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. 2025 Aug 7;58(11):2116–2125. doi: 10.1002/eat.24517

A Pilot Evaluation of a Focused Acceptance and Commitment Therapy Program for Individuals With an Eating Disorder Waitlisted for Treatment

Jessica Tone 1, Belinda Chelius 1,2,✉, Yvette D Miller 2
PMCID: PMC12605652  PMID: 40772755

ABSTRACT

Objective

Increasing demand for eating disorder treatment services has placed pressure on service capacity and extended wait times. Although wait times have been associated with treatment disengagement, there is limited evidence for interventions to mitigate their impact for adults with eating disorders. The aim of this study was to evaluate the implementation and impact of a pilot Brief Intervention/Therapy for Eating Disorders (bITE) for adults waiting for outpatient eating disorder treatment.

Method

The bITE pilot program provided six sessions of Focused Acceptance and Commitment Therapy for participants in Brisbane South, Australia, who were on the treatment waitlist at an outpatient specialist eating disorder service for adults. Implementation was evaluated using routinely collected participant record data and self‐reported participant feedback. Impact on participants' eating disorder symptomology and psychological distress was evaluated using repeated (pre‐ and post‐participation) self‐reported measures.

Results

From 90 waitlist individuals referred to the bITE pilot, 47.7% commenced and 65.1% of those completed all six sessions. Mean wait times for referral to bITE were significantly shorter (18.6 days) for those joining the waitlist after bITE implementation compared to those who joined the waitlist prior to bITE commencement (149.4 days). Participants reported significantly reduced severity of eating disorder symptomology, frequency of overeating episodes, and psychological distress after participating.

Discussion

Providing bITE reduced wait time for a face‐to‐face intervention by approximately 18 weeks on average. These findings suggest that a brief therapeutic intervention may reduce wait time for an intermediate intervention and facilitate early improvements in symptomology. Longitudinal follow‐up and comparison to alternative interventions are required.

Keywords: ACT, anorexia nervosa, binge eating disorder, brief intervention, bulimia nervosa, eating disorders, eating disorder treatment, FACT, waitlisting, waitlist management

Summary.

  • Waitlist interventions offer intermediary support while people wait for eating disorder treatment, but further examination of their effectiveness is needed.

  • We pilot tested a brief, six‐session Focused Acceptance and Commitment Therapy (FACT) program as a wait list intervention for adults waiting for more intensive, long‐term therapeutic eating disorder treatment.

  • We found that participation in the FACT wait list intervention improved the severity of eating disorder symptoms and psychological distress.

1. Introduction

Eating disorder (ED) prevalence has been increasing over the past two decades (Hay et al. 2023). Globally, ED point prevalence doubled between 2000 (3.5%) and 2018 (7.8%) (Galmiche et al. 2019). These trends were further exacerbated by the COVID‐19 pandemic, with worsening ED symptomology and disordered eating behaviors documented in individuals with a living or lived experience of an ED and in the general population (McLean et al. 2022; Miskovic‐Wheatley et al. 2022; Phillipou et al. 2020). Growing demand for specialist ED treatment services has not subsided since the conclusion of the pandemic (Boltri et al. 2024; Nuffield Trust 2024). The increased pressure placed on service capacity has adversely impacted already lengthy waitlist times (Iacobucci 2021; Nuffield Trust 2024), with individuals waiting up to nine months to commence treatment (Hamilton et al. 2022; Volpe et al. 2019). This is concerning, as extended waitlist periods have been shown to increase treatment drop‐out for people with EDs (Carter et al. 2012). Adequate engagement in treatment is important to mitigate the various psychiatric, physical, social, and economic impacts of EDs (Chesney et al. 2014; Hambleton et al. 2022; Hay et al. 2017; van Hoeken and Hoek 2020). Thus, identifying strategies to mitigate treatment wait time is crucial.

Waitlist interventions may reduce wait time for service interaction by providing intermediary support whilst people wait for treatment. Only four studies have examined two types of waitlist interventions for adults with EDs, with mixed results (Wade et al. 2024). A single session psychoeducation intervention evaluated using a sequential case‐cohort study was associated with reduced wait time, improved ED symptomology and depression over the waiting period, and increased likelihood of starting treatment (Fursland et al. 2018). Findings from a randomized controlled trial (RCT) evaluating a single session of cognitive remediation therapy or psychoeducation showed improved treatment retention (Keegan et al. 2024) but no effect on clinical outcomes during the waitlist period or subsequent treatment compared to a usual waitlist group (Keegan et al. 2024). Two RCTs evaluating low‐cost guided self‐help (GSH) interventions have demonstrated no impact on treatment commencement or retention (Vollert et al. 2024; Wade et al. 2024), although one showed faster and greater reductions in ED symptomology over a 12‐month follow‐up period in waitlist intervention participants (Vollert et al. 2024). Further evidence for the value of waitlist interventions and alternative waitlist intervention types for adults with EDs is needed to inform best practice responses to mitigate the growing burden of treatment wait times. The current evidence supports interventions that are low resource, feasible to implement into existing services, and brief (Wade et al. 2024).

