1
|
Muzi L, Carone N, Mirabella M, Franco A, Rugo MA, Mazzeschi C, Lingiardi V. Direct and indirect effects of psychological well-being and therapeutic alliance on therapy outcome in eating disorders. Front Psychol 2024; 15:1392887. [PMID: 38855305 PMCID: PMC11162114 DOI: 10.3389/fpsyg.2024.1392887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/13/2024] [Indexed: 06/11/2024] Open
Abstract
Introduction Outcome research in eating disorders (EDs) is commonly focused on psychopathological dysfunction. However, Ryff's model of psychological well-being (PWB) has shown promising-yet preliminary-results with ED patients. Additionally, despite substantial evidence highlighting the association between the therapeutic alliance and treatment outcome, findings in ED samples remain unclear. The present study aimed at exploring the direct effect of PWB dimensions and the early therapeutic alliance on ED patients' individual treatment responses, as well as the mediating role played by the early therapeutic alliance in the relationship between PWB dimensions and overall pre-post symptom change. Methods A sample of N = 165 ED patients assigned female at birth, who were receiving treatment in a residential program, completed the Psychological Well-Being Scale at treatment intake and the Working Alliance Inventory after the first four psychotherapy sessions. Patients also completed the Outcome Questionnaire-45.2 at the same time point and during the week prior to discharge. Results The PWB dimensions of autonomy, positive relations, and self-acceptance were associated with clinically significant change, while the dimensions of personal growth and self-acceptance were associated with reliable change. The early therapeutic alliance showed both direct and indirect effects on therapy outcome, predicting clinically significant and reliable symptom reduction. It also emerged as a significant mediator in the relationship between all PWB dimensions and overall symptomatic change. Conclusion The identification of individual, adaptive characteristics in ED patients that might influence their development of an early therapeutic alliance may help therapists to predict relationship ruptures and tailor their interventions to enhance treatment effectiveness.
Collapse
Affiliation(s)
- Laura Muzi
- Department of Philosophy, Social Sciences, Humanities and Education, University of Perugia, Perugia, Italy
| | - Nicola Carone
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Marta Mirabella
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome, Italy
| | - Anna Franco
- Eating Disorder Clinic “Residenza Gruber”, Bologna, Italy
| | | | - Claudia Mazzeschi
- Department of Philosophy, Social Sciences, Humanities and Education, University of Perugia, Perugia, Italy
| | - Vittorio Lingiardi
- Department of Dynamic and Clinical Psychology, and Health Studies, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
2
|
Russell H, Aouad P, Le A, Marks P, Maloney D, Touyz S, Maguire S. Psychotherapies for eating disorders: findings from a rapid review. J Eat Disord 2023; 11:175. [PMID: 37794513 PMCID: PMC10548609 DOI: 10.1186/s40337-023-00886-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 09/11/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Psychotherapy is considered central to the effective treatment of eating disorders-focusing on behavioural, psychological, and social factors that contribute to the illness. Research indicates psychotherapeutic interventions out-perform placebo, waitlist, and/or other treatments; but, outcomes vary with room for major improvement. Thus, this review aims to (1) establish and consolidate knowledge on efficacious eating disorder psychotherapies; (2) highlight select emerging psychotherapeutic interventions; and (3) identify knowledge gaps to better inform future treatment research and development. METHODS The current review forms part of a series of Rapid Reviews published in a special issue in the Journal of Eating Disorders to inform the development of the Australian-government-funded National Eating Disorder Research and Translation Strategy 2021-2031. Three databases were searched for studies published between 2009 and 2023, published in English, and comprising high-level evidence studies (meta-analyses, systematic reviews, moderately sized randomised controlled studies, moderately sized controlled-cohort studies, and population studies). Data pertaining to psychotherapies for eating disorders were synthesised and outlined in the current paper. RESULTS 281 studies met inclusion criteria. Behavioural therapies were most commonly studied, with cognitive-behavioural and family-based therapies being the most researched; and thus, having the largest evidence-base for treating anorexia nervosa, bulimia nervosa, and binge eating disorder. Other therapies, such as interpersonal and dialectical behaviour therapies also demonstrated positive treatment outcomes. Emerging evidence supports specific use of Acceptance and Commitment; Integrative Cognitive Affective; Exposure; Mindfulness; and Emotionally-Focused therapies; however further research is needed to determine their efficacy. Similarly, growing support for self-help, group, and computer/internet-based therapeutic modalities was noted. Psychotherapies for avoidant/restrictive food intake disorder; other, and unspecified feeding and eating disorders were lacking evidence. CONCLUSIONS Currently, clinical practice is largely supported by research indicating that behavioural and cognitive-behavioural psychotherapies are most effective for the treatment of eating disorders. However, the efficacy of psychotherapeutic interventions varies across studies, highlighting the need for investment and expansion of research into enhanced variants and novel psychotherapies to improve illness outcomes. There is also a pressing need for investigation into the whole range of eating disorder presentations and populations, to determine the most effective interventions.
