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Eating Disorders: The Journal of Treatment & Prevention Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uedi20
The Role of the Therapeutic Alliance in Eating Disorder Treatment Outcomes: A Systematic Review a
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Shannon Zaitsoff , Rachelle Pullmer , Maeve Cyr & Hilary Aime
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Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada Published online: 20 Oct 2014.
Click for updates To cite this article: Shannon Zaitsoff, Rachelle Pullmer, Maeve Cyr & Hilary Aime (2015) The Role of the Therapeutic Alliance in Eating Disorder Treatment Outcomes: A Systematic Review, Eating Disorders: The Journal of Treatment & Prevention, 23:2, 99-114, DOI: 10.1080/10640266.2014.964623 To link to this article: http://dx.doi.org/10.1080/10640266.2014.964623
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Eating Disorders, 23:99–114, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2014.964623
The Role of the Therapeutic Alliance in Eating Disorder Treatment Outcomes: A Systematic Review SHANNON ZAITSOFF, RACHELLE PULLMER, MAEVE CYR, and HILARY AIME Downloaded by [University of Otago] at 09:57 24 July 2015
Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada
The therapeutic alliance has proven to be an important construct in psychotherapy outcomes research for numerous psychiatric disorders. Given that dropout rates from treatment are especially high for individuals with eating disorders, it is critical to clarify the role that the therapeutic alliance plays in predicting treatment outcomes for this specific population. MEDLINE, CINAHL, and PsycINFO databases were systematically reviewed for studies that formally measured the therapeutic alliance construct and at least one other treatment variable in the context of eating disorder treatment. We identified 19 studies that indicate the therapeutic alliance may be an important factor in eating disorder treatment, yet reflect on the paucity of research on this topic in the context of treatment outcomes for both adult and adolescent populations. Current trends and limitations in the literature are highlighted to guide future research and ultimately improve clinical outcomes for patients with eating disorders.
INTRODUCTION Individuals with eating disorders are notoriously ambivalent to change, and drop-out rates from treatment are particularly high among this clinical population (DeJong, Broadbent, & Schmidt, 2011; Fassino, Piero, Tomba, & Abbate-Daga, 2009; Geller, Williams, & Srikameswaran, 2001). Often, individuals with anorexia nervosa deny the seriousness of the disorder and are referred to treatment by others, making these patients particularly difficult to Address correspondence to Rachelle Pullmer, Department of Psychology, Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6, Canada. E-mail: [email protected] 99
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engage in therapy (Vitousek, Watson, & Wilson, 1998). Individuals with other distressing eating disorder symptoms (i.e., binge eating, purging, and other compensatory behaviors) may also experience ambivalence about recovery, and demonstrate resistance to change detrimental dietary behaviors (Geller, Zaitsoff, & Srikameswaran, 2005; Serpell & Treasure, 2001). To effectively engage and treat individuals with eating disorders, a clear understanding of the therapeutic alliance in eating disorder treatment outcomes is of paramount importance. Bordin’s pantheoretical model of working alliance is one of the most frequently cited definitions of the therapeutic alliance (Bordin, 1979). In Bordin’s view, the working alliance is contingent on the constructive collaboration between the therapist and their patient, which involves the development of an emotional connection (bond), unanimity of therapeutic objectives (goal), and cooperative efforts toward change (task). To date, very little research has been conducted on the role that the therapeutic alliance plays in predicting treatment outcomes for eating disorder patients. However, in the past century, research on the alliance-outcome association for other psychiatric disorders has accumulated in an overwhelming fashion. Across different measures and definitions of alliance, various therapeutic modalities, and diverse patient diagnoses, the therapeutic alliance is consistently associated with treatment outcome (Friedlander, Escudero, Heatherington, & Diamond, 2011; Horvath & Symonds, 1991; Karver, Handelsman, Fields, & Bickman, 2006; Martin, Garske, & Davis, 2000; McLeod, 2011; Shirk & Karver, 2003; Shirk, Karvey, & Brown, 2011). Given the robustness of the alliance-outcome association in other clinical populations, and general resistance to change of patients with eating disorders, the therapeutic alliance may be an essential factor contributing to treatment outcomes (de la Rie, Noordenbos, Donker, & van Furth, 2008; Swain-Campbell, Surgenor, & Snell, 2001; Travis, Heywood-Everett, & Hill, 2013; Wright & Hacking, 2012). However, despite the necessity of research on the alliance-outcome association for patients with eating disorders, this topic has been under-studied relative to research in individuals with other psychiatric disorders. To date, only one review has attempted to summarize the research on this topic. However, the researchers failed to extensively search numerous databases, and did not focus on studies examining the role that alliance plays in predicting treatment efficacy (Antoniou & Cooper, 2013). To accurately understand research on the therapeutic alliance in eating disorder treatment, a more comprehensive literature review that summarizes research across eating disorder diagnoses, ages, and treatment settings is needed. Thus, the primary purpose of this review is to describe and thematically analyze extant literature on the role that the therapeutic alliance plays in predicting treatment outcomes for patients with eating disorders.
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METHODS
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Study Selection The data extraction process was performed according to the guidelines outlined by the PRISMA Statement (Preferred Reporting Items for Systematic reviews and Meta-Analyses; Moher, Liberati, Tetzlaff, Altmen, & The PRISMA Group, 2009). PsycINFO (1972 to July 2014), MEDLINE (1946 to July 2014), and CINAHL (1982 to July 2014) databases were searched using the EBSCO interface for studies conducted on whether the therapeutic alliance predicts treatment outcomes for patients with eating disorders. The search outline was created in PsycINFO and applied to other databases (see Appendix). The Cochrane library was searched for additional publications. After eliminating duplicate studies, the titles, abstracts, and full-length articles of identified studies were reviewed independently by two authors (R.P. and H.A.; Figure 1). There was no uncertainty about whether or not studies met inclusion criteria. Additional studies were identified via hand searches of the reference section of already identified papers, and by conducting cited reference searches in the Web of Science database (1898 to July 2014) for all included studies.
Study Inclusion and Evaluation Criteria Studies were included if they (a) quantitatively measured the therapeutic alliance, (b) quantitatively measured at least one other treatment variable (e.g., dropout, baseline symptom severity), (c) were published in peer-reviewed journals, and (d) were written in the English language. All included articles were reviewed in detail and thematically analyzed according to age and diagnostic classification. Current themes and limitations in the literature as well as areas of future research are addressed below.
RESULTS Nineteen articles published between 1994 and 2014 met inclusion criteria (Table 1). Seven different measures of therapeutic alliance were used across studies, irrespective of the different versions of these measures. The perspectives from which the therapeutic alliance was measured varied across the studies, and included client only (10 studies), observer only (four studies), parent only (one study), or some combination of patient, parent, and treatment-provider (four studies) ratings. Articles pertaining to the role that the therapeutic alliance plays in predicting treatment outcomes for adult and adolescent eating disorders are categorized below according to diagnostic classification (i.e., anorexia nervosa, bulimia nervosa, binge eating disorder, and mixed eating disorder samples).
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S. Zaitsoff et al. References identified from databases (n = 371)
References identified after duplicates removed (n = 222)
Reviewer 1: Screening of all titles and/or abstracts
Reviewer 2: Screening of all titles and/or abstracts
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Rejections based on titles and/or abstracts (n = 198)
Rejections based on titles and/or abstracts (n = 203)
Reviewer 1: Full text reviewed for inclusion criteria (n = 24)
Reviewer 2: Full text reviewed for inclusion criteria (n = 19)
Excluded references (n = 6) 6 Not on alliance predicting outcome
Excluded references (n = 1) 1 Not on alliance predicting outcomes
Reviewer 1: Included studies (n = 18)
Included crossreferences (n = 1)
Reviewer 2: Included studies (n = 18)
Consensus (n = 18)
Studies included in systematic review (n = 19)
FIGURE 1 Literature review flow chart.