Psychotherapy is a first‐line treatment for EDs that targets the multifaceted psychological and social factors that contribute to ED etiology (Russell et al. 2023). Focused acceptance and commitment therapy (FACT) is a brief psychotherapy model that provides an abridged version of traditional acceptance and commitment therapy (ACT) (Strosahl et al. 2012) delivering the core methods of ACT in one to six sessions (Robinson and Reiter 2007). FACT has been implemented in primary care settings due to its succinct approach that can rapidly provide scalable therapeutic services to large volumes of patients (Allen et al. 2024; Kanzler et al. 2022; Robinson and Reiter 2007; Strosahl et al. 2012). Processes targeted in ACT are congruent with key factors contributing to ED development and maintenance, including motivation for change and experiential avoidance (Onnink et al. 2022; Russell et al. 2023). Experiential avoidance has also been associated with ED treatment drop‐out (Carter et al. 2012). No studies have examined FACT as a waitlist intervention for ED treatment despite its potential feasibility and emerging evidence for ACT as an effective ED treatment (Onnink et al. 2022; Russell et al. 2023).

1.1. Aim

The aim of this study was to evaluate the implementation (quality of referrals, recruitment, responsiveness, retention, onward referral, and perceived value of the program from participants) and impact (reduced eating disorder symptomology and psychological distress, and improve self‐reported recovery) of a FACT waitlist intervention for adults waiting for outpatient ED treatment.

2. Method

2.1. Study Site

Eating Disorders Queensland (EDQ) is a community‐based specialist ED outpatient service in Queensland, Australia. The number of individuals accessing structured psychological therapy (20 session treatment protocol) at EDQ increased by 126% in the 2 years following the declaration of the COVID‐19 pandemic (Eating Disorders Queensland 2020, 2022). Wait times for structured psychological therapy increased to 12 months during the pandemic and remained elevated at six‐ and nine‐months post‐pandemic. The Brief Intervention/Therapy for EDs (bITE) program was developed at EDQ to reduce wait time for therapeutic support through providing FACT as a waitlist auxiliary. This study describes the pilot evaluation of bITE.

2.2. Design and Procedure

We used a single‐arm, uncontrolled case series design with repeated measures to evaluate the bITE pilot conducted between 31 January 2022 and 7 March 2023 for EDQ clients in the South Brisbane Primary Health Network (PHN) catchment area in Queensland, Australia. All individuals entering EDQ's service attend an initial intake assessment to ensure appropriate referral to internal services. Following intake, clients who are referred to structured psychological therapy are triaged by the Care Navigator before being placed on the waitlist. The Care Navigator sequentially referred eligible clients from this waitlist into the bITE pilot program by sending an offer to participate via email. At least one follow‐up email was sent if the first offer received no response. Both clients who were already on the waitlist at pilot implementation and clients who joined the waitlist during the pilot period were given a soft assisted referral into the program.

During intake assessment, participants were informed about the potential utilization of their deidentified demographic and outcome data and provided consent for its collection and use (including dissemination of findings) for evaluation purposes.

Demographic and implementation data were obtained from client records maintained by EDQ using the CSnet Client Management System. Practitioners delivering the intervention administered electronic pre‐ and post‐participation self‐report assessments of ED symptomology and psychological distress to participants via a direct email link, which automatically uploaded to their CSnet client record. Participants were also separately invited to self‐complete an online post‐program feedback survey via Qualtrics. J.T. exported and linked the participant data from all sources using a unique participant identifier.

2.3. Participants

Individuals were eligible to participate in the bITE program if they were on the EDQ waitlist for structured psychological therapy during the pilot evaluation period (31 January 2022 to 7 March 2023), aged 16 years or older, resided in the Brisbane South PHN catchment area (to comply with funding agreements), and were not engaged in another individual therapeutic treatment for an ED. A formal diagnosis of an ED was not required for inclusion.

