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

The therapeutic alliance has demonstrated an association with favorable psychotherapeutic outcomes in the treatment of eating disorders (EDs). However, questions remain about the inter-relationships between early alliance, early symptom improvement, and treatment outcome. We conducted a meta-analysis on the relations among these constructs, and possible moderators of these relations, in psychosocial treatments for EDs. Twenty studies met inclusion criteria and supplied sufficient supplementary data. Results revealed small-to-moderate effect sizes, ßs = 0.13 to 0.22 (p < .05), indicating that early symptom improvement was related to subsequent alliance quality and that alliance ratings also were related to subsequent symptom reduction. The relationship between early alliance and treatment outcome was partially accounted for by early symptom improvement. With regard to moderators, early alliance showed weaker associations with outcome in therapies with a strong behavioral component relative to nonbehavioral therapies. However, alliance showed stronger relations to outcome for younger (vs. older) patients, over and above the variance shared with early symptom improvement. In sum, early symptom reduction enhances therapeutic alliance and treatment outcome in EDs, but early alliance may require specific attention for younger patients and for those receiving nonbehaviorally oriented treatments.

Focused vs. Broad enhanced cognitive behavioral therapy for bulimia nervosa with comorbid borderline personality: A randomized controlled trial.

OBJECTIVE: A subset of individuals with bulimia nervosa (BN) have borderline personality disorder (BPD) symptoms, including chronic negative affect and interpersonal problems. These symptoms predict poor BN treatment outcome in some studies. The broad version of Enhanced Cognitive Behavior Therapy (CBT-E) was developed to address co-occurring problems that interfere with treatment response. The current study investigated the relative effects, predictors, and moderators of CBT-E for BN with BPD and co-occurring mood/anxiety disorders. METHOD: Fifty patients with BN and threshold or sub-threshold BPD and current or recent Axis I mood or anxiety disorders were randomly assigned to receive focused CBT-E (CBT-Ef) or broad CBT-E (CBT-Eb) specifically including an interpersonal module and additional attention to mood intolerance. RESULTS: Forty-two percent of the sample reported remission from binge eating and purging at termination. Significant changes across symptom domains were observed at termination and at 6-month follow-up. Though CBT-Ef predicted good outcomes in multivariate models, the severity of affective/interpersonal problems moderated treatment effects: participants with higher severity showed better ED outcomes in CBT-Eb, whereas those with lower severity showed better outcomes in CBT-Ef. Severity of affective/interpersonal BPD symptoms at baseline predicted negative outcomes overall. Follow-up BPD affective/interpersonal problems were predicted by baseline affective/interpersonal problems and by termination EDE score. DISCUSSION: This study supports the utility of CBT-E for patients with BN and complex comorbidity. CBT-Ef appears to be more efficacious for patients with relatively less severe BPD symptoms, whereas CBT-Eb appears to be more efficacious for patients with more severe BPD symptoms.

The role and meaning of eating disorder therapist experience level.

Warren, Schafer, Crowley, and Olivardia's (2013, pp. 553-564) study reports that therapist experience level in the treatment of eating disorders (EDs) is predictive of burnout. What contributes to "experience level" beyond years of training, however, has not been well described. There may be unique factors to working with patients with EDs, particularly among early career clinicians, that influence the experience of treating this unique population. The purpose of this comment is to identify different aspects of therapist experience and how these factors may influence therapist burnout in the treatment of EDs. Specific ways to address challenging experiences early in training are also proposed. Three specific areas of therapist experience that may contribute to burnout were described: (1) tendencies to overprescribe interventions and problem-solve; (2) overidentification with patients; and (3) the influence of a previous ED history on the treatment process. Specific techniques in the supervision of early career clinicians, engagement in one's own psychotherapy, as well as anticipating intrapersonal challenges that this population is likely to inspire are important areas for intervention.

Clinician reactions to patients with eating disorders: a review of the literature.

OBJECTIVE: The delivery of psychiatric services may be affected by clinicians' negative reactions to treatment-resistant or stigmatized patient groups. Some research has found that clinicians across professional disciplines react negatively to patients with eating disorders, but empirical data related to this topic have not been systematically reviewed. The authors sought to review all published empirical studies of clinician reactions to patients with eating disorders in order to characterize negative reactions to these patients and identify patient or clinical factors associated with negative reactions. METHODS: The authors conducted a comprehensive online search for all published studies of clinician reactions in regard to patients with eating disorders. The reference lists of articles found in the literature search were examined to identify additional studies. RESULTS: Twenty studies, published between 1984 and 2010, were found. Clinician negative reactions in regard to patients with eating disorders typically reflected frustration, hopelessness, lack of competence, and worry. Inexperienced clinicians appeared to hold more negative attitudes toward patients with eating disorders than toward other patient groups, but experienced psychotherapists did not experience strong negative reactions to patients with eating disorders. Medical practitioners consistently reported strong feelings of lack of competence in treating eating disorders. Negative reactions to patients with eating disorders were associated with patients' lack of improvement and personality pathology and with clinicians' stigmatizing beliefs, inexperience, and gender. CONCLUSIONS: Research about the impact of negative clinician attitudes toward patients with eating disorders on psychiatric service delivery, including multivariate analyses using larger samples, comparison groups, validated instruments, and experimental methods, is much needed.

Alliance-focused therapy for anorexia nervosa: integrative relational and behavioral change treatments in a single-case experimental design.