Bulimia Nervosa The present literature search yielded eight studies pertaining to the allianceoutcome association for treatment of bulimia nervosa. Of these eight studies, seven were conducted with adult populations and one with adolescents. Notably, all but one (i.e., Raykos et al., 2014) of these studies are randomized controlled trials (RCTs). With respect to studies on the alliance-outcome association for adult bulimia nervosa, four suggest that the alliance-outcome association exists (Constantino, Arnow, Blasey, & Agras, 2005; Loeb et al., 2005; Treasure et al., 1999; Wilson et al., 1999). In particular, two RCTs have demonstrated a negative association between the therapeutic alliance and post-treatment purge
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Bourion-Bedes et al. (2013) Brown et al. (2013) Forsberg et al. (2013) Sly et al. (2013)
IT/ST program CBT AFT and FBT Hospitalized treatment
65 78
90
FBT FBT FBT
Inpatient and day hospital treatment CBT-E
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41 59 14
Anorexia nervosa (AN) Pereira et al. (2006) Ellison et al. (2012) Isserlin & Couturier (2012)
43
Hartmann et al. (2010)
114
80
Zaitsoff et al. (2008)
Raykos et al. (2014)
CBT and IPT
81 FBT and SPT
CBT and SPT CBT and IPT CBT and IPT
CBT and MET
120 220 220
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Bulimia nervosa (BN) Treasure et al. (1999)
Treatment
Wilson et al. (1999) Wilson et al. (2002) Constantino et al. (2005) Loeb et al. (2005)
N
Citation
TABLE 1 Included Studies
27.7
25.7 Not reported
15.3
15.1 14.6 14.0
Not reported
25.1
16.1
28.9
18-45 Not reported 28.1
28.8
Mean age (years)
WAI-SR
WAI-SR WAI
HAQ
WAI WAI SOFTA
HAQ
HAQ
HRq
VTAS
HRq HRq HAQ
WAI
Therapeutic alliance measure
C
C O
C, T, P
O P O
C
C, T
C
O
C C C
C, T
Alliance type
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N
N Y
N
N N N
N
Y
Y
Y
Y Y Y
Y
RCT
(Continued)
Treatment completion
No significant association Partial remission status
Weight gain; dropout rates Weight gain; dropout rates Dropout rates; post-treatment weight gain; remission in ED cognitions Time to achieve target weight
No significant association
Improvements in binge-eating and purging Remission No significant association Post-treatment purge frequency Post-treatment purge frequency Binge and purge frequency throughout treatment No significant association
Outcomes associated with the therapeutic alliance
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42 238
Waller et al. (2012) Tasca et al. (2012)
Hospitalized treatment CBT Group-based day treatment
25.4c 25.8 27.2 26.1
46.9b 44.1
33.4
Mean age (years)
WAI-SR CALPAS-G
WAI
BPSR-P
HRQ
Therapeutic alliance measure
C C
C, T
C
P
Alliance type
N N
N
Y
Y
RCT
No significant association Urge to restrict eating behaviors
Premature discharge
Premature termination
Overall ED symptoms; post-treatment weight change; depressive symptoms
Outcomes associated with the therapeutic alliance
Note: CBT = cognitive behavioral therapy; MET = motivational enhancement therapy; SPT = supportive psychotherapy; IPT = interpersonal psychotherapy; FBT = family based therapy; CBT-E = enhanced cognitive behavioral therapy; IT/ST program = individual and supportive therapy program; AFT = adolescent-focused therapy; SE-AN = specialist supportive clinical management for the treatment of severe and enduring AN; Group-BWLT = group behavior weight loss therapy; WAI = Working Alliance Inventory; HRq = Helping Relationships Questionnaire; HAQ = Helping Alliance Questionnaire; VTAS = Vanderbilt Therapeutic Alliance Scale (modified version); SOFTA = System for Observing Family Therapy Alliances; WAI-SR = Working Alliance Inventory – Revised Short Form; BPSR-P = Bern Post-Session Reports for Patients; CALPAS-G = California Therapeutic Alliance Scales Group Patient Version; C = client-reported; T = treatment provider-reported; O = observer-reported; P = parent-reported. a Sample included participants aged 16 and above. b Completers (n = 51; M = 46.9 years); dropouts (n = 27; M = 44.1 years). c Completers (n = 21; M = 25.4 years); dropouts (n =10; M = 25.8 years).
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Mixed eating disorders Gallop et al. (1994)
Group-CBT and group- BWLT
Binge eating disorder (BED) Fluckiger et al. 78 (2011)
Treatment CBT and SE-AN
N
63
Stiles-Shields et al. (2013)
Citation
TABLE 1 Continued
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frequency after accounting for baseline purge frequency (Constantino et al., 2005; Loeb et al., 2005). While one of these studies found that only alliance measured early in treatment (session 6) was predictive of post-treatment purge frequency (Loeb et al., 2005), the other study found that alliance measured early (session 4) and in the middle (session 12) of treatment was predictive of the same outcome (Constantino et al., 2005). Further, two studies demonstrated a positive association between the therapeutic alliance and overall bulimia nervosa symptoms (Treasure et al., 1999; Wilson et al., 1999). Treasure and colleagues (1999) assessed the therapeutic alliance with the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989), which assess three key aspects of the therapeutic alliance: (a) the quality of the bond between the patient and therapist, (b) agreement on tasks to be carried out and (c) agreement on goals to be achieved. They found that both therapist and patient ratings of task were positively related to improvements in binge eating and vomiting. Patient (but not therapist) ratings of goal were also significantly related to improvements in binge eating and vomiting. However, neither therapist nor patient ratings of bond were significantly correlated with improvement in overall symptomatology. Wilson and colleagues (1999) found a more general positive association, demonstrating that patients’ ratings of overall therapeutic alliance predicted remission status for women receiving cognitive behavioral therapy or supportive psychotherapy. Conversely, three studies found no significant association between the therapeutic alliance and treatment outcomes for adult patients with bulimia nervosa (Hartmann, Orlinsky, Weber, Sandholz, & Zeeck, 2010; Raykos et al., 2014; Wilson, Fairburn, Agras, Walsh, & Kraemer, 2002). Hartmann and colleagues (2010) suggest that experiences of therapy between sessions may be more pertinent to outcome than in-session experiences, as researchers have found that patient efforts to apply therapy between sessions was a better predictor of outcome than ratings of the therapeutic alliance. Raykos and colleagues (2014) assessed the therapeutic alliance at three time-points during enhanced cognitive behavioral therapy for bulimia nervosa but found no evidence that alliance was related to treatment outcomes. Similarly, Wilson and colleagues (2002) assessed the therapeutic alliance during a RCT comparing treatments for bulimia nervosa, and found no evidence that the therapeutic alliance mediated treatment outcome. With respect to research on the alliance-outcome association for adolescent bulimia nervosa, one study was identified (Zaitsoff, Doyle, Hoste, & le Grange, 2008). Zaitsoff and colleagues (2008) found that reductions in binge and purge behaviors over the course of treatment were not related to alliance in adolescents receiving family-based treatment for bulimia nervosa. However, for adolescents receiving supportive psychotherapy, a stronger alliance midway through treatment was related to a greater percentage reduction in both binge eating and purging over the course of treatment.
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Anorexia Nervosa Eight studies were identified that investigated the role of the therapeutic alliance in the context of treatment for anorexia nervosa. Of these eight studies, three were conducted with adult populations and five with adolescents. Of the studies pertaining to the treatment of adult anorexia nervosa, two studies demonstrate support for the existence of an alliance-outcome association (Sly, Morgan, Mountford, & Lacey, 2013; Stiles-Shields et al., 2013). Sly and colleagues (2013) found that changes in the therapeutic alliance do not predict premature treatment termination. However, therapeutic alliance measured at admission was a significant predictor of treatment completion. Another study not only found that therapeutic alliance was associated with outcomes, but also that this association became stronger over time (StilesShield et al., 2013). While therapeutic alliance measured early in treatment significantly predicted some eating disorder symptomatology (i.e., Restraint and Shape Concern subscales of the Eating Disorder Examination; Cooper & Fairburn, 1987), therapeutic alliance measured at the end of treatment predicted weight change, depressive symptomatology, and all eating disorder symptomatology at the end of treatment and at follow-up (12 months post-treatment; Stiles-Shield et al., 2013). In an exploratory study of patients receiving manualized cognitive behavioral therapy for anorexia nervosa, researchers investigated potential relationships between patient-rated alliance and treatment outcome (weight gain and drop out), both of which were measured throughout the course of treatment (Brown, Mountford, & Waller, 2013). Early therapeutic alliance (measured at session 6) was not significantly associated with subsequent weight gain (early, late, or overall) or dropout. Rather, greater early and overall weight gain was associated with stronger subsequent therapeutic alliance. Based on these findings, the authors suggest that increased emphasis on weight gain, as opposed to the therapeutic relationship, may be particularly beneficial in early stages of treatment for adults with anorexia nervosa. Five studies have investigated the relationship between therapeutic alliance and outcome in the context of adolescent treatment for anorexia nervosa (Bourion-Bedes et al., 2013; Ellison et al., 2012; Forsberg et al., 2013; Isserlin & Couturier, 2012; Pereira, Lock, & Oggins, 2006). Several of these studies suggest that parent and adolescent ratings of alliance are differentially associated with outcome. Three studies have found that parent-rated alliance is positively associated with adolescent post-treatment weight gain and negatively associated with dropout in family based treatment for adolescent anorexia nervosa (Ellison et al., 2012; Isserlin & Couturier, 2012; Pereira et al., 2006). In contrast, adolescent-rated alliance has been positively linked to remission in eating disorder cognitions (Isserlin & Couturier, 2012) as well as early weight gain (Pereira et al., 2006), and negatively linked to time to
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recovery (Bourion-Bedes et al., 2013). A recent study conducted by Ellison and colleagues (2012) further differentiated mothers’ and fathers’ alliance ratings in family based treatment for adolescent anorexia nervosa, finding that a strong mother-therapist alliance predicts greater adolescent weight gain and less dropout, while a strong father-therapist alliance predicts less adolescent weight gain throughout treatment. Interestingly, Forsberg and colleagues (2013) report that observer-rated alliance differentially predicts full and partial remission for adolescents in treatment for anorexia nervosa (Forsberg et al., 2013). Specifically, they found that observer-rated alliance positively predicts partial remission status (i.e., greater than the 85th percentile for mean body weight for age, height, and gender), but not full remission status (i.e., greater the 95th percentile) at the end of treatment, regardless of whether the adolescent received family based treatment or adolescent-focused therapy.
Binge Eating Disorder Only one study was identified that investigated the role of the therapeutic alliance in the treatment of binge eating disorder. The one identified study provides preliminary evidence that therapeutic alliance predicts treatment outcomes for adult patients with binge eating disorder (Fluckiger et al., 2011). Specifically, an RCT comparing group cognitive behavioral therapy and group behavior weight loss therapy determined that patient-rated alliance predicts premature termination in patients who express discontentment with therapy, while controlling for type of treatment.