2.4. Intervention

The bITE pilot program utilized a Focused Acceptance and Commitment Therapy FACT framework (Strosahl et al. 2012) to provide participants with essential skills, coping strategies, and resources to utilize while they await further psychotherapeutic treatment. The intervention comprised six individual sessions, attended weekly to fortnightly, that followed a structured treatment protocol designed to be accessible for delivery by trainee or early‐career clinicians with foundational training in cognitive behavioral therapy (CBT; see Supporting Information S1). The intervention was delivered in person and through telehealth services based on participant need. During the final intervention session, practitioners collaboratively reviewed progress with participants and referred participants into appropriate services. Participants could concurrently access up to six individual sessions with a lived experience (LE) worker to further enhance the application and practice of acquired skills.

When implementation of the pilot program commenced, the intervention was delivered by existing mental health clinicians (e.g., psychologists, social workers, or counselors) who were employed part‐time and agreed to take on an additional case load of bITE participants by temporarily increasing their work hours. This ensured that the existing full‐time equivalent (FTE) dedicated to treatment provision was maintained. To ensure sustainability of the program, a trainee psychologist (i.e., currently completing required education and training to receive registration) was then recruited to take on all new bITE referrals. All clinicians delivering the program completed FACT training before delivering the intervention (Harris 2024).

2.5. Measures

2.5.1. Participant Characteristics

Participant demographic data (age, gender, Aboriginal and/or Torres Strait Islander identification, country of birth, employment status, and ED presentation) was collected as part of standard EDQ intake procedures and obtained from client records. Further details are outlined in Supporting Information S2.

2.5.2. Program Implementation

Implementation (referrals, recruitment, responsiveness, retention, onward referral, and perceived value of the program from participants) was assessed using data from client records at the conclusion of the pilot period and self‐report surveys completed by participants at post‐participation. Implementation data was collected to evaluate the feasibility of implementing the intervention into existing service delivery, including the feasibility of recruiting participants from treatment waitlists. Measures of onward referral and subsequent treatment commencement were collected to assess the impact on subsequent treatment. Specifically, onward referral was included to understand the extent to which participants were re‐evaluated at the completion of the intervention and referred to the most appropriate services for their current stage of recovery. This could include referral to remain on the waitlist for structured psychological therapy, referral to lower intensity EDQ services, or referral to external services. Further details on these indicators are outlined in Supporting Information S2.

2.5.3. Impact on Eating Disorder Symptomology

The 28‐item Eating Disorder Examination Questionnaire (Fairburn and Beglin 2008, 1994) was self‐administered pre‐ and post‐participation to assess change in ED symptomology. Twenty‐two of the 28 items are scored on a seven‐point Likert scale (range = “0” to “6”), with respondents asked to rate the frequency or impact of key ED behaviors and psychological features over the past 28 days. Four subscale scores: Restraint (5 items); Eating Concern (5 items); Shape Concern (8 items); and Weight Concern (5 items; 1 item repeated from Shape Concern), are derived from these 22 items by taking the average of item scores in each subscale. Subscale scores were calculated if the number of missing items for a subscale was less than half the total number of items in that subscale (Fairburn and Cooper 1993). A global score is calculated by taking the average of the four subscale scores. Global scores were calculated when at least two of the four subscale scores were available. Subscale and global scores range between zero and six, with higher scores indicative of greater severity. The subscale and global scores of the EDE‐Q have previously been shown to have acceptable internal consistency, discriminant validity, and to be a valid measure of ED symptomology (Aardoom et al. 2012; Berg et al. 2012). In this study, Cronbach's α values at pre‐ and post‐participation were 0.80 and 0.90, respectively, for the Restraint subscale, 0.77 and 0.82 for the Eating Concern subscale, 0.85 and 0.94 for the Shape Concern subscale, 0.76 and 0.79 for the Weight Concern subscale, and 0.88 and 0.91, respectively, for the EDE‐Q Global score. The remaining six items assess the frequency of disordered eating behaviors over the past 28 days and were assessed as individual variables.

2.5.4. Impact on Psychological Distress

Psychological distress was assessed using the Kessler Psychological Distress Scale (K10) (Kessler et al. 2002). The K10 is a 10‐item measure of non‐specific psychological distress that asked respondents to rate experiences of anxiety and depression over the past 4 weeks on a five‐level response scale (‘all of the time’, ‘most of the time’, ‘some of the time’, ‘a little of the time’ and ‘none of the time’). A total score is calculated by summing the 10 item scores. The maximum score is 50, indicating severe distress, and the minimum score is 10, indicating no distress. Improvements of seven points or more in the K10 score from pre‐ to post‐participation were considered clinically meaningful (Rickwood et al. 2015). The K10 scale has demonstrated reliability and validity in detecting mental distress (Furukawa et al. 2003; Kessler et al. 2002).

