Facilitators and obstacles to therapeutic alliance among patients with anorexia nervosa: A qualitative dyadic research

Abstract

ObjectiveStudies indicate a significant challenge for therapists in forming a therapeutic alliance (TA) with patients coping with anorexia nervosa (AN). While TA is a significant predictor of treatment outcomes, and AN treatment has low success rates, little is known about factors that affect the formation of an alliance and its quality in the treatment of AN. This study aimed at examining the factors associated with alliance formation, as perceived by patient–therapist dyads throughout AN therapy.MethodsA total of 18 dyads of patients with AN and their therapists were recruited from an eating disorder unit. The semistructured interviews focussed on the TA between the therapist and patient and examined facilitators towards, and barriers to, TA formation. Data analysis followed a thematic approach.ResultsThe data analysis revealed an overarching theme: the mutual wish of the patient and therapist to form a close relationship and related challenges. This theme was divided into subthemes: (1) the role of self‐disclosure of affection; (2) the meaning of the therapeutic setting; (3) coping with relationship ruptures; and (4) the importance of empathic acknowledgements.ConclusionA major barrier to TA formation between patients with AN and their therapists is patients' conflict between a need for meaningful relationships and fear of re‐experiencing disappointment and pain. Self‐disclosures of affection, flexible treatment setting, acknowledgement of therapists' empathic failures and ability to see things from patients' perspectives are perceived by therapists and patients to facilitate alliance formation. This study also presents practical implications derived from these themes.

Direct and indirect effects of psychological well-being and therapeutic alliance on therapy outcome in eating disorders

“…The findings align with broader recognition that outcome research in the field of EDs is dramatically biased towards psychopathological dysfunction, on the assumption that mental health is predicated on the absence of illness rather than the presence of psychological wellness (Fava and Tomba, 2009;de Vos et al, 2018). Additionally, evidence relating the therapeutic alliance to ED treatment outcome are of limited clinical use without a better understanding of the facilitators or barriers to therapeutic alliance formation in ED patients (Lev Ari et al, 2024).…”

“…Furthermore, despite the mixed findings on ED samples, we hypothesized that the early therapeutic alliance would significantly predict clinically significant and reliable symptom reduction (Zaitsoff et al, 2015;Graves et al, 2017). Furthermore, in line with studies showing an indirect effect of the therapeutic alliance on therapy outcome (Baier et al, 2020) and the potential relevance of ED patients' individual characteristics in determining this association (Prusiński, 2022;Lev Ari et al, 2024), we expected that the therapeutic alliance would mediate the relationship between PWB dimensions and overall symptomatic change.…”

“…These observations underline the need for a deeper understanding of the role played by the therapeutic alliance in ED treatment, and its potential association with ED patient characteristics (Zaitsoff et al, 2015;Graves et al, 2017;Marzola et al, 2019). Nevertheless, to date, little is known about the individual factors that may contribute to (or hinder) the development of a strong therapeutic alliance with ED patients (Waller et al, 2012;Katznelson et al, 2020;Lev Ari et al, 2024). In this regard, several PWB dimensions may be explored as potential predictive factors for the therapeutic alliance with ED patients and the influence of the therapeutic alliance on ED treatment outcome (e.g., Prusiński, 2022).…”

“…A potential explanation for this is that ED patients' struggle to maintain their body condition and their general difficulties in self-regulation may hinder the formation of a therapeutic alliance (Antoniou and Cooper, 2013). Additionally, the general egosyntonic nature of EDs may reinforce patients' ambivalence towards change and disagreement regarding treatment goals and tasks (Lev Ari et al, 2024).…”

Therapist ratings of technique and alliance among adults with eating disorders: Support for integrative treatment.

“…There is a poor treatment retention rate for ED patients (Satir et al, 2011; Sly et al, 2013), which can make it difficult to form a long-term alliance and may be a result of poor alliance formation in itself. It can also be difficult for ED patients to engage in a meaningful relationship with their therapists, whether due to a fear of reexperiencing disappointment and pain in intimate relationships (Ari et al, 2024) or interpersonal difficulties that are characteristic of EDs interfering (Constantino et al, 2005). Oyer et al (2016) demonstrated that both therapists and patients find a lack of attunement to patient needs to be detrimental to the therapeutic alliance with ED patients, though this lack of attunement may be common in this population as patients are particularly resistant to change (Abbate-Daga et al, 2013) and often experience their EDs as egosyntonic (Gagnon-Girouard et al, 2019).…”