Mixed Eating Disorders To date, three studies have investigated the alliance-outcome association in a mixed eating disorder sample (i.e., samples consisting of patients with anorexia nervosa, bulimia nervosa, or eating disorders not otherwise specified; Gallop, Kennedy, & Stern, 1994; Tasca & Lampard, 2012; Waller, Evans, & Stringer, 2012). All three of these studies were conducted in adult populations. One study assessed the therapeutic alliance from the perspectives of both staff members and patients on an inpatient unit for anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified, determining that low patient-rated alliances predicted premature discharge from treatment (Gallop et al., 1994). The researchers reported that staff perceptions of alliance were not predictive of premature discharge, suggesting that measuring the alliance from the patient’s perspective may be of particular consequence in inpatient settings. In a more recent study, Tasca and Lampard (2012) investigated the relationship between patients’ self-rated alliance to their treatment group and symptom improvement in a day treatment program
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for various eating disorders, determining that the alliance-improvement relationship was reciprocal. In particular, the researchers reported that reduction in patients’ urges to restrict was both predictive of and predicted by patients’ alliance to the group throughout the course of therapy. Finally, Waller and colleagues (2012) found that the therapeutic alliance was not related to levels of eating pathology at any stage of treatment.
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DISCUSSION The role that the therapeutic alliance plays in predicting treatment outcomes for patients with eating disorders remains understudied relative to other clinical populations. This review highlights a number of emerging trends in the literature on the alliance-outcome association in eating disorder populations that are in need of future research to further elucidate and delineate this relationship according to diagnostic classification, age, and treatment modality. Current research on the therapeutic alliance indicates that the time at which alliance is assessed may be influential in predicting outcome. While two studies included in this review demonstrate a negative association between alliance and post-treatment purging frequency in an RCT comparing cognitive behavioral therapy and interpersonal therapy for adult bulimia nervosa (Constantino et al., 2005; Loeb et al., 2005), these studies differed in the time in treatment at which alliance was found to have the most predictive validity. Results regarding the predictive validity of alliance in family based treatment for adolescents with eating disorders also differ depending on when alliance is assessed. To elaborate, while Zaitsoff and colleagues’ (2008) findings support the predictive validity of alliance at mid-treatment, two other studies support the importance of early and late alliance in family based treatment (Isserlin & Couturier, 2012; Pereira et al., 2006). It also appears that researchers have different definitions of early, middle, and late alliance. Despite the fact that the two studies noted above on adult treatment for bulimia nervosa assessed alliance over 19 sessions of treatment, one study assessed early alliance at session 6 (Loeb et al., 2005), whereas the other study measured the same construct at session 4 (Constantino et al., 2005). Assessments of alliance are similarly heterogeneous in studies involving family based treatment for adolescent eating disorders, with measurements of early, middle, and late alliance taking place between sessions 1 to 9, 7 to 13, and 4 to 27, respectively (Isserlin & Couturier, 2012; Pereira et al., 2006; Zaitsoff et al., 2008). These discrepancies in timing of alliance assessment mimics alliance research in non-eating disorder populations (Elvins & Green, 2008; Horvath, Del Re, Fluckiger, & Symonds, 2011). However, a recent meta-analysis on the alliance-outcome association in non-eating disorder populations indicates
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that the alliance-outcome association remains significant irrespective of the time of alliance assessment (Horvath et al., 2011). Nevertheless, given the lack of research on the alliance-outcome association in patients with eating disorders, and initial evidence that timing with regard to alliance assessment may be important, it is imperative that future research is conducted to elucidate whether changes in the therapeutic alliance throughout the course of treatment differentially impact outcome variables. Another interesting trend in this developing field of research pertains to the discrepancy between parent and adolescent reports of alliance in treatment for adolescent eating disorders (Isserlin & Couturier, 2012; Pereira et al., 2006). In studies on the alliance-outcome association in non-eating disorder youth, researchers have concluded that youth and parent ratings of alliance are not interchangeable because the two perspectives are weakly correlated and associated with different outcome variables (Hawley & Garland, 2008; Zack, Castonguay, & Boswell, 2007). Specifically, parent-rated alliance has been found to predict variables related to treatment retention (i.e., cancellations, no-shows, and dropout; Garcia & Weisz, 2002; Hawley & Garland, 2008; Hawly & Weisz, 2005; Pereira et al., 2006), whereas youth-rated alliance has been found to directly predict symptom improvement (Hawley & Garland, 2008; Hawley & Weisz, 2005). Based on the results of the present review, it appears that the differential impact of parent and adolescent alliance ratings may carry over into treatment for adolescent eating disorders. Three studies included in this review demonstrate that parent-rated alliance is associated with adolescent posttreatment weight gain and dropout in family based treatment for adolescent eating disorders (Ellison et al., 2012; Isserlin & Couturier, 2012; Pereira et al., 2006). Two of the same studies demonstrate that adolescent-rated alliance is linked to remission on psychological variables in addition to post-treatment weight gain (Isserlin & Couturier, 2012; Pereira et al., 2006). Thus, as is the case for non-eating disorder populations, both adolescent and parent reports of therapeutic alliance appear to be important and related to different aspects of treatment efficacy. While this differentiation may result from the varying responsibilities that parents and adolescents have in eating disorder treatment (e.g., parents are responsible for ensuring their children attend treatment), more research on this topic is needed. Lastly, although it may seem intuitive that focusing on symptom reduction in treatment-resistant populations may hinder the development of therapeutic alliance, the development of the therapeutic alliance may not necessarily predate symptom improvement. Several studies with patients across diagnostic groups have found that symptom improvement either predicts development of the therapeutic alliance or that the relationship is bi-directional (Brown et al., 2013; Tasca & Lampard, 2012; Wilson et al., 1999). For example, one study determined that early weight gain in adults with anorexia nervosa enhanced the development of alliance (Brown et al.,
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2013), while another found that reductions in urges to restrict eating behaviors both predicted, and were predicted by, a stronger therapeutic alliance (Tasca & Lampard, 2012). The high rates of treatment retention and high ratings of alliance in family-based treatment for adolescents also suggest that an early focus on symptom reduction does not necessarily hinder development of the therapeutic alliance (Pereira et al., 2006; Zaitsoff et al., 2008). It may be that when individuals are able to make changes to their symptoms, they view their therapist as more trustworthy and helpful. Alternatively, the physiological changes associated with weight restoration may allow patients to develop stronger connections with their treatment providers. Further research employing more sophisticated data analytic techniques is needed to disentangle the pattern of associations between symptom improvement and development of the therapeutic alliance across eating disorder diagnoses and treatment modalities.
Limitations of Current Research Despite the trends that emerged in the literature thus far, limitations of this field of research must be noted. The paucity of research on the allianceoutcome association in eating disorder patients indicates that the role of the therapeutic alliance—the most extensively studied construct in the field of psychotherapy—remains poorly understood in eating disorder treatment. This not only renders research in this area antiquated, but also may limit the extent to which clinicians can provide effective treatment to patients struggling with eating disorders. Furthermore, the multiple measures used to assess the therapeutic alliance in the context of eating disorder treatment make it difficult to compare results across studies. This lack of consensus on the assessment of therapeutic alliance mirrors the methodological limitations of the general literature on the therapeutic alliance, where researchers have noted the multiplicity of alliance measures that exist, and have argued that a consensus must be reached before our understanding of the therapeutic alliance can progress any further (Elvins & Green, 2008; Horvath et al., 2011). With these recommendations in mind, future studies on the therapeutic alliance in eating disorder treatment would ideally involve further testing of the psychometric properties of existing therapeutic alliance measures to identify the best way to measure alliance in patients with eating disorders. The use of consistent measures will facilitate comparisons of results across studies and ultimately enhance our understanding of the alliance-outcome association in the treatment of eating disorders. Another profound limitation in this field of research that has been highlighted by this review is the lack of empirical focus on the outcome-alliance association in the specific context of treatment for adult anorexia nervosa. While the therapeutic alliance may have a significant impact on the efficacy
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of treatments for resistant anorexia nervosa patients, this potentially pivotal construct has only been applied in three studies to adult anorexia nervosa treatment (Brown et al., 2013). This is likely due to the fact that RCTs for anorexia nervosa are not cost effective, due to high dropout rates (DeJong et al., 2011). Given these constraints, alternate methods, such as the use of case studies or qualitative research, may be useful in examining the alliance-outcome association in patients with anorexia nervosa.
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CONCLUSION A vast amount of research in various clinical populations suggests that the therapeutic alliance may be a particularly integral factor affecting treatment outcomes for eating disorder patients. Overall, the findings from this review indicate that while the alliance-outcome association is likely significant for patients with anorexia nervosa, the importance of this association is unclear for individuals with bulimia nervosa, binge eating disorder, and mixed eating disorder symptoms. It is therefore imperative that methodologically sound research in this field continues in order to further clarify and delineate the role the that therapeutic alliance plays in predicting treatment outcomes for adult and adolescent patients with varying eating disorder diagnoses.
REFERENCES Antoniou, P., & Cooper, M. (2013). Psychological treatments for eating disorders: What is the importance of the quality of the therapeutic alliance for outcomes? Counselling Psychology Review, 28, 34–46. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy Theory, Research and Practice, 16, 352–360. Bourion-Bedes, S., Baumann, C., Kermarrec, S., Ligier, F., Feillet, F., Bonnmains, C., . . . Kabuth, B. (2013). Prognostic value of early therapeutic alliance in weight recovery: A prospective cohort of 108 adolescents with anorexia nervosa. Journal of Adolescent Health, 52, 344–350. Brown, A., Mountford, V., & Waller, G. (2013). Therapeutic alliance and weight gain during cognitive behavioural therapy for anorexia nervosa. Behaviour Research and Therapy, 51, 216–220. Constantino, M., Arnow, B. A., Blasey, C., & Agras, W. S. (2005). The association between patient characteristics and the therapeutic alliance in cognitive-behavioural and interpersonal therapy for bulimia nervosa. Journal of Consulting and Clinical Psychology, 73, 203–211. doi: 10.1037/0022-006X.73.2.203 Cooper, Z., & Fairburn, C. G. (1987). The eating disorder examination: A semistructured interview for the assessment of the specific psychopathology of eating disorders. International Journal of Eating Disorders, 6, 1–8.