2.5.5. Impact on Recovery

A measure of self‐assessed recovery progress was included to understand participant's own perceptions of their recovery following bITE‐participation, as participant criteria for recovery may differ from researcher/clinician definitions (Slof‐Op 't Landt et al. 2019). Self‐reported perceived recovery was assessed using a single item in the post‐participation feedback survey that asked: “Since you started bITE, do you think that you…” with three mutually exclusive response options: Have moved forward in your recovery?; Have stayed pretty much the same?; Have moved backwards in your recovery?

2.6. Statistical Analysis

Data were analyzed using SPSS (Version 29.0.1.0 (171)). Descriptive statistics were used to describe participant characteristics and program implementation. Associations between participants' engagement and characteristics were assessed using chi‐square and t‐tests (with p < 0.05 used as the criterion for significant differences). Scores on the EDE‐Q and K10 were reported as Ms and SDs. Change from pre‐ to post‐participation in these continuous outcome measures was tested using one‐sample repeated measures (paired samples) t‐tests. Change in the frequency (number of times/days) of ED behaviors from pre‐ to post‐program was calculated for each participant, and one‐sample t‐tests were used to determine if the change values were statistically different from 0 (i.e., no change) due to the non‐normal distribution of pre‐program and post‐program frequency ‘score’. Pairwise exclusion for missing data was applied for all analyses. An alpha level of p < 0.05 was used as the criterion for statistically significant change.

3. Results

3.1. Participant Characteristics

Participants in the bITE pilot evaluation (N = 43) ranged in age from 18 to 61 years (M = 28.77, SD = 9.75). Participants predominately identified their gender as female (93%); two (4.7%) identified as male, and one (2.3%) as non‐binary. Of the 43 participants, 15 (34.9%) presented with symptomology associated with anorexia nervosa (AN), two (4.7%) with avoidant/restrictive food intake disorder (ARFID), 14 (32.6%) with binge eating disorder (BED), seven (16.3%) with bulimia nervosa (BN), four (9.3%) with other specified food or eating disorder (OSFED), and one (2.3%) with unspecified feeding or eating disorder (UFED). Participants were predominately employed in either full‐time (n = 15; 34.9%) or part‐time (n = 14; 34.9%) work. Eight (18.6%) participants were unemployed; three (7.0%) participants were not in the labour force, and two (4.7%) participants did not have employment data. No participants identified as Aboriginal or Torres Strait Islander. Most were born in Australia (n = 33; 76.7%), identified their ethnicity as Australian (n = 33; 76.7%) and spoke English at home (n = 41; 95.3%).

3.2. Implementation

3.2.1. Referral and Recruitment

During the pilot evaluation period, 90 eligible EDQ clients were on the waitlist for structured psychological therapy. Of these, 51 (56.6%) were on the waitlist at the commencement of the bITE pilot evaluation period; the remaining 39 (43.3%) joined the waitlist during the pilot evaluation period. All 90 clients (100%) received a referral to participate in bITE. Six (6.7%) clients were ineligible to commence bITE because they had already commenced alternative individual therapeutic services; 15 (16.7%) did not respond to any offer to participate, and 13 (14.4%) declined to participate (see Figure 1).

FIGURE 1.

FIGURE 1

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Flow of participants from waitlist to bITE program and evaluation participation.

The final recruitment rate (consent to participate in bITE) was 56 (62.2%) of all eligible waitlist clients; 74.7% of those who provided any response to an offer to participate. Those who consented to participate in bITE had a significantly higher average age (M = 31.1 years; SD 11.1 years) than those who did not (M = 24.9 years; SD = 7.0 years; t(88) = −2.904, p = 0.005). Consent rates did not significantly vary according to whether waitlist clients were born within or outside Australia, although those who identified as having'Australia' ethnicity were more likely to consent (73.1%) than those who did not (47.4%; X 2(1) = 6.173, p = 0.013). Consent rates did not significantly vary according to waitlist clients' main source of income or their type of ED presentation. Associations between other characteristics and consent to participate could not be examined due to lack of variation in gender (92.2% female), Aboriginal or Torres Strait Islander identification (98.9% did not identify), and language spoken at home (96.7% spoke English) among eligible waitlist clients.

