Alliance, technique, both, or more? Clinicians' views on what works in cognitive‐behavioral therapy for eating disorders

Abstract

Objective This study examined clinicians' views of the roles of two elements of cognitive behavioral therapy (CBT) in explaining treatment outcomes—CBT techniques and the therapeutic alliance. Method Ninety‐eight clinicians who reported delivering CBT for eating disorders completed measures addressing their beliefs about what is effective in CBT, their use of specific techniques, and their own anxiety levels. Results Clinicians substantially overestimated the role of both therapeutic techniques and the alliance in explaining treatment outcomes in CBT. Weak but significant correlations were found between therapist anxiety levels and their beliefs about the value of therapeutic techniques or the alliance. However, these associations were in different directions, with higher levels of clinician anxiety associated with more belief in the effects of the alliance but with less belief in the role of CBT techniques. Belief in the role of the therapeutic alliance was associated with a lower likelihood of encouraging the patient to change their eating pattern, while belief in the role of techniques was linked to greater use of case formulation, cognitive restructuring, behavioral experiments and body image work. Discussion Clinicians overestimate the value of both the alliance and therapy techniques in explaining treatment outcomes in CBT for eating disorders. Their beliefs about the strength of these factors are related to their own anxiety, and to their choice of techniques. Clinicians and supervisors should attend to the evidence regarding the impact of a range of elements of therapy, and work with all of those factors to enhance outcomes.

Maladaptive therapist schemas in CBT practice, training and supervision: A scoping review

“…The findings of Deacon et al (2013) indicate that specific beliefs about the dangers or unacceptability of exposure therapy are implicated in therapist intentions to drift from evidence‐based practice. Other studies looked at therapist IU, anxiety sensitivity or low self‐esteem and their correlations with restricted use of specific therapy or supervision methods (D'Souza Walsh et al, 2019; Simpson‐Southward et al, 2018). IU and LSE are arguably different to beliefs, more likely to be representative of dispositional characteristics (Carleton, 2012) yet could also be modified through similar methods used in CBT treatment (e.g.…”

“…The SP element requires therapists to use CBT methods on themselves to deepen their understanding of various techniques, and the SR component often involves the use of a workbook and group discussion and reflection (Freeston et al, 2019). The findings revealed a range of beliefs including some therapists not seeing the value of SP/SR, a perceived lack of time to engage with the process, a fear of being judged for revealing personal material in a group or a fear of intensifying existing personal problems Therapist characteristics A number of therapist characteristics such as anxiety sensitivity, intolerance of uncertainty (IU), perfectionism and self‐esteem were described in the literature (Deacon et al, 2013; D'Souza Walsh et al, 2019; Meyer et al, 2014; Parker & Waller, 2019; Presley et al, 2017; Simpson‐Southward et al, 2018). Simpson‐Southward et al (2018) sought to understand the role that supervisors might play in therapist drift and the psychological traits that might predispose them to this.…”

“…Higher self‐esteem was also associated with a greater use of non‐CBT methods which the authors hypothesize as being due to therapists having ‘greater self‐belief and do not see as strong a need to focus on evidence‐based approaches’. (p9). D'Souza Walsh et al (2019) conducted a survey with ( n = 98) clinicians working in eating disorders services to understand the degree to which they attributed change to the techniques used or the therapeutic alliance. The authors analysed response to the IU scale and found that clinicians who scored highly in inhibitory anxiety were more likely to attribute successful client outcomes to the therapeutic alliance rather than specific techniques.…”

New developments in cognitive-behavioural therapy for eating disorders (CBT-ED)

“…[ 34 ]. In particular, it appears that apparently inflated beliefs about the therapeutic power of the working alliance results in lower adherence to core CBT-ED methods [ 35 ].…”

‘When it goes well, it works fantastically’: motivations to train and their impact on the practice of CBT

“…‘It is too hard to implement in real life settings’) have been identified amongst CBT therapists and trainee clinical psychologists (Parker and Waller, 2017; Rodwell et al ., 2023). Dislike towards or discomfort with key elements of CBT such as agenda setting, homeworking setting, Socratic dialogue and the weighing of patients have been documented previously (D’Souza et al ., 2019; Waller and Turner, 2016; Waltman et al ., 2017). Alternatively, some therapists have misconceptions of CBT models or treatment plans that are never corrected during training or supervision (e.g.…”