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de la Rie, S., Noordenbos, G., Donker, M., & van Furth, E. (2008). The quality of treatment of eating disorders: A comparison of the therapists’ and the patients’ perspective. International Journal of Eating Disorders, 41, 307–317. DeJong, H., Broadbent, H., & Schmidt, U. (2011). A systemative review of dropout from treatment in outpatients with anorexia nervosa. International Journal of Eating Disorders, 45, 635–647. Ellison, R., Rhodes, P., Madden, S., Miskovic, J., Wallis, A., Baillie, A., . . . . Touyz, S. (2012). Do the components of manualized family-based treatment for anorexia nervosa predict weight gain? International Journal of Eating Disorders, 45, 609–614. Elvins, R., & Green, J. (2008). The conceptualization and measurement of the therapeutic alliance: An empirical review. Clinical Psychology Review, 28, 1167–1187. doi:10.1016/j.cpr.2008.04.002 Fassino, S., Piero, A., Tomba, E., & Abbate-Daga, G. (2009). Factors associated with dropout from treatment for eating disorders: A comprehensive literature review. BMC Psychiatry, 9, 1–9. doi:10.1186/1471-244X-9-67 Fluckiger, C., Meyer, A., Wampold, B. E., Gassmann, D., Messerli-Burgy, N., & Munsch, S. (2011). Predicting premature termination within a randomized controlled trial for binge-eating patients. Behavior Therapy, 42, 716–725. Forsberg, S., LoTempio, E., Bryson, S., Fitzpatrick, K. K., Le Grange, D., & Lock, J. (2013). Therapeutic alliance in two treatments for adolescent anorexia nervosa. International Journal of Eating Disorders, 46, 34–38. Friedlander, M., Escudero, V., Heatherington, L., & Diamond, G. M. (2011). Alliance in couple and family therapy. Psychotherapy, 48, 25–33. Gallop, R., Kennedy, S. H., & Stern, D. (1994). Therapeutic alliance on an inpatient unit for eating disorders. International Journal of Eating Disorders, 16, 405–410. Garcia, J. A., & Weisz, J. R. (2002). When youth mental health care stops: Therapeutic relationship problems and other reasons for ending youth outpatient treatment. Journal of Consulting and Clinical Psychology, 70, 439–443. Geller, J., Williams, K. D., & Srikmeswaran, S. (2001). Clinician stance on the treatment of chronic eating disorders. European Eating Disorders Review, 9, 365–373. Geller, J., Zaitsoff, S., & Srikmeswaran, S. (2005). Tracking readiness and motivation for change in individuals with eating disorders over the course of treatment. Cognitive Therapy and Research, 29, 611–625. doi:10.1007/s10608-005-5774-1 Hartmann, A., Orlinsky, D., Weber, S., Sandholz, A., & Zeeck, A. (2010). Session and intersession experience related to treatment outcome in bulimia nervosa. Psychotherapy Theory, Research, Practice, Training, 47, 355–370. Hawley, K. M., & Garland, A. F. (2008). Working alliance in adolescent outpatient therapy: Youth, parent, and therapist reports and associations with therapy outcomes. Child and Youth Care Forum, 37, 59–74. Hawley, K. M., & Weisz, J. R. (2005). Youth versus parent working alliance in usual clinical care: Distinctive associations with retention, satisfaction, and treatment outcome. Journal of Clinical Child and Adolesecnt Psychology, 34, 117–128. Horvath, A. O., Del Re, A. C., Fluckiger, C., & Symonds, B. D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9–16.
Downloaded by [University of Otago] at 09:57 24 July 2015
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Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36, 223–233. Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 19–149. Isserlin, L., & Couturier, J. (2012). Therapeutic alliance and family-based treatment for adolescents with anorexia nervosa. Psychotherapy, 49, 46–51. Karver, M. S., Handelsman, J. B., Fields, S., & Bickman, L. (2006). Meta-analysis of therapeutic relationship variables in youth and family therapy: The evidence for different relationship variables in the child and adolescent treatment outcome literature. Clinical Pyschology Review, 26, 50–65. Loeb, K. L., Wilson, G. T., Labouvie, E., Pratt, E., Hayaki, J., Walsh, B. T., & Agras, W. S. (2005). Therapeutic alliance and treatment adherence in two interventions for bulimia nervosa: A study of process and outcome. Journal of Consulting and Clinical Psychology, 73, 1097–1107. doi:10.1037/0022-006X.73.6.1097 Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438–450. McLeod, B. D. (2011). Relation of the alliance with outcomes in youth psychotherapy: A meta-analysis. Clinical Pyschology Review, 31, 603–616. Moher, D., Liberati, A., Tetzlaff, J., & Altman, G. D. (2009). The PRISMA group preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Open Medicine, 3, 123–130. Pereira, T., Lock, J., & Oggins, J. (2006). Role of therapeutic alliance in family therapy for adolescent anorexia nervosa. International Journal of Eating Disorders, 39, 677–684. Raykos, B. C., McEvoy, P. M., Erceg-Hurn, D., Byrne, S., Fursland, A., & Nathan, P. (2014). Therapeutic alliance in Enhanced Cognitive Behavioural Therapy for bulimia nervosa: Probably necessary but definitely insufficient. Behaviour Research and Therapy, 57, 65–71. Serpell, L., & Treasure, J. (2001). Bulimia nervosa: Friend or foe? The pros and cons of bulimia nervosa. International Journal of Eating Disorders, 32, 164–170. Shirk, S. R., & Karver, M. S. (2003). Prediction of treatment outcome from relationship variables in child and adolescent therapy: A meta-analytic review. Journal of Consulting and Clinical Psychology, 71, 452–464. doi: 10.1037/0022-006X.71.3.452 Shirk, S. R., Karver, M. S., & Brown, R. (2011). The alliance in child and adolescent psychotherapy. Psychotherapy, 48, 17–24. doi:10.1037/a0022181 Sly, R., Morgan, J. F., Mountford, V., & Lacey, J. H. (2013). Predicting premature termination of hospitalised treatment for anorexia nervosa: The roles of therapeutic alliance, motivation, and behaviour change. Eating Behaviours, 119–123. Stiles-Shields, C., Touyz, S., Hay, P., Lacey, J. H., Crosby, R. D., Rieger, E., . . . Le Grange, D. (2013). Therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa. International Journal of Eating Disorders, 46, 783–789.
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Swain-Campbell, N. R., Surgenor, L., & Snell, D. (2001). Analysis of consumer perspectives following contact with an eating disorder service. Australian and New Zealand Journal of Psychiatry, 35, 99–103. Tasca, G., & Lampard, A. M. (2012). Reciprocal influence of alliance to the group and outcome in day treatment for eating disorders. Journal of Counseling Psychology, 59, 507–517. doi:10.1037/a0029947 Traviss, G., Heywood-Everett, S., & Hill, A. J. (2013). Understanding the “guide” in self-help for disordered eating: A qualitative process study. Psychology and Psychotherapy: Theory, Research and Practice, 86, 86–104. doi: 10.1111/j.2044-8341.2011.02049.x Treasure, J., Katzman, M., Schmidt, U., Troop, N., Todd, G., & de Silva, P. (1999). Engagement and outcome in the treatment of bulimia nervosa: First phase of a sequential design comparing motivation enhancement therapy and cognitive behavioural therapy. Behaviour Research and Therapy, 37, 405–418. Vitousek, K., Watson, S., & Wilson, G. T. (1998). Enhancing motivation for change in treatment-resistant eating disorders. Clinical Pyschology Review, 18, 391–420. Waller, G., Evans, J., & Stringer, H. (2012). The therapeutic alliance in the early part of cognitive-behavioral therapy for eating disorders. International Journal of Eating Disorders, 45, 63–69. Wilson, G. T., Fairburn, C. C., Agras, W. S., Walsh, B. T., & Kraemer, H. (2002). Cognitive behavioral therapy for bulimia nervosa: Time course and mechanisms of change. Journal of Consulting and Clinical Psychology, 70, 267–274. Wilson, G. T., Loeb, K. L., Walsh, B. T., Labouvie, E., Petkova, E., Liu, X., & Waternaux, C. (1999). Psychological versus pharmacological treatments for bulimia nervosa: Predictors and processes of change. Journal of Consulting and Clinical Psychology, 67, 451–459. Wright, K. M., & Hacking, S. (2012). An angel on my shoulder: A study of relationships between women with anorexia nervosa and healthcare professionals. Journal of Psychiatric and Mental Health Nursing, 19, 107–115. doi: 10.1111/j.1365-2850.2011.01760.x Zack, S. E., Castonguay, L. G., & Boswell, J. F. (2007). Youth working alliance: A core clinical construct in need of empirical maturity. Harvard Review of Psychiatry, 15, 278–288. doi:10.1080/10673220701803867. Zaitsoff, S., Celio Doyle, A., Hoste, R. R., & Le Grange, D. (2008). How do adolescents with bulimia nervosa rate the acceptability and therapeutic relationship in family-based treatment? International Journal of Eating Disorders, 41, 390–398.
APPENDIX: SEARCH OUTLINE 1. Therapeutic alliance OR working alliance OR therapeutic relationship OR therapeutic bond. 2. Eating disorder OR anorex∗ OR bulim∗ OR bing∗ OR purg∗ . 3. Treat∗ OR outcome OR eff∗ . 4. 1 AND 2 AND 3.