Collapse
Affiliation(s)
- Haley Russell
- InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, Level 2, Charles Perkins Centre (D17), University of Sydney, Sydney, NSW, 2006, Australia
| | - Phillip Aouad
- InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, Level 2, Charles Perkins Centre (D17), University of Sydney, Sydney, NSW, 2006, Australia.
| | - Anvi Le
- Healthcare Management Advisors, Melbourne, Australia
| | - Peta Marks
- InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, Level 2, Charles Perkins Centre (D17), University of Sydney, Sydney, NSW, 2006, Australia
| | - Danielle Maloney
- InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, Level 2, Charles Perkins Centre (D17), University of Sydney, Sydney, NSW, 2006, Australia
- Sydney Local Health District, New South Wales Health, Sydney, Australia
| | - Stephen Touyz
- InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, Level 2, Charles Perkins Centre (D17), University of Sydney, Sydney, NSW, 2006, Australia
| | - Sarah Maguire
- InsideOut Institute, Central Clinical School, Faculty of Medicine and Health, Level 2, Charles Perkins Centre (D17), University of Sydney, Sydney, NSW, 2006, Australia
| |
Collapse
|
3
|
Schaper R, Nowotny C, Michalek S, Schmidt U, Brockmeyer T. Language style matching and treatment outcome in anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2023; 31:110-120. [PMID: 35962959 DOI: 10.1002/erv.2943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 06/30/2022] [Accepted: 07/05/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Psychotherapy is the treatment of choice for anorexia nervosa (AN) but mechanisms of action are still largely unknown. Growing research suggests that synchrony between patient and therapist contributes to treatment success. Adding to this literature, this study examined the association between language style matching (LSM) among patient and therapist as an indicator of interpersonal (verbal) synchrony and treatment outcome in AN. METHOD Audio recordings of mid-treatment therapy sessions (n = 25) in a multi-centre randomized controlled trial on the Maudsley Model of Anorexia Nervosa Treatment for Adults were transcribed and used to calculate LSM for each patient-therapist dyad. These scores were used to predict treatment outcome at 12-month follow-up. RESULTS LSM did not predict body mass index (primary outcome) at follow-up. However, higher LSM (M = 0.87, SD = 0.04) was associated with lower eating disorder psychopathology (accounting for 11% of the variance) and higher recovery rates (accounting for 28% of variance) at follow-up. CONCLUSIONS These preliminary findings suggest that verbal synchrony between patients with AN and their therapists contributes to favourable treatment outcomes. High levels of LSM may reflect therapeutic empathy, cooperation, or mutual positive perception. Further research should explore the mechanisms of linguistic synchrony with larger samples to allow for stronger conclusions.
Collapse
Affiliation(s)
- Rachel Schaper
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, University of Goettingen, Goettingen, Germany
| | - Christina Nowotny
- Department of Psychosomatic Medicine and Psychotherapy, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Silke Michalek
- Department of Psychosomatic Medicine and Psychotherapy, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Ulrike Schmidt
- Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Timo Brockmeyer
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, University of Goettingen, Goettingen, Germany.,Department of Psychosomatic Medicine and Psychotherapy, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.,Section of Eating Disorders, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
4
|
Alliance matters: but how much? A systematic review on therapeutic alliance and outcome in patients with anorexia nervosa and bulimia nervosa. Eat Weight Disord 2022; 27:1279-1295. [PMID: 34374966 PMCID: PMC9079014 DOI: 10.1007/s40519-021-01281-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/23/2021] [Indexed: 12/26/2022] Open
Abstract
PURPOSE Patients with eating disorders (ED) pose a high-risk group regarding relapse. The understanding of factors contributing to a better outcome is much-needed. Therapeutic alliance (TA) is one important, pantheoretical variable in the treatment process, which has shown to be connected with outcome. This review looks into a possible predictive effect of TA on outcome as well as related variables. METHODS A systematic review with pre-determined inclusion criteria following the PRISMA guidelines was conducted for studies published since 2014. Three previous reviews including studies up until 2014 were analyzed for studies matching our inclusion criteria. A total of 26 studies were included. RESULTS The results were heterogeneous between different patient groups. Regarding the predictive effect of TA, in adolescent samples, the TA of either the patients or their parents seems to impact outcome as well as completion. For adults, results are mixed, with a tendency to a greater impact of TA for anorexia nervosa (AN) patients, while some samples of adult bulimia nervosa (BN) patients did not find any relation between TA and outcome. CONCLUSION The effect of TA on clinical outcome depends on the patient group. TA has a greater impact on adolescents, irrespective of diagnosis, and on adults with AN. The examined studies have different limitations which include small sample sizes and questionable study design. The examination of motivation as a potential influencing factor is recommended. LEVEL OF EVIDENCE Level I, systematic review.