3.2.2. Responsiveness and Wait Times

Wait times for a referral to bITE were significantly shorter for those who joined the waitlist after program commencement (M = 18.6 days; SD = 28.4 days; t(78) = −14.593, p < 0.001) compared to those who joined the waitlist prior to program commencement (M = 149.4 days; SD = 55.1 days). The time between receiving a referral and commencing bITE ranged from 1 to 123 days (M = 39.7; SD = 34.7). The median time between accepting a referral and commencing was 18 days, and 50% (n = 22) of commencing participants (n = 43) had a lapse between a referral and commencing that was 22 days or less.

3.2.3. Program Delivery

Over the pilot evaluation period, the program was delivered by eight alternative practitioners—44.2% of commencing participants (n = 19) saw the designated bITE practitioner (trainee psychologist), with the remaining practitioners (registered mental health clinicians) seeing between 18.6% (n = 8) and 2.3% (n = 1) participants who commenced.

3.2.4. Retention

In total, 43 participants (47.8% of waitlist clients invited; 76.7% of those who consented) commenced the bITE program (i.e., completed at least one session of bITE). Approximately half of the commencing participants (51.2%) were already on the waitlist prior to implementation of the bITE pilot evaluation period, and 21 (48.8%) had joined the waitlist after bITE implementation. Six participants who commenced bITE (14%) withdrew (see Figure 1). All six participants who withdrew completed two sessions of bITE prior to withdrawal. Nine participants who commenced bITE (20.9%) were lost to follow‐up (LTF; Figure 1). Most of these completed one (n = 3) or two (n = 3) sessions of bITE; one completed three sessions, and two participants completed four sessions before discontinuing. Of participants who commenced, 65.1% (n = 28; 51.8% of all those who consented) completed all six sessions. Participants who completed six sessions (n = 28) took between 35 and 116 days to complete bITE, with an average time of 71.8 (SD = 20.7) days between session 1 and session 6 (complete program delivery).

3.3. Impact

There were statistically significant reductions in eating disorder symptom severity for all four EDE‐Q subscales and the global score (see Table 1). Table 2 shows the change in frequency of eating disorder behaviors over the last 28 days from pre‐ to post‐program. There was a statistically significant decrease in the mean frequency of reported episodes of overeating from pre‐ to post‐participation. No other significant differences (from nil change) in the frequency of eating disorder behaviors were observed.

TABLE 1.

The severity of eating disorder symptomology and psychological distress at pre‐ and post‐bITE participation.

Outcome N Pre‐program Post‐program Change (pre‐ to post‐program) Paired samples effect sizes
M (SD) M (SD) M (SD) t (df) p Hedge's g (95% CI)
EDE‐Q restraint subscale 27 2.8 (1.8) 1.8 (1.7) −1.0 (1.6) −3.26 (26) 0.003 0.572 (0.176–0.968)
EDE‐Q eating concern subscale 27 3.1 (1.5) 2.3 (1.6) −0.8 (1.3) −3.32 (26) 0.003 0.505 (0.160–0.850)
EDE‐Q shape concern subscale 27 4.2 (1.3) 3.3 (1.8) −0.9 (1.3) −3.40 (26) 0.002 0.508 (0.169–0.846)
EDE‐Q weight concern subscale 27 4.1 (1.5) 3.3 (1.6) −0.8 (1.3) −3.37 (26) 0.002 0.518 (0.170–0.867)
EDE‐Q global score 27 3.5 (1.4) 2.6 (1.5) −0.9 (1.1) −4.09 (26) 0.001 0.602 (0.254–0.950)
K10 29 28.6 (9.0) 25.1 (8.5) −3.5 (6.6) −2.84 (28) < 0.001 0.387 (0.088–0.686)
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TABLE 2.

Change in frequency of binge eating and compensatory behaviors in the last 28 days from pre‐o post‐bITE.

N a Change (pre‐ to post‐program) Occurrence (≥once)
M (SD) t (df) p Pre‐program % Post‐program %
Overeating (episode) 26 −3.7 (8.5) −2.2 (25) 0.034 62% 46%
OBE 25 −3.32 (10.0) −1.7 (24) 0.110 68% 48%
OBE (days) 24 −3.58 (8.8) −2.0 (23) 0.058 67% 42%
Self‐induced vomiting 24 −1.0 (4.3) −1.2 (23) 0.245 29% 21%
Laxative misuse 22 −0.2 (1.1) −1.00 (21) 0.329 9% 9%
Excessive or compulsive exercise 24 0.5 (4.2) 0.6 (23) 0.560 21% 25%
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Abbreviation: OBE, Objective binge episode.

a

Participants with a valid change score (i.e., who reported frequencies at both pre‐ and post‐program).