Eating Disorders: The Journal of Treatment & Prevention Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uedi20
The Role of the Therapeutic Alliance in Eating Disorder Treatment Outcomes: A Systematic Review a
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Shannon Zaitsoff , Rachelle Pullmer , Maeve Cyr & Hilary Aime
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Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada Published online: 20 Oct 2014.
Click for updates To cite this article: Shannon Zaitsoff, Rachelle Pullmer, Maeve Cyr & Hilary Aime (2015) The Role of the Therapeutic Alliance in Eating Disorder Treatment Outcomes: A Systematic Review, Eating Disorders: The Journal of Treatment & Prevention, 23:2, 99-114, DOI: 10.1080/10640266.2014.964623 To link to this article: http://dx.doi.org/10.1080/10640266.2014.964623
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Eating Disorders, 23:99–114, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2014.964623
The Role of the Therapeutic Alliance in Eating Disorder Treatment Outcomes: A Systematic Review SHANNON ZAITSOFF, RACHELLE PULLMER, MAEVE CYR, and HILARY AIME Downloaded by [University of Otago] at 09:57 24 July 2015
Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada
The therapeutic alliance has proven to be an important construct in psychotherapy outcomes research for numerous psychiatric disorders. Given that dropout rates from treatment are especially high for individuals with eating disorders, it is critical to clarify the role that the therapeutic alliance plays in predicting treatment outcomes for this specific population. MEDLINE, CINAHL, and PsycINFO databases were systematically reviewed for studies that formally measured the therapeutic alliance construct and at least one other treatment variable in the context of eating disorder treatment. We identified 19 studies that indicate the therapeutic alliance may be an important factor in eating disorder treatment, yet reflect on the paucity of research on this topic in the context of treatment outcomes for both adult and adolescent populations. Current trends and limitations in the literature are highlighted to guide future research and ultimately improve clinical outcomes for patients with eating disorders.
INTRODUCTION Individuals with eating disorders are notoriously ambivalent to change, and drop-out rates from treatment are particularly high among this clinical population (DeJong, Broadbent, & Schmidt, 2011; Fassino, Piero, Tomba, & Abbate-Daga, 2009; Geller, Williams, & Srikameswaran, 2001). Often, individuals with anorexia nervosa deny the seriousness of the disorder and are referred to treatment by others, making these patients particularly difficult to Address correspondence to Rachelle Pullmer, Department of Psychology, Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6, Canada. E-mail: [email protected] 99
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engage in therapy (Vitousek, Watson, & Wilson, 1998). Individuals with other distressing eating disorder symptoms (i.e., binge eating, purging, and other compensatory behaviors) may also experience ambivalence about recovery, and demonstrate resistance to change detrimental dietary behaviors (Geller, Zaitsoff, & Srikameswaran, 2005; Serpell & Treasure, 2001). To effectively engage and treat individuals with eating disorders, a clear understanding of the therapeutic alliance in eating disorder treatment outcomes is of paramount importance. Bordin’s pantheoretical model of working alliance is one of the most frequently cited definitions of the therapeutic alliance (Bordin, 1979). In Bordin’s view, the working alliance is contingent on the constructive collaboration between the therapist and their patient, which involves the development of an emotional connection (bond), unanimity of therapeutic objectives (goal), and cooperative efforts toward change (task). To date, very little research has been conducted on the role that the therapeutic alliance plays in predicting treatment outcomes for eating disorder patients. However, in the past century, research on the alliance-outcome association for other psychiatric disorders has accumulated in an overwhelming fashion. Across different measures and definitions of alliance, various therapeutic modalities, and diverse patient diagnoses, the therapeutic alliance is consistently associated with treatment outcome (Friedlander, Escudero, Heatherington, & Diamond, 2011; Horvath & Symonds, 1991; Karver, Handelsman, Fields, & Bickman, 2006; Martin, Garske, & Davis, 2000; McLeod, 2011; Shirk & Karver, 2003; Shirk, Karvey, & Brown, 2011). Given the robustness of the alliance-outcome association in other clinical populations, and general resistance to change of patients with eating disorders, the therapeutic alliance may be an essential factor contributing to treatment outcomes (de la Rie, Noordenbos, Donker, & van Furth, 2008; Swain-Campbell, Surgenor, & Snell, 2001; Travis, Heywood-Everett, & Hill, 2013; Wright & Hacking, 2012). However, despite the necessity of research on the alliance-outcome association for patients with eating disorders, this topic has been under-studied relative to research in individuals with other psychiatric disorders. To date, only one review has attempted to summarize the research on this topic. However, the researchers failed to extensively search numerous databases, and did not focus on studies examining the role that alliance plays in predicting treatment efficacy (Antoniou & Cooper, 2013). To accurately understand research on the therapeutic alliance in eating disorder treatment, a more comprehensive literature review that summarizes research across eating disorder diagnoses, ages, and treatment settings is needed. Thus, the primary purpose of this review is to describe and thematically analyze extant literature on the role that the therapeutic alliance plays in predicting treatment outcomes for patients with eating disorders.
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METHODS
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Study Selection The data extraction process was performed according to the guidelines outlined by the PRISMA Statement (Preferred Reporting Items for Systematic reviews and Meta-Analyses; Moher, Liberati, Tetzlaff, Altmen, & The PRISMA Group, 2009). PsycINFO (1972 to July 2014), MEDLINE (1946 to July 2014), and CINAHL (1982 to July 2014) databases were searched using the EBSCO interface for studies conducted on whether the therapeutic alliance predicts treatment outcomes for patients with eating disorders. The search outline was created in PsycINFO and applied to other databases (see Appendix). The Cochrane library was searched for additional publications. After eliminating duplicate studies, the titles, abstracts, and full-length articles of identified studies were reviewed independently by two authors (R.P. and H.A.; Figure 1). There was no uncertainty about whether or not studies met inclusion criteria. Additional studies were identified via hand searches of the reference section of already identified papers, and by conducting cited reference searches in the Web of Science database (1898 to July 2014) for all included studies.
Study Inclusion and Evaluation Criteria Studies were included if they (a) quantitatively measured the therapeutic alliance, (b) quantitatively measured at least one other treatment variable (e.g., dropout, baseline symptom severity), (c) were published in peer-reviewed journals, and (d) were written in the English language. All included articles were reviewed in detail and thematically analyzed according to age and diagnostic classification. Current themes and limitations in the literature as well as areas of future research are addressed below.
RESULTS Nineteen articles published between 1994 and 2014 met inclusion criteria (Table 1). Seven different measures of therapeutic alliance were used across studies, irrespective of the different versions of these measures. The perspectives from which the therapeutic alliance was measured varied across the studies, and included client only (10 studies), observer only (four studies), parent only (one study), or some combination of patient, parent, and treatment-provider (four studies) ratings. Articles pertaining to the role that the therapeutic alliance plays in predicting treatment outcomes for adult and adolescent eating disorders are categorized below according to diagnostic classification (i.e., anorexia nervosa, bulimia nervosa, binge eating disorder, and mixed eating disorder samples).
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S. Zaitsoff et al. References identified from databases (n = 371)
References identified after duplicates removed (n = 222)
Reviewer 1: Screening of all titles and/or abstracts
Reviewer 2: Screening of all titles and/or abstracts
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Rejections based on titles and/or abstracts (n = 198)
Rejections based on titles and/or abstracts (n = 203)
Reviewer 1: Full text reviewed for inclusion criteria (n = 24)
Reviewer 2: Full text reviewed for inclusion criteria (n = 19)
Excluded references (n = 6) 6 Not on alliance predicting outcome
Excluded references (n = 1) 1 Not on alliance predicting outcomes
Reviewer 1: Included studies (n = 18)
Included crossreferences (n = 1)
Reviewer 2: Included studies (n = 18)
Consensus (n = 18)
Studies included in systematic review (n = 19)
FIGURE 1 Literature review flow chart.