Evidence supporting outpatient treatments for anorexia nervosa (AN) is severely lacking, due to low retention and poor outcome. One explanation for drop-out is weak treatment alliances. A single-case experimental analysis accompanied by in-depth qualitative description is presented for Ms. O, who received a novel treatment for AN called Alliance Focused Treatment (AFT) that attends to ruptures in the alliance, interpersonal difficulties and emotional avoidance. At intake Ms. O met diagnostic criteria for AN, Major Depressive Disorder, and Social Phobia. She was characterized as having symptoms of Obsessive Compulsive, Avoidant, and Depressive personality disorders. Treatment began with a Baseline followed by the experimental (AFT) and comparison treatments (Behavioral Change Treatment [BCT]) using a replicated experimental single-case phase change design. Graphs of slopes of kilocalorie and alliance change facilitated observation of treatment effects. Ms. O participated in 16 sessions of AFT and 8 sessions of BCT with specific benefits. Ratings of the treatment alliance were consistently high and she evidenced significant changes in weight, quality of life, and personality pathology. Associations between rupture/repair episodes and kilocalorie increases were observed. The utility of the treatment relationship in facilitating emotional expression was evident. At posttreatment, Ms. O endorsed cognitive AN symptoms, although these were not explicitly treated. This study provides preliminary support for the feasibility and effect of AFT and BCT, and highlights the importance of the alliance in treating adults with AN. Further research on emotion regulation in AN and its effect on the treatment relationship are needed.

Adolescent eating disorders: treatment and response in a naturalistic study.

This naturalistic study investigated the treatment and outcome of adolescents with eating disorders (EDs) in the community. Clinicians from a practice-research network provided data on ED symptoms, global functioning, comorbidity, treatment, and outcome for 120 adolescents with EDs. ED "not otherwise specified" was the most common ED diagnosed. After an average of 8 months of treatment, about one third of patients had recovered, with patients with anorexia nervosa showing the most improvement. Clinicians utilized a range of psychotherapy interventions and two thirds of the patients had received adjunct psychoactive medication. Although CBT showed the strongest association with outcome in a subsample characterized by poor relational/personality functioning, dynamic therapy was associated with better global outcome in the overall sample.

Impulsivity and personality variables in adolescents with eating disorders.

Impulsivity among individuals with eating disorders (EDs) is associated with severe comorbidities and poor treatment outcome. However, research investigating the construct of impulsivity in EDs is limited. The objectives of the present study were to characterize multiple dimensions of impulsivity in adolescents with EDs; determine if differences in impulsivity were associated with ED diagnosis and/or broader personality traits; and explore the relationship between impulsivity and etiologically significant variables. Experienced clinicians from a practice-research network provided data on ED symptoms, impulsive characteristics, personality pathology, The Diagnostic and Statistical Manual of Mental Disorders comorbidity, and family and developmental history for 120 adolescent patients with EDs. Three distinct types of impulsivity were identified: general, acting out, and aggressive/destructive. The impulsivity types showed specific relationships to ED diagnosis, broader personality factors, individual histories of adverse (traumatic) events, and family histories of externalizing disorders, supporting the importance of taking, assessing, and addressing impulsivity in ED research and treatment.

Countertransference reactions to adolescents with eating disorders: relationships to clinician and patient factors.

OBJECTIVE: Clinical report suggests that therapists have strong and sometimes difficult-to-manage reactions to patients with eating disorders (EDs); however, systematic research is largely absent. The purpose of this study was to explore the emotional responses, or countertransference (CT) reactions, clinicians experience when working with patients with EDs, and to identify clinician, patient, and therapy variables associated with these responses. METHOD: One hundred twenty clinicians reported on multiple variables related to an adolescent female patient they were treating for an ED. RESULTS: Six patterns of reactions were identified: angry/frustrated, warm/competent, aggressive/sexual, failing/incompetent, bored/angry at parents and overinvested/worried feelings. The factors showed meaningful relationships across clinician demographics, patient characteristics, and treatment techniques. DISCUSSION: Overall, clinician's reactions were most frequently associated with the clinician's gender, patient's level of functioning and improvement during treatment, and patient personality style. These issues have important implications for treatment, training and supervision.

Personality subtypes in adolescents with eating disorders: validation of a classification approach.

BACKGROUND: Research has identified three personality subtypes in adults with eating disorders (EDs): a high-functioning, an undercontrolled, and an overcontrolled group. The current study investigated whether similar personality prototypes exist in adolescents with EDs, and whether these personality prototypes show relationships to external correlates indicative of diagnostic validity. METHODS: Experienced clinicians from an adolescent practice-research network provided data on ED symptoms, DSM-IV comorbidity, personality pathology, and family and developmental history for 120 adolescent patients with EDs. RESULTS: Consistent with the findings from the adult literature, three types of personality pathology emerged in adolescents: High-functioning/Perfectionistic, Emotionally Dysregulated, and Avoidant/Depressed. The High-functioning prototype showed negative associations with comorbidity and positive associations with treatment response. The Emotionally Dysregulated prototype was specifically associated with externalizing Axis I and Cluster B Axis II disorders, poor school functioning, and adverse events in childhood. The Avoidant/Depressed prototype showed specific associations with internalizing Axis I and Clusters A Axis II disorders, poor peer relationships, poor maternal relationships, and internalizing disorders in first-degree relatives. CONCLUSIONS: These data support the presence of at least three diagnostically meaningful personality prototypes in adolescents with EDs, similar to those found previously in adults. Diagnosis of adolescents with EDs may be usefully supplemented by the assessment of personality style.