There was a statistically significant reduction in K10 scores from pre‐participation to post‐participation in bITE, with a mean decrease in K10 scores of 3.5 (see Table 1). Following bITE participation (N = 29), 62.1% had decreased their K10 score (13.8% had no change); and 24.1% had a clinically significant improvement in K10 score (7 points or more) (Rickwood et al. 2015).

Of the participants who completed the post‐participation feedback survey (N = 20), most reported that they had moved forward in their recovery since commencing bITE (n = 16, 80%); a further 15% (n = 3) reported they had stayed pretty much the same and 5% (n = 1) reported they had moved backwards in their recovery since starting bITE.

3.4. Perceived Value (Participants)

3.4.1. Perceived Helpfulness

Most participants who completed the post‐participation feedback survey (N = 20) strongly agreed (n = 12; 60%) or agreed (n = 6; 30%) that bITE had supported them in their recovery; two participants (10%) said they were unsure whether bITE had supported their recovery. No participants disagreed that bITE had supported them in their recovery.

3.4.2. Perceived Suitability of Amount of Service Contact

More than half of participants either agreed (n = 8; 40%) or strongly agreed (n = 3; 15%) that the number of sessions they received in bITE was sufficient. However, most participants either agreed (n = 5; 25%) or strongly agreed (n = 9; 45%) that they felt they needed further treatment after completing the bITE program. Only 15% (n = 3) of participants indicated that they did not feel they needed further treatment.

3.4.3. Willingness to Recommend to a Friend

Most participants either agreed or strongly agreed (n = 18; 90%) that they would recommend the bITE Program to a friend who was waiting for ED treatment. Two (10%) participants reported they were unsure if they would recommend the bITE program.

3.5. Participation in Lived Experience Services

Seven commencing participants (16%) expressed interest in an offer of concurrent participation in individual LE support sessions, and one participant commenced. Of those who expressed interest but did not commence, two did not provide a reason; three were non‐responsive to multiple LE worker contact attempts, and one opted out due to telehealth requirements at the time.

3.6. Onward Referral and Subsequent Treatment Commencement

Of all commencing participants, 79.1% received at least one onward referral, and approximately half (46.6%, n = 20) received at least two referrals (to other/additional EDQ services or external services). Approximately one fifth of participants (n = 9, 20.9%) were LTF and could not be referred to subsequent services. Approximately three quarters (n = 32, 74.4%) of commencing participants were referred to remain on the structured psychological therapy waitlist. Referrals to services external to EDQ included private psychologists (n = 3), an EMDR therapist (non‐ED specific; n = 1), and a counselor (n = 1).

Following their bITE participation, 18 (41.86%) participants disengaged from further services at EDQ (14 were non‐responsive and 4 disengaged after reaching the top of the waitlist). Half of the participants who were referred to remain on the structured psychological therapy waitlist commenced treatment during the pilot evaluation period (n = 16). Four (9.3%) participants were still on the waitlist but had not yet commenced treatment at the end of the pilot evaluation period. Four (9.3%) participants opted out of the structured psychological therapy that they were waiting for but commenced other treatment: three commenced lower‐intensity EDQ services (e.g., group treatment, LE support) and two commenced external treatment services (one of those in addition to other EDQ services). Four of the 16 participants who engaged in structured psychological therapy also commenced other lower‐intensity EDQ services concurrently after participating in bITE. Overall, at the conclusion of the pilot period, 48.8% of the bITE sample (n = 21) had commenced subsequent treatment.

4. Discussion

The bITE program was introduced to mitigate wait time for psychotherapeutic support at EDQ. Participants who were on the structured psychological therapy waitlist when the pilot began waited an average of 149.4 days before referral to bITE, which decreased to 18.6 days during the pilot period, reducing wait time for a face‐to‐face intervention by approximately 18 weeks. The average wait time between referral and commencement of the intervention was 40 days, and half of the participants had commenced within 22 days of referral. The recruitment rate for the intervention (62.2%) was nearly two times greater than the uptake of GSH waitlist interventions previously reported (Wade et al. 2024). Waitlist interventions can be negatively perceived as holding patterns rather than an active intervention (Wade et al. 2024); perhaps offering a face‐to‐face psychotherapeutic intervention delivered by a mental health practitioner (or trainee practitioner) was perceived more favorably by participants in this study. Recruitment for concurrent LE support sessions was surprisingly low. The stage of recovery where LE support can be most effectively utilized needs to be further explored.