Bulimia Nervosa The present literature search yielded eight studies pertaining to the allianceoutcome association for treatment of bulimia nervosa. Of these eight studies, seven were conducted with adult populations and one with adolescents. Notably, all but one (i.e., Raykos et al., 2014) of these studies are randomized controlled trials (RCTs). With respect to studies on the alliance-outcome association for adult bulimia nervosa, four suggest that the alliance-outcome association exists (Constantino, Arnow, Blasey, & Agras, 2005; Loeb et al., 2005; Treasure et al., 1999; Wilson et al., 1999). In particular, two RCTs have demonstrated a negative association between the therapeutic alliance and post-treatment purge
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Bourion-Bedes et al. (2013) Brown et al. (2013) Forsberg et al. (2013) Sly et al. (2013)
IT/ST program CBT AFT and FBT Hospitalized treatment
65 78
90
FBT FBT FBT
Inpatient and day hospital treatment CBT-E
108
41 59 14
Anorexia nervosa (AN) Pereira et al. (2006) Ellison et al. (2012) Isserlin & Couturier (2012)
43
Hartmann et al. (2010)
114
80
Zaitsoff et al. (2008)
Raykos et al. (2014)
CBT and IPT
81 FBT and SPT
CBT and SPT CBT and IPT CBT and IPT
CBT and MET
120 220 220
125
Bulimia nervosa (BN) Treasure et al. (1999)
Treatment
Wilson et al. (1999) Wilson et al. (2002) Constantino et al. (2005) Loeb et al. (2005)
N
Citation
TABLE 1 Included Studies
27.7
25.7 Not reported
15.3
15.1 14.6 14.0
Not reported
25.1
16.1
28.9
18-45 Not reported 28.1
28.8
Mean age (years)
WAI-SR
WAI-SR WAI
HAQ
WAI WAI SOFTA
HAQ
HAQ
HRq
VTAS
HRq HRq HAQ
WAI
Therapeutic alliance measure
C
C O
C, T, P
O P O
C
C, T
C
O
C C C
C, T
Alliance type
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N
N Y
N
N N N
N
Y
Y
Y
Y Y Y
Y
RCT
(Continued)
Treatment completion
No significant association Partial remission status
Weight gain; dropout rates Weight gain; dropout rates Dropout rates; post-treatment weight gain; remission in ED cognitions Time to achieve target weight
No significant association
Improvements in binge-eating and purging Remission No significant association Post-treatment purge frequency Post-treatment purge frequency Binge and purge frequency throughout treatment No significant association
Outcomes associated with the therapeutic alliance
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42 238
Waller et al. (2012) Tasca et al. (2012)
Hospitalized treatment CBT Group-based day treatment
25.4c 25.8 27.2 26.1
46.9b 44.1
33.4
Mean age (years)
WAI-SR CALPAS-G
WAI
BPSR-P
HRQ
Therapeutic alliance measure
C C
C, T
C
P
Alliance type
N N
N
Y
Y
RCT
No significant association Urge to restrict eating behaviors
Premature discharge
Premature termination
Overall ED symptoms; post-treatment weight change; depressive symptoms
Outcomes associated with the therapeutic alliance
Note: CBT = cognitive behavioral therapy; MET = motivational enhancement therapy; SPT = supportive psychotherapy; IPT = interpersonal psychotherapy; FBT = family based therapy; CBT-E = enhanced cognitive behavioral therapy; IT/ST program = individual and supportive therapy program; AFT = adolescent-focused therapy; SE-AN = specialist supportive clinical management for the treatment of severe and enduring AN; Group-BWLT = group behavior weight loss therapy; WAI = Working Alliance Inventory; HRq = Helping Relationships Questionnaire; HAQ = Helping Alliance Questionnaire; VTAS = Vanderbilt Therapeutic Alliance Scale (modified version); SOFTA = System for Observing Family Therapy Alliances; WAI-SR = Working Alliance Inventory – Revised Short Form; BPSR-P = Bern Post-Session Reports for Patients; CALPAS-G = California Therapeutic Alliance Scales Group Patient Version; C = client-reported; T = treatment provider-reported; O = observer-reported; P = parent-reported. a Sample included participants aged 16 and above. b Completers (n = 51; M = 46.9 years); dropouts (n = 27; M = 44.1 years). c Completers (n = 21; M = 25.4 years); dropouts (n =10; M = 25.8 years).
33
Mixed eating disorders Gallop et al. (1994)
Group-CBT and group- BWLT
Binge eating disorder (BED) Fluckiger et al. 78 (2011)
Treatment CBT and SE-AN
N
63
Stiles-Shields et al. (2013)
Citation
TABLE 1 Continued
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frequency after accounting for baseline purge frequency (Constantino et al., 2005; Loeb et al., 2005). While one of these studies found that only alliance measured early in treatment (session 6) was predictive of post-treatment purge frequency (Loeb et al., 2005), the other study found that alliance measured early (session 4) and in the middle (session 12) of treatment was predictive of the same outcome (Constantino et al., 2005). Further, two studies demonstrated a positive association between the therapeutic alliance and overall bulimia nervosa symptoms (Treasure et al., 1999; Wilson et al., 1999). Treasure and colleagues (1999) assessed the therapeutic alliance with the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989), which assess three key aspects of the therapeutic alliance: (a) the quality of the bond between the patient and therapist, (b) agreement on tasks to be carried out and (c) agreement on goals to be achieved. They found that both therapist and patient ratings of task were positively related to improvements in binge eating and vomiting. Patient (but not therapist) ratings of goal were also significantly related to improvements in binge eating and vomiting. However, neither therapist nor patient ratings of bond were significantly correlated with improvement in overall symptomatology. Wilson and colleagues (1999) found a more general positive association, demonstrating that patients’ ratings of overall therapeutic alliance predicted remission status for women receiving cognitive behavioral therapy or supportive psychotherapy. Conversely, three studies found no significant association between the therapeutic alliance and treatment outcomes for adult patients with bulimia nervosa (Hartmann, Orlinsky, Weber, Sandholz, & Zeeck, 2010; Raykos et al., 2014; Wilson, Fairburn, Agras, Walsh, & Kraemer, 2002). Hartmann and colleagues (2010) suggest that experiences of therapy between sessions may be more pertinent to outcome than in-session experiences, as researchers have found that patient efforts to apply therapy between sessions was a better predictor of outcome than ratings of the therapeutic alliance. Raykos and colleagues (2014) assessed the therapeutic alliance at three time-points during enhanced cognitive behavioral therapy for bulimia nervosa but found no evidence that alliance was related to treatment outcomes. Similarly, Wilson and colleagues (2002) assessed the therapeutic alliance during a RCT comparing treatments for bulimia nervosa, and found no evidence that the therapeutic alliance mediated treatment outcome. With respect to research on the alliance-outcome association for adolescent bulimia nervosa, one study was identified (Zaitsoff, Doyle, Hoste, & le Grange, 2008). Zaitsoff and colleagues (2008) found that reductions in binge and purge behaviors over the course of treatment were not related to alliance in adolescents receiving family-based treatment for bulimia nervosa. However, for adolescents receiving supportive psychotherapy, a stronger alliance midway through treatment was related to a greater percentage reduction in both binge eating and purging over the course of treatment.
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Anorexia Nervosa Eight studies were identified that investigated the role of the therapeutic alliance in the context of treatment for anorexia nervosa. Of these eight studies, three were conducted with adult populations and five with adolescents. Of the studies pertaining to the treatment of adult anorexia nervosa, two studies demonstrate support for the existence of an alliance-outcome association (Sly, Morgan, Mountford, & Lacey, 2013; Stiles-Shields et al., 2013). Sly and colleagues (2013) found that changes in the therapeutic alliance do not predict premature treatment termination. However, therapeutic alliance measured at admission was a significant predictor of treatment completion. Another study not only found that therapeutic alliance was associated with outcomes, but also that this association became stronger over time (StilesShield et al., 2013). While therapeutic alliance measured early in treatment significantly predicted some eating disorder symptomatology (i.e., Restraint and Shape Concern subscales of the Eating Disorder Examination; Cooper & Fairburn, 1987), therapeutic alliance measured at the end of treatment predicted weight change, depressive symptomatology, and all eating disorder symptomatology at the end of treatment and at follow-up (12 months post-treatment; Stiles-Shield et al., 2013). In an exploratory study of patients receiving manualized cognitive behavioral therapy for anorexia nervosa, researchers investigated potential relationships between patient-rated alliance and treatment outcome (weight gain and drop out), both of which were measured throughout the course of treatment (Brown, Mountford, & Waller, 2013). Early therapeutic alliance (measured at session 6) was not significantly associated with subsequent weight gain (early, late, or overall) or dropout. Rather, greater early and overall weight gain was associated with stronger subsequent therapeutic alliance. Based on these findings, the authors suggest that increased emphasis on weight gain, as opposed to the therapeutic relationship, may be particularly beneficial in early stages of treatment for adults with anorexia nervosa. Five studies have investigated the relationship between therapeutic alliance and outcome in the context of adolescent treatment for anorexia nervosa (Bourion-Bedes et al., 2013; Ellison et al., 2012; Forsberg et al., 2013; Isserlin & Couturier, 2012; Pereira, Lock, & Oggins, 2006). Several of these studies suggest that parent and adolescent ratings of alliance are differentially associated with outcome. Three studies have found that parent-rated alliance is positively associated with adolescent post-treatment weight gain and negatively associated with dropout in family based treatment for adolescent anorexia nervosa (Ellison et al., 2012; Isserlin & Couturier, 2012; Pereira et al., 2006). In contrast, adolescent-rated alliance has been positively linked to remission in eating disorder cognitions (Isserlin & Couturier, 2012) as well as early weight gain (Pereira et al., 2006), and negatively linked to time to
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recovery (Bourion-Bedes et al., 2013). A recent study conducted by Ellison and colleagues (2012) further differentiated mothers’ and fathers’ alliance ratings in family based treatment for adolescent anorexia nervosa, finding that a strong mother-therapist alliance predicts greater adolescent weight gain and less dropout, while a strong father-therapist alliance predicts less adolescent weight gain throughout treatment. Interestingly, Forsberg and colleagues (2013) report that observer-rated alliance differentially predicts full and partial remission for adolescents in treatment for anorexia nervosa (Forsberg et al., 2013). Specifically, they found that observer-rated alliance positively predicts partial remission status (i.e., greater than the 85th percentile for mean body weight for age, height, and gender), but not full remission status (i.e., greater the 95th percentile) at the end of treatment, regardless of whether the adolescent received family based treatment or adolescent-focused therapy.
Binge Eating Disorder Only one study was identified that investigated the role of the therapeutic alliance in the treatment of binge eating disorder. The one identified study provides preliminary evidence that therapeutic alliance predicts treatment outcomes for adult patients with binge eating disorder (Fluckiger et al., 2011). Specifically, an RCT comparing group cognitive behavioral therapy and group behavior weight loss therapy determined that patient-rated alliance predicts premature termination in patients who express discontentment with therapy, while controlling for type of treatment.
