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Objective The aim of this study was to examine the relationship between therapeutic alliance and treatment outcome (remission status) in Family-Based Treatment (FBT) and Adolescent Focused Therapy (AFT) for adolescents with Anorexia Nervosa (AN). Method Independent observers rated audiotapes of early therapy sessions using the Working Alliance Inventory-Observer Version (WAI-o). Outcome was defined using established cut-points for full and partial remission. To control for effects of early symptom improvement, changes in weight and eating related psychopathology prior to the alliance session were calculated and entered as a covariate in each analysis. Results Participants in AFT had significantly higher alliance scores; however, overall scores were high in both therapies. The alliance was not a predictor of full remission for either treatment, though it was a non-specific predictor for partial remission. Conclusions Therapeutic alliance is achievable in adolescents with AN in both AFT and FBT, but demonstrated no relationship to full remission of the disorder.

In FBT, parents developed a strong alliance with the therapist early in treatment. These scores were consistent with the focus in FBT on parental management of eating disorder symptoms, as was the fact that alliance between adolescents and therapists was lower. Although parental therapeutic alliance was likely important in FBT, its role in treatment response remains uncertain.

This study examines the relationship between patients' characteristics and the therapeutic alliance in family-based therapy (FBT) and adolescent focused therapy (AFT) for adolescents with anorexia nervosa (AN). Independent observers rated audiotapes of therapy sessions using the working alliance inventory-observer version (WAI-o). Patients' characteristics examined to predict the development of the therapeutic alliance included their socioeconomic characteristics, markers of eating disorder psychopathology and expectancy of their treatment. Baseline scores on the eating disorder examination (EDE) were positively correlated with the alliance early in treatment in FBT but no patients' characteristics were correlated with the alliance in AFT. EDE was a moderator of alliance, with higher baseline EDE scores predicting higher alliance scores in the FBT group than in the AFT group. The results suggest that the therapeutic alliance can be successfully developed with adolescents with AN, even those initially reporting high levels of symptomatology. Adolescents' acknowledgement of their symptoms may be an important factor in their ability to develop an alliance with the therapist.Practitioner points • Despite common clinical impressions, it is possible to form a strong therapeutic alliance with adolescents with AN in both family and individual therapy. • Adolescents' own reports and perceptions of their eating disorder may be an important factor in their ability to build the therapeutic alliance. • Clinical strategies hypothesized to promote a strong therapeutic alliance include the externalization of AN, decreasing blame and a focus on adolescent developmental issues.

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