Overall, the program was acceptable to participants, with most participants agreeing that the program supported their recovery. The duration of the intervention was perceived as suitable by participants. As the optimal length of waitlist interventions should provide adequate support whilst not delaying the commencement of treatment, a six‐session protocol may be appropriate for services with longer wait times (Wade et al. 2024). Nonetheless, most participants agreed they required further treatment, supporting bITE as a waitlist intervention or supplement to a more intensive treatment program. Nearly half of the participants who participated in the bITE program went on to commence some form of treatment within the evaluation period, which is within the range (44% to 71%) previously reported for GSH waitlist interventions (Vollert et al. 2024; Wade et al. 2024). Nine per cent commenced services alternant to the treatment they were initially waiting for. From a stepped‐care perspective, providing a scalable waitlist intervention may present an opportunity for re‐assessment of treatment suitability and goals based on intervention response and referral to more appropriate services when needed. This in turn may contribute to shorter waitlists by identifying and removing participants more suited to other treatment earlier on (Fursland et al. 2018). The extent to which this would impact waitlist numbers would be dependent on the service's treatment intensity and placing within the Stepped System of Care for EDs (National Eating Disorders Collaboration 2023). EDQ is placed within community‐based treatment to provide services across the spectrum of symptomology (i.e., inclusive of subthreshold EDs and disordered eating behaviors) to support early identification and access to treatment and reduce the likelihood of acute deterioration requiring intensive treatment or hospitalization. Eligibility for our services is not based on specific clinical cut‐offs and considers various factors including contributing and maintaining factors and client values and preferences as per evidence‐based practice (Peterson et al. 2016). Other services seeking to implement a brief waitlist intervention should consider the potential impacts on treatment uptake and waitlist numbers in the context of their own service's placing within the Stepped System of Care and policies regarding eligibility for treatment.

We also observed significant reductions in ED symptomology and psychological distress following bITE participation, consistent with two previous studies examining a single‐session intervention (Fursland et al. 2018) and a GSH intervention (Vollert et al. 2024). This result is promising, as rapid response to treatment, defined as robust response to treatment within the treatment early stages (i.e., four to six sessions), has been associated with greater improvements in post‐treatment outcomes (Vall and Wade 2015). Consequently, waitlist interventions could facilitate early symptom improvement, in turn positively impacting subsequent treatment outcomes. Whilst this study did not allow for longitudinal follow‐up of participants, this is consistent with a previous finding by Vollert et al. (2024) who observed both faster and greater reductions in clinical outcomes following participation in a GSH waitlist intervention. Longitudinal assessment of subsequent treatment retention and outcomes is recommended for future evaluations.

4.1. Strengths and Limitations

The implementation and evaluation of our study in a treatment setting supports translation into real‐world practice and provides a basis to further substantiate ecological validity through additional evaluation. Our reporting is strengthened by including a description of the assessment protocol for allocation into our intervention, which has been lacking in the reporting of previous studies (Wade et al. 2024). To ensure sustainability of the program, we transitioned the program delivery from existing clinicians within the service to a trainee psychologist who was hired specifically for bITE delivery. This ensures that existing treatment resources are maintained, while contributing to workforce development by providing opportunities for trainee or early‐career clinicians to gain valuable experience. A limitation of this approach is that we did not assess the effectiveness of the program delivery between the registered mental health clinicians and the trainee psychologist. Trainee clinicians may offer a cost‐effective option for waitlist intervention facilitation (Wade et al. 2024); it would be important to determine if their effectiveness to deliver the bITE program is comparable to experienced clinicians.

The study includes several other limitations. First, the lack of a control group did not allow us to determine the extent to which the intervention contributed to observed improvements in symptomology. Incorporating a psychotherapy such as ACT into a waitlist intervention may have resulted in these early improvements, as psychotherapies target factors that contribute to ED development and maintenance. However, other factors, such as early access to face‐to‐face professional support regardless of intervention type, and general improvements in symptoms over the evaluation period, may have also contributed to these observed changes. Comparison to an alternative intervention and a usual waitlist control group may provide more robust evidence for whether waitlist interventions, and which interventions, are effective in improving symptomology. Second, we recruited participants who were already on the waitlist prior to the commencement of the pilot and had already been waiting for an extended period. This may have contributed to the attrition rate during the intervention and in subsequent treatment, as longer wait times have been shown to predict treatment drop‐out (Carter et al. 2012). Lastly, the sample was small, predominately identified as female, and did not include any Aboriginal or Torres Strait Islander participants. Increasing the sample size and representativeness is important in replication research to improve the generalizability of results.