Mixed Eating Disorders To date, three studies have investigated the alliance-outcome association in a mixed eating disorder sample (i.e., samples consisting of patients with anorexia nervosa, bulimia nervosa, or eating disorders not otherwise specified; Gallop, Kennedy, & Stern, 1994; Tasca & Lampard, 2012; Waller, Evans, & Stringer, 2012). All three of these studies were conducted in adult populations. One study assessed the therapeutic alliance from the perspectives of both staff members and patients on an inpatient unit for anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified, determining that low patient-rated alliances predicted premature discharge from treatment (Gallop et al., 1994). The researchers reported that staff perceptions of alliance were not predictive of premature discharge, suggesting that measuring the alliance from the patient’s perspective may be of particular consequence in inpatient settings. In a more recent study, Tasca and Lampard (2012) investigated the relationship between patients’ self-rated alliance to their treatment group and symptom improvement in a day treatment program
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for various eating disorders, determining that the alliance-improvement relationship was reciprocal. In particular, the researchers reported that reduction in patients’ urges to restrict was both predictive of and predicted by patients’ alliance to the group throughout the course of therapy. Finally, Waller and colleagues (2012) found that the therapeutic alliance was not related to levels of eating pathology at any stage of treatment.
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DISCUSSION The role that the therapeutic alliance plays in predicting treatment outcomes for patients with eating disorders remains understudied relative to other clinical populations. This review highlights a number of emerging trends in the literature on the alliance-outcome association in eating disorder populations that are in need of future research to further elucidate and delineate this relationship according to diagnostic classification, age, and treatment modality. Current research on the therapeutic alliance indicates that the time at which alliance is assessed may be influential in predicting outcome. While two studies included in this review demonstrate a negative association between alliance and post-treatment purging frequency in an RCT comparing cognitive behavioral therapy and interpersonal therapy for adult bulimia nervosa (Constantino et al., 2005; Loeb et al., 2005), these studies differed in the time in treatment at which alliance was found to have the most predictive validity. Results regarding the predictive validity of alliance in family based treatment for adolescents with eating disorders also differ depending on when alliance is assessed. To elaborate, while Zaitsoff and colleagues’ (2008) findings support the predictive validity of alliance at mid-treatment, two other studies support the importance of early and late alliance in family based treatment (Isserlin & Couturier, 2012; Pereira et al., 2006). It also appears that researchers have different definitions of early, middle, and late alliance. Despite the fact that the two studies noted above on adult treatment for bulimia nervosa assessed alliance over 19 sessions of treatment, one study assessed early alliance at session 6 (Loeb et al., 2005), whereas the other study measured the same construct at session 4 (Constantino et al., 2005). Assessments of alliance are similarly heterogeneous in studies involving family based treatment for adolescent eating disorders, with measurements of early, middle, and late alliance taking place between sessions 1 to 9, 7 to 13, and 4 to 27, respectively (Isserlin & Couturier, 2012; Pereira et al., 2006; Zaitsoff et al., 2008). These discrepancies in timing of alliance assessment mimics alliance research in non-eating disorder populations (Elvins & Green, 2008; Horvath, Del Re, Fluckiger, & Symonds, 2011). However, a recent meta-analysis on the alliance-outcome association in non-eating disorder populations indicates
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that the alliance-outcome association remains significant irrespective of the time of alliance assessment (Horvath et al., 2011). Nevertheless, given the lack of research on the alliance-outcome association in patients with eating disorders, and initial evidence that timing with regard to alliance assessment may be important, it is imperative that future research is conducted to elucidate whether changes in the therapeutic alliance throughout the course of treatment differentially impact outcome variables. Another interesting trend in this developing field of research pertains to the discrepancy between parent and adolescent reports of alliance in treatment for adolescent eating disorders (Isserlin & Couturier, 2012; Pereira et al., 2006). In studies on the alliance-outcome association in non-eating disorder youth, researchers have concluded that youth and parent ratings of alliance are not interchangeable because the two perspectives are weakly correlated and associated with different outcome variables (Hawley & Garland, 2008; Zack, Castonguay, & Boswell, 2007). Specifically, parent-rated alliance has been found to predict variables related to treatment retention (i.e., cancellations, no-shows, and dropout; Garcia & Weisz, 2002; Hawley & Garland, 2008; Hawly & Weisz, 2005; Pereira et al., 2006), whereas youth-rated alliance has been found to directly predict symptom improvement (Hawley & Garland, 2008; Hawley & Weisz, 2005). Based on the results of the present review, it appears that the differential impact of parent and adolescent alliance ratings may carry over into treatment for adolescent eating disorders. Three studies included in this review demonstrate that parent-rated alliance is associated with adolescent posttreatment weight gain and dropout in family based treatment for adolescent eating disorders (Ellison et al., 2012; Isserlin & Couturier, 2012; Pereira et al., 2006). Two of the same studies demonstrate that adolescent-rated alliance is linked to remission on psychological variables in addition to post-treatment weight gain (Isserlin & Couturier, 2012; Pereira et al., 2006). Thus, as is the case for non-eating disorder populations, both adolescent and parent reports of therapeutic alliance appear to be important and related to different aspects of treatment efficacy. While this differentiation may result from the varying responsibilities that parents and adolescents have in eating disorder treatment (e.g., parents are responsible for ensuring their children attend treatment), more research on this topic is needed. Lastly, although it may seem intuitive that focusing on symptom reduction in treatment-resistant populations may hinder the development of therapeutic alliance, the development of the therapeutic alliance may not necessarily predate symptom improvement. Several studies with patients across diagnostic groups have found that symptom improvement either predicts development of the therapeutic alliance or that the relationship is bi-directional (Brown et al., 2013; Tasca & Lampard, 2012; Wilson et al., 1999). For example, one study determined that early weight gain in adults with anorexia nervosa enhanced the development of alliance (Brown et al.,
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2013), while another found that reductions in urges to restrict eating behaviors both predicted, and were predicted by, a stronger therapeutic alliance (Tasca & Lampard, 2012). The high rates of treatment retention and high ratings of alliance in family-based treatment for adolescents also suggest that an early focus on symptom reduction does not necessarily hinder development of the therapeutic alliance (Pereira et al., 2006; Zaitsoff et al., 2008). It may be that when individuals are able to make changes to their symptoms, they view their therapist as more trustworthy and helpful. Alternatively, the physiological changes associated with weight restoration may allow patients to develop stronger connections with their treatment providers. Further research employing more sophisticated data analytic techniques is needed to disentangle the pattern of associations between symptom improvement and development of the therapeutic alliance across eating disorder diagnoses and treatment modalities.
Limitations of Current Research Despite the trends that emerged in the literature thus far, limitations of this field of research must be noted. The paucity of research on the allianceoutcome association in eating disorder patients indicates that the role of the therapeutic alliance—the most extensively studied construct in the field of psychotherapy—remains poorly understood in eating disorder treatment. This not only renders research in this area antiquated, but also may limit the extent to which clinicians can provide effective treatment to patients struggling with eating disorders. Furthermore, the multiple measures used to assess the therapeutic alliance in the context of eating disorder treatment make it difficult to compare results across studies. This lack of consensus on the assessment of therapeutic alliance mirrors the methodological limitations of the general literature on the therapeutic alliance, where researchers have noted the multiplicity of alliance measures that exist, and have argued that a consensus must be reached before our understanding of the therapeutic alliance can progress any further (Elvins & Green, 2008; Horvath et al., 2011). With these recommendations in mind, future studies on the therapeutic alliance in eating disorder treatment would ideally involve further testing of the psychometric properties of existing therapeutic alliance measures to identify the best way to measure alliance in patients with eating disorders. The use of consistent measures will facilitate comparisons of results across studies and ultimately enhance our understanding of the alliance-outcome association in the treatment of eating disorders. Another profound limitation in this field of research that has been highlighted by this review is the lack of empirical focus on the outcome-alliance association in the specific context of treatment for adult anorexia nervosa. While the therapeutic alliance may have a significant impact on the efficacy
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of treatments for resistant anorexia nervosa patients, this potentially pivotal construct has only been applied in three studies to adult anorexia nervosa treatment (Brown et al., 2013). This is likely due to the fact that RCTs for anorexia nervosa are not cost effective, due to high dropout rates (DeJong et al., 2011). Given these constraints, alternate methods, such as the use of case studies or qualitative research, may be useful in examining the alliance-outcome association in patients with anorexia nervosa.
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CONCLUSION A vast amount of research in various clinical populations suggests that the therapeutic alliance may be a particularly integral factor affecting treatment outcomes for eating disorder patients. Overall, the findings from this review indicate that while the alliance-outcome association is likely significant for patients with anorexia nervosa, the importance of this association is unclear for individuals with bulimia nervosa, binge eating disorder, and mixed eating disorder symptoms. It is therefore imperative that methodologically sound research in this field continues in order to further clarify and delineate the role the that therapeutic alliance plays in predicting treatment outcomes for adult and adolescent patients with varying eating disorder diagnoses.
REFERENCES Antoniou, P., & Cooper, M. (2013). Psychological treatments for eating disorders: What is the importance of the quality of the therapeutic alliance for outcomes? Counselling Psychology Review, 28, 34–46. Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy Theory, Research and Practice, 16, 352–360. Bourion-Bedes, S., Baumann, C., Kermarrec, S., Ligier, F., Feillet, F., Bonnmains, C., . . . Kabuth, B. (2013). Prognostic value of early therapeutic alliance in weight recovery: A prospective cohort of 108 adolescents with anorexia nervosa. Journal of Adolescent Health, 52, 344–350. Brown, A., Mountford, V., & Waller, G. (2013). Therapeutic alliance and weight gain during cognitive behavioural therapy for anorexia nervosa. Behaviour Research and Therapy, 51, 216–220. Constantino, M., Arnow, B. A., Blasey, C., & Agras, W. S. (2005). The association between patient characteristics and the therapeutic alliance in cognitive-behavioural and interpersonal therapy for bulimia nervosa. Journal of Consulting and Clinical Psychology, 73, 203–211. doi: 10.1037/0022-006X.73.2.203 Cooper, Z., & Fairburn, C. G. (1987). The eating disorder examination: A semistructured interview for the assessment of the specific psychopathology of eating disorders. International Journal of Eating Disorders, 6, 1–8.
