The therapeutic alliance in the early part of cognitive‐behavioral therapy for the eating disorders

Abstract

Objective: This study examined the strength of the therapeutic alliance in the early stages of cognitive-behavioral therapy (CBT) for the eating disorders, and whether the strength of that alliance is associated with early eating characteristics, comorbid Axis 1 and 2 features.Method: Forty-four eating-disordered patients completed measures of eating and Axis 1 and 2 characteristics at the start of therapy, and measures of the therapeutic alliance and eating characteristics at the sixth session of CBT.Results: The therapeutic alliance was strong, including in the domain of attachment. It was unrelated to initial eating pathology and early changes in eating cognitions and behaviors. However, there were links between initial emotional and interpersonal features and therapeutic alliance by the sixth session.Discussion: The findings counter suggestions that CBT for eating disorders is characterized by a poor therapeutic relationship. The therapeutic alliance is likely to be enhanced by addressing high levels of emotional distress and difficulties in interpersonal function where appropriate. This research needs to be extended to other therapies, other domains of function and different time points in therapy, to build a fuller picture of the role of the therapeutic relationship in working with the eating disorders.

Clinicians' concerns about delivering cognitive-behavioural therapy for eating disorders

“…However, it is important to note that the eating-disordered patients of CBT clinicians rate the working alliance relative positively (Waller, Evans & Stringer, 2012), and that the alliance might be driven by behavioural change rather than vice versa (Brown, Mountford & Waller, 2013), as found in CBT for other disorders (e.g., Tang & DeRubeis, 1999 However, it is also necessary to attend to how clinicians feel about delivering these aspects of therapy. As such, supervision could usefully provide a safe space for discussion of the process of therapy in combination with the development of technical competence, so that those aspects of treatment that might be more anxiety-provoking can be regularly discussed.…”

A meta‐analysis of the relation between therapeutic alliance and treatment outcome in eating disorders

“…However, multiple studies have shown alliance to be relatively strong among patients with AN (Sly, Morgan, Mountford, & Lacey, 2013;Waller, et al, 2012). In fact, Antoniou and Cooper's qualitative review of the relationship between alliance and outcome in EDs (2013) suggested that the alliance strongly predicted outcome for patients with AN, whereas findings for BN, binge eating disorder (BED), and subthreshold eating disorders were mixed.…”

Therapeutic alliance in Enhanced Cognitive Behavioural Therapy for bulimia nervosa: Probably necessary but definitely insufficient

“…In a large RCT, stronger early (session 4) and mid-treatment (session 12) alliance was associated with fewer purge episodes at the end of CBT for BN, after accounting for baseline purge frequency (Constantino et al, 2005). Other studies fail to find that alliance is associated with change in eating disorder symptoms (e.g., Brown, Mountford, & Waller, 2013;Loeb et al, 2005;Waller et al, 2012). In a clinical trial comparing interpersonal psychotherapy (IPT) and CBT for BN, alliance at sessions 6, 10, or 18 failed to predict post-treatment purge frequency in either treatment condition, after accounting for baseline purge frequency (Loeb et al, 2005).…”

“…Yet a prevailing view is that treatment outcome is related to individual therapist differences over and above therapeutic approach (e.g., Luborsky et al, 1986;Messer & Wampold, 2002) and that manual-based treatment approaches are less caring, less intuitive, less authentic, and even inappropriate for 'real-world clients' (Addis & Krasnow, 2000). Empirical research provides no evidence that therapeutic alliance is adversely affected by implementing manual-based treatments for BN, with patients rating the alliance favourably in randomised controlled trials (RCTs;Loeb et al, 2005) and naturalistic clinic settings (Waller, Evans, & Stringer, 2012).…”

“…In several studies the earliest measure of alliance has been at session 6 (e.g., Brown et al, 2013;Loeb et al, 2005;Waller et al, 2012), andLoeb et al (2005) noted that 74% of the change in BN symptoms in CBT occurred prior to session 6. This leaves the possibility that an earlier measure of alliance might better predict treatment outcome and retention, with Waller et al (2012) recommending that future studies measure the alliance from the earliest time point in therapy. One study found no evidence that alliance at session two predicted drop-out from CBT-E in a transdiagnostic sample of eating disorder patients (Carter et al, 2012).…”