app design. Recommended best practice includes clinician involvement in translating evidence-based treatments (particularly CBT) into digital formats to preserve therapeutic integrity, and conducting qualitative research with clinicians early in development to inform planning, design, and engagement strategies.

Design and setting: A qualitative, semistructured web-based interview study with therapists in the United Kingdom, nested within a broader program to develop and evaluate an ED app module for mild to moderate EDs. Reporting followed COREQ guidelines. Participants and recruitment: Twelve participants (therapists, counselors, and one psychiatrist) from First Steps ED (specialist ED service) and Thrive Mental Wellbeing (workplace mental health provider) were recruited via convenience sampling, with inclusion criteria of ≥3 months in role and completed mandatory training. Recruitment ensured relevant ED experience/training via team managers at both organizations. Data collection: One-on-one online interviews (Microsoft Teams) were conducted January–February 2024, lasting 45–60 minutes (mean ~50). An interview guide, co-developed with a public and patient involvement (PPI) group at First Steps ED, covered treatment approaches, implementation, engagement and motivation, potential app role, and desired app content/design. Sessions were audio/video recorded; field notes were taken post-session. Data management and ethics: Recordings were transcribed via Microsoft Teams, anonymized, and checked for accuracy. Data were securely stored; baseline characteristics were collected via Microsoft Forms on a secure UCL server. Ethical approval was granted by UCL Research Ethics Committee (23943/001). Informed consent was obtained via REDCap and re-confirmed at session start. No compensation was provided. Analysis: Transcripts were imported into NVivo 12 and analyzed using structured thematic analysis per Clarke and Braun. The primary researcher iteratively coded all transcripts and developed an initial coding framework; a second coder independently coded 25% of transcripts. Coders refined a shared framework through iterations; the final framework was validated with a PPI team. Themes and subthemes could overlap; the aim was meaningful insight rather than saturation, supported by relatively homogeneous data across interviews. Reflexivity: The primary researcher reflected on potential biases (e.g., assumptions about app potential) and probed for concerns, including from skeptical participants.

- Sample: Twelve participants (8 therapists, 3 counselors, 1 psychiatrist); age 21–52 (mean 28.7, SD 7.3); 58% female (n=7). Most (11/12) trained in CBT; additional training included DBT and ACT. All had higher education (83% master’s). Half (6/12) had direct experience working alongside apps. Most (10/12) were positive about app potential; 8/12 likely to recommend a person-centered app; 3/12 reported significant concerns. - Theme 1 (Treatment approach): CBT considered the “gold standard,” valued for structured, skill-based tools addressing cognitive distortions and avoidance. However, therapists routinely went beyond traditional CBT, adapting to person-centered care and integrating complementary approaches (e.g., ACT, compassion-focused therapy, psychodynamic elements), particularly for deeper emotional issues and diverse needs (e.g., neurodivergence). - Theme 2 (Implementation in practice): Therapy typically spanned ~10 sessions (NHS-commissioned cases), with assessments, psychoeducation (nutrition, body image, social media/diet culture), cognitive restructuring, behavioral experiments, self-monitoring (food/thought diaries), and relapse prevention. Sessions were flexibly tailored to individual goals, pace, and needs; continuous evaluation guided focus (e.g., binging, body image). Collaboration/referral occurred for severe symptoms or comorbidities (multidisciplinary team, dietitians/nutritionists). Step-down supports (groups, befriending) and relapse prevention plans were common; an app was seen as a potential step-down adjunct. - Theme 3 (Engagement and motivation): The therapeutic relationship (trust, empathy, safe space) was seen as fundamental yet hard to replicate digitally. Engagement strategies included customization of resources, gentle challenges, positive feedback, celebrating small wins, and breaking tasks into manageable steps. Empowerment emphasized client ownership, goal setting, progress tracking, mindfulness, and self-reflection; one therapist referenced using an AI tool for reflection between sessions. Motivational techniques included values work and future visualizations; setbacks reframed as learning. - Theme 4 (Perspectives on an ED app): Overall cautiously positive. Value seen in accessibility, psychoeducation, continuity between sessions, bridging waiting times, homework follow-up, and relapse prevention. Best suited for mild to moderate severity, early intervention, or post-treatment maintenance; could aid recovery after more severe episodes as a relapse prevention tool. Critical concerns: safeguarding and crisis support, data privacy/security and distrust of third-party data handling, potential triggering content or unmoderated forums, risk of overreliance on phones, limited ability to replicate a therapeutic relationship, and challenges with personalization and sustained engagement. Suggested mitigations: personalization (including trigger management), strong moderation, crisis links/panic button, privacy transparency, engaging features (progress review, gamification, personalized feedback, celebrating wins). - Theme 5 (App content and design): Design should be simple, intuitive, low text, engaging, with optional reminders/notifications (not intrusive), rewards/gamification (not tied to eating behaviors), safeguarding built-in, and personalization (themes, names, customizable home). Content deemed suitable includes psychoeducation (e.g., set-point theory, myths, consequences), coping strategies (breathing, grounding, safe space), self-monitoring (food/mood diary), CBT tools (thought records, cognitive restructuring), goal setting/tracking (SMART goals, action plans), motivational tools (quotes, affirmations), distraction techniques (urge surfing, distress hills, trigger toolbox), body image and self-esteem work, peer and recovery stories, and gratitude journaling. Exposure tools (e.g., fear ladders, behavior experiments) were viewed more cautiously for self-guided use without therapist support. Overall, therapists saw potential for evidence-based apps across pretreatment, during therapy, and posttreatment, contingent on addressing safety, privacy, personalization, and engagement.