Downloaded by [University of Otago] at 09:57 24 July 2015
112
S. Zaitsoff et al.
de la Rie, S., Noordenbos, G., Donker, M., & van Furth, E. (2008). The quality of treatment of eating disorders: A comparison of the therapists’ and the patients’ perspective. International Journal of Eating Disorders, 41, 307–317. DeJong, H., Broadbent, H., & Schmidt, U. (2011). A systemative review of dropout from treatment in outpatients with anorexia nervosa. International Journal of Eating Disorders, 45, 635–647. Ellison, R., Rhodes, P., Madden, S., Miskovic, J., Wallis, A., Baillie, A., . . . . Touyz, S. (2012). Do the components of manualized family-based treatment for anorexia nervosa predict weight gain? International Journal of Eating Disorders, 45, 609–614. Elvins, R., & Green, J. (2008). The conceptualization and measurement of the therapeutic alliance: An empirical review. Clinical Psychology Review, 28, 1167–1187. doi:10.1016/j.cpr.2008.04.002 Fassino, S., Piero, A., Tomba, E., & Abbate-Daga, G. (2009). Factors associated with dropout from treatment for eating disorders: A comprehensive literature review. BMC Psychiatry, 9, 1–9. doi:10.1186/1471-244X-9-67 Fluckiger, C., Meyer, A., Wampold, B. E., Gassmann, D., Messerli-Burgy, N., & Munsch, S. (2011). Predicting premature termination within a randomized controlled trial for binge-eating patients. Behavior Therapy, 42, 716–725. Forsberg, S., LoTempio, E., Bryson, S., Fitzpatrick, K. K., Le Grange, D., & Lock, J. (2013). Therapeutic alliance in two treatments for adolescent anorexia nervosa. International Journal of Eating Disorders, 46, 34–38. Friedlander, M., Escudero, V., Heatherington, L., & Diamond, G. M. (2011). Alliance in couple and family therapy. Psychotherapy, 48, 25–33. Gallop, R., Kennedy, S. H., & Stern, D. (1994). Therapeutic alliance on an inpatient unit for eating disorders. International Journal of Eating Disorders, 16, 405–410. Garcia, J. A., & Weisz, J. R. (2002). When youth mental health care stops: Therapeutic relationship problems and other reasons for ending youth outpatient treatment. Journal of Consulting and Clinical Psychology, 70, 439–443. Geller, J., Williams, K. D., & Srikmeswaran, S. (2001). Clinician stance on the treatment of chronic eating disorders. European Eating Disorders Review, 9, 365–373. Geller, J., Zaitsoff, S., & Srikmeswaran, S. (2005). Tracking readiness and motivation for change in individuals with eating disorders over the course of treatment. Cognitive Therapy and Research, 29, 611–625. doi:10.1007/s10608-005-5774-1 Hartmann, A., Orlinsky, D., Weber, S., Sandholz, A., & Zeeck, A. (2010). Session and intersession experience related to treatment outcome in bulimia nervosa. Psychotherapy Theory, Research, Practice, Training, 47, 355–370. Hawley, K. M., & Garland, A. F. (2008). Working alliance in adolescent outpatient therapy: Youth, parent, and therapist reports and associations with therapy outcomes. Child and Youth Care Forum, 37, 59–74. Hawley, K. M., & Weisz, J. R. (2005). Youth versus parent working alliance in usual clinical care: Distinctive associations with retention, satisfaction, and treatment outcome. Journal of Clinical Child and Adolesecnt Psychology, 34, 117–128. Horvath, A. O., Del Re, A. C., Fluckiger, C., & Symonds, B. D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9–16.
Downloaded by [University of Otago] at 09:57 24 July 2015
Systemic Review of Therapeutic Alliance in Eating Disorder Treatment
113
Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36, 223–233. Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 19–149. Isserlin, L., & Couturier, J. (2012). Therapeutic alliance and family-based treatment for adolescents with anorexia nervosa. Psychotherapy, 49, 46–51. Karver, M. S., Handelsman, J. B., Fields, S., & Bickman, L. (2006). Meta-analysis of therapeutic relationship variables in youth and family therapy: The evidence for different relationship variables in the child and adolescent treatment outcome literature. Clinical Pyschology Review, 26, 50–65. Loeb, K. L., Wilson, G. T., Labouvie, E., Pratt, E., Hayaki, J., Walsh, B. T., & Agras, W. S. (2005). Therapeutic alliance and treatment adherence in two interventions for bulimia nervosa: A study of process and outcome. Journal of Consulting and Clinical Psychology, 73, 1097–1107. doi:10.1037/0022-006X.73.6.1097 Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438–450. McLeod, B. D. (2011). Relation of the alliance with outcomes in youth psychotherapy: A meta-analysis. Clinical Pyschology Review, 31, 603–616. Moher, D., Liberati, A., Tetzlaff, J., & Altman, G. D. (2009). The PRISMA group preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Open Medicine, 3, 123–130. Pereira, T., Lock, J., & Oggins, J. (2006). Role of therapeutic alliance in family therapy for adolescent anorexia nervosa. International Journal of Eating Disorders, 39, 677–684. Raykos, B. C., McEvoy, P. M., Erceg-Hurn, D., Byrne, S., Fursland, A., & Nathan, P. (2014). Therapeutic alliance in Enhanced Cognitive Behavioural Therapy for bulimia nervosa: Probably necessary but definitely insufficient. Behaviour Research and Therapy, 57, 65–71. Serpell, L., & Treasure, J. (2001). Bulimia nervosa: Friend or foe? The pros and cons of bulimia nervosa. International Journal of Eating Disorders, 32, 164–170. Shirk, S. R., & Karver, M. S. (2003). Prediction of treatment outcome from relationship variables in child and adolescent therapy: A meta-analytic review. Journal of Consulting and Clinical Psychology, 71, 452–464. doi: 10.1037/0022-006X.71.3.452 Shirk, S. R., Karver, M. S., & Brown, R. (2011). The alliance in child and adolescent psychotherapy. Psychotherapy, 48, 17–24. doi:10.1037/a0022181 Sly, R., Morgan, J. F., Mountford, V., & Lacey, J. H. (2013). Predicting premature termination of hospitalised treatment for anorexia nervosa: The roles of therapeutic alliance, motivation, and behaviour change. Eating Behaviours, 119–123. Stiles-Shields, C., Touyz, S., Hay, P., Lacey, J. H., Crosby, R. D., Rieger, E., . . . Le Grange, D. (2013). Therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa. International Journal of Eating Disorders, 46, 783–789.
Downloaded by [University of Otago] at 09:57 24 July 2015
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Swain-Campbell, N. R., Surgenor, L., & Snell, D. (2001). Analysis of consumer perspectives following contact with an eating disorder service. Australian and New Zealand Journal of Psychiatry, 35, 99–103. Tasca, G., & Lampard, A. M. (2012). Reciprocal influence of alliance to the group and outcome in day treatment for eating disorders. Journal of Counseling Psychology, 59, 507–517. doi:10.1037/a0029947 Traviss, G., Heywood-Everett, S., & Hill, A. J. (2013). Understanding the “guide” in self-help for disordered eating: A qualitative process study. Psychology and Psychotherapy: Theory, Research and Practice, 86, 86–104. doi: 10.1111/j.2044-8341.2011.02049.x Treasure, J., Katzman, M., Schmidt, U., Troop, N., Todd, G., & de Silva, P. (1999). Engagement and outcome in the treatment of bulimia nervosa: First phase of a sequential design comparing motivation enhancement therapy and cognitive behavioural therapy. Behaviour Research and Therapy, 37, 405–418. Vitousek, K., Watson, S., & Wilson, G. T. (1998). Enhancing motivation for change in treatment-resistant eating disorders. Clinical Pyschology Review, 18, 391–420. Waller, G., Evans, J., & Stringer, H. (2012). The therapeutic alliance in the early part of cognitive-behavioral therapy for eating disorders. International Journal of Eating Disorders, 45, 63–69. Wilson, G. T., Fairburn, C. C., Agras, W. S., Walsh, B. T., & Kraemer, H. (2002). Cognitive behavioral therapy for bulimia nervosa: Time course and mechanisms of change. Journal of Consulting and Clinical Psychology, 70, 267–274. Wilson, G. T., Loeb, K. L., Walsh, B. T., Labouvie, E., Petkova, E., Liu, X., & Waternaux, C. (1999). Psychological versus pharmacological treatments for bulimia nervosa: Predictors and processes of change. Journal of Consulting and Clinical Psychology, 67, 451–459. Wright, K. M., & Hacking, S. (2012). An angel on my shoulder: A study of relationships between women with anorexia nervosa and healthcare professionals. Journal of Psychiatric and Mental Health Nursing, 19, 107–115. doi: 10.1111/j.1365-2850.2011.01760.x Zack, S. E., Castonguay, L. G., & Boswell, J. F. (2007). Youth working alliance: A core clinical construct in need of empirical maturity. Harvard Review of Psychiatry, 15, 278–288. doi:10.1080/10673220701803867. Zaitsoff, S., Celio Doyle, A., Hoste, R. R., & Le Grange, D. (2008). How do adolescents with bulimia nervosa rate the acceptability and therapeutic relationship in family-based treatment? International Journal of Eating Disorders, 41, 390–398.
APPENDIX: SEARCH OUTLINE 1. Therapeutic alliance OR working alliance OR therapeutic relationship OR therapeutic bond. 2. Eating disorder OR anorex∗ OR bulim∗ OR bing∗ OR purg∗ . 3. Treat∗ OR outcome OR eff∗ . 4. 1 AND 2 AND 3.
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