5. Conclusion

To manage long wait times resulting from an increase in demand for services, we implemented a six‐session FACT protocol as a waitlist intervention to provide intermediary support to individuals on our waitlist. The implementation of the bITE program was associated with reduced wait time for support and improvements in ED symptomology and psychological distress for participants. This study contributes to the emerging body of research supporting waitlist interventions for ED treatment. Longitudinal follow‐up of participants and comparison across alternative interventions is an important next step for future research to identify best practices.

Author Contributions

Jessica Tone: investigation, writing – original draft, methodology, writing – review and editing, software, project administration, data curation, formal analysis. Belinda Chelius: conceptualization, funding acquisition, supervision, resources, writing – review and editing, project administration. Yvette D. Miller: investigation, methodology, validation, visualization, formal analysis, software, data curation, supervision, writing – original draft, writing – review and editing.

Ethics Statement

Ethics approval was not sought for this research project as it was conducted as part of the ongoing quality assurance monitoring routinised at EDQ. The participant outcome data collection coincides with standard operating procedures at EDQ and forms part of routine clinical practice. The analyses of de‐identified participant data were undertaken as part of an external program evaluation for EDQ. The analyses performed did not deviate from the purpose for which the data was obtained, and the findings reported in this study are the results of the program evaluation. All EDQ participants signed a consent form allowing the use of their data for research and evaluation purposes before commencing treatment, which included consent for sharing findings. There were no other triggers for ethical review as specified by the Australian National Health and Medical Research Council present in the study's design, procedure, or analyses.

Conflicts of Interest

B.C. is the Chief Executive Officer of EDQ and J.T. was employed by EDQ during the study period.

Supporting information

Data S1: Supporting Information.

EAT-58-2116-s001.docx (23KB, docx)

Data S2: Supporting Information.

EAT-58-2116-s002.docx (18.6KB, docx)

Acknowledgments

We would like to acknowledge that this pilot evaluation was conducted on stolen land. We respectfully acknowledge the traditional owners of the land on which this work was conducted, the Turrbal and Jagera People, and pay our respects to their Elders past and present. We acknowledge that sovereignty was never ceded. This land always was, and always will be, Aboriginal land. We would like to thank the participants who contributed outcomes to this evaluation and the EDQ practitioners who facilitated data collection from participants. We sincerely thank Christophe Langlasse for suggesting using the FACT component, initiating the training, and delivering the first sessions. Brisbane South Primary Health Network provided funding to implement and evaluate the bITE pilot program. Open access publishing facilitated by Queensland University of Technology, as part of the Wiley ‐ Queensland University of Technology agreement via the Council of Australian University Librarians.

Tone, J. , Chelius B., and Miller Y. D.. 2025. “A Pilot Evaluation of a Focused Acceptance and Commitment Therapy Program for Individuals With an Eating Disorder Waitlisted for Treatment.” International Journal of Eating Disorders 58, no. 11: 2116–2125. 10.1002/eat.24517.

Action Editor: Tracey Wade

Funding: This work was supported by Brisbane South PHN, CSC‐0000001151.

Data Availability Statement

The de‐identified data and code supporting the results of this study may be available on reasonable request to the corresponding author, subject to agreement from Eating Disorders Queensland (EDQ) as the data custodian. The bITE Pilot Program is the Intellectual Property of EDQ. Any replication of EDQ programs or use of program materials requires direct, written permission from the EDQ Chief Executive Officer. Requests for program materials or program replication can be directed to the corresponding author.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Data S1: Supporting Information.

EAT-58-2116-s001.docx (23KB, docx)

Data S2: Supporting Information.

EAT-58-2116-s002.docx (18.6KB, docx)

Data Availability Statement

The de‐identified data and code supporting the results of this study may be available on reasonable request to the corresponding author, subject to agreement from Eating Disorders Queensland (EDQ) as the data custodian. The bITE Pilot Program is the Intellectual Property of EDQ. Any replication of EDQ programs or use of program materials requires direct, written permission from the EDQ Chief Executive Officer. Requests for program materials or program replication can be directed to the corresponding author.

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