The study addresses how therapists’ real-world practices—often extending beyond standard CBT to person-centered, integrative approaches—can inform ED app design that is credible to clinicians and engaging for users. Findings support blended care: apps can extend continuity of care, facilitate self-management, and strengthen psychoeducation, but should complement, not replace, the therapeutic relationship. Elements of a “digital therapeutic alliance” may be approximated through personalization, supportive and empathic language, interactive features, just-in-time prompts, peer stories, and regular, person-centered communication. However, there are inherent limitations to replicating empathy, trust, and nuanced real-time support digitally, and any AI integration must prioritize safety, privacy, and ethical considerations. Customization to diverse needs (e.g., neurodiversity, gender-specific considerations) and inclusive content can improve engagement. Emphasizing user agency through personalized goals, progress tracking, feedback loops, and reframing setbacks as learning aligns with collaborative therapy. Apps can also enhance delivery of key concepts (e.g., hot cross bun model) via interactive formats and, when paired with therapist oversight, may support more challenging tasks (e.g., graded exposure). The study’s recommendations include strong data privacy and transparency, clear audience definition (mild to moderate EDs; early/recovery/relapse prevention), immediate safeguarding and crisis support, trigger management, hybrid integration with therapist workflows (e.g., summaries, feedback), and co-design with therapists and users. These findings align with prior literature on barriers (safety, security, personalization) and extend it by translating clinical techniques into actionable app features that may improve engagement and effectiveness across the treatment pathway.

A therapist-centered exploration indicates that clinically safe, evidence-based ED apps can play a valuable, adjunctive role across pretreatment, in-treatment, and posttreatment phases. Apps should reflect integrative, adaptive CBT practices, support engagement and motivation, and prioritize safety, privacy, and personalization. While replicating the therapeutic relationship remains challenging, thoughtful design—including features that support a digital therapeutic alliance—can enhance continuity of care and self-management. Future work should employ co-design with therapists and users, iterative usability testing, mixed-methods evaluation of engagement and outcomes, and pilot studies to assess safety and effectiveness. Exploration of blended models, just-in-time adaptive interventions, and ethically integrated AI may further enhance impact, provided robust safeguards are in place.

- Convenience sampling of a small sample (N=12) limits generalizability and representativeness; the study did not aim for saturation, focusing instead on generating meaningful insights. - Participants were drawn from UK community-based services (First Steps ED and Thrive Mental Wellbeing), which may limit transferability to other settings or countries. - Findings rely on self-report via interviews and may be influenced by participant perspectives and experiences; the homogeneity of themes suggests commonalities but may obscure outlier views. - The study did not empirically evaluate an app; recommendations are based on therapist perspectives and require subsequent user-centered co-design, feasibility, and efficacy testing.