Collapse
|
5
|
Murphy ST, Garcia RA, Cheavens JS, Strunk DR. The therapeutic alliance and dropout in cognitive behavioral therapy of depression. Psychother Res 2022; 32:995-1002. [PMID: 35041574 DOI: 10.1080/10503307.2021.2025277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Identifying predictors of dropout is an important step in improving treatment outcomes. The alliance is the most frequently studied psychotherapy process variable, but its relation to dropout in cognitive behavioral therapy (CBT) of depression is not well understood. We evaluated the alliance at session one as reported by clients and therapists as predictors of dropout among 126 clients with major depressive disorder participating in CBT for depression. Over a similar time period, those who dropped out experienced less symptom change than those who did not. Client, but not therapist reported alliance was related to reduced risk for dropout. This relation remained significant even when clients' pre-treatment predictions of the alliance were included as a covariate. Concurrent use of medication did not moderate the alliance-dropout relation. Our findings are consistent with alliance being an important contributor to risk of dropout in CBT for depression. Future research should investigate intervention strategies that might promote the alliance as a means of reducing dropout.
Collapse
|
6
|
Wolf N, van Oppen P, Hoogendoorn AW, van Balkom AJLM, Visser HAD. Therapeutic Alliance and Treatment Outcome in Cognitive Behavior Therapy for Obsessive-Compulsive Disorder. Front Psychiatry 2022; 13:658693. [PMID: 35401280 PMCID: PMC8987103 DOI: 10.3389/fpsyt.2022.658693] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Therapeutic alliance has consistently been found to predict treatment outcomes across various psychotherapies and patient diagnosis. However, the relationship between therapeutic alliance and outcome in Cognitive Behavioral Therapy (CBT) has shown mixed results. This study investigated the impact of different aspects of therapeutic alliance in CBT for Obsessive-Compulsive Disorder (OCD). METHOD Data from two previously completed randomized controlled trials of 208 patients with OCD and their therapists were analyzed. Therapeutic alliance was assessed at week 4 of treatment with the patient-rated and therapist-rated Working Alliance Inventory (WAI), which includes three subscales to measure alliance domains (Goal, Task and Bond). Higher WAI score reflects a better therapeutic relationship. OCD severity was rated by independent assessors at baseline and post-treatment using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Linear regression analyses were used to examine the effects of the different aspects of therapeutic alliance on treatment outcome, adjusted for baseline symptom severity. RESULTS A higher total WAI score as rated by therapists significantly predicted a lower post-treatment Y-BOCS. Further, higher scores on the Goal and Task subscales of the WAI were associated with lower post-treatment severity. However, these significant outcomes reflected only small effect sizes. CONCLUSIONS In the treatment of OCD, the strength of the therapeutic alliance contributes to outcomes, though to a limited extent. Effective OCD treatment involves the delivery of specific therapy interventions, in the context of a strong therapeutic alliance.
Collapse
Affiliation(s)
- Nadja Wolf
- Mental Health Care Institute Geestelijke gezondheidszorg (GGZ) Centraal, Amersfoort, Netherlands
| | - Patricia van Oppen
- Department of Psychiatry, Amsterdam Public Health, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, Netherlands.,Geestelijke Gezondheidszorg (GGZ) InGeest Specialized Mental Health Care, Amsterdam, Netherlands
| | - Adriaan W Hoogendoorn
- Department of Psychiatry, Amsterdam Public Health, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, Netherlands.,Geestelijke Gezondheidszorg (GGZ) InGeest Specialized Mental Health Care, Amsterdam, Netherlands
| | - Anton J L M van Balkom
- Department of Psychiatry, Amsterdam Public Health, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, Netherlands.,Geestelijke Gezondheidszorg (GGZ) InGeest Specialized Mental Health Care, Amsterdam, Netherlands
| | - Henny A D Visser
- Mental Health Care Institute Geestelijke gezondheidszorg (GGZ) Centraal, Amersfoort, Netherlands
| |
Collapse
|
7
|
Calugi S, Dametti L, Chimini M, Dalle Grave A, Dalle Grave R. Change in eating-disorder psychopathology network structure in patients with anorexia nervosa treated with intensive cognitive behavior therapy. Int J Eat Disord 2021; 54:1800-1809. [PMID: 34331465 DOI: 10.1002/eat.23590] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/23/2021] [Accepted: 07/22/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE This study was designed to compare the change in eating-disorder feature networks in patients with anorexia nervosa after treatment with intensive enhanced cognitive behavior therapy (CBT-E). METHODS Patients seeking treatment for anorexia nervosa were consecutively recruited from January 2016 to September 2020. All patients aged ≥16 years who completed a 20-week intensive CBT-E program (13 weeks of inpatient followed by 7 weeks of day-hospital treatment) were included in the study. Body mass index (BMI) was measured, and the Eating Disorder Examination Questionnaire completed for each patient, both at baseline and the end of treatment. RESULTS The sample comprised 214 patients with anorexia nervosa. Treated patients showed significant improvements in BMI and eating-disorder psychopathology. Network analysis revealed a significant reduction in the network global and connection strengths at the end of treatment. The most central and highly interconnected nodes in the network at baseline were related to the drive for thinness, but at the end of treatment to body image concerns. Some edge connections were significantly stronger at baseline than at the end of treatment, while others were significantly stronger at the end of treatment than at baseline. DISCUSSION CBT-E reduces the psychopathology network connectivity over time in patients with anorexia nervosa. The differences in central nodes and edge connections between baseline and end of treatment, not detected by classical inferential analysis, may be informative for understanding the centrality of symptoms in the psychopathology network, and how a specific treatment may act to reduce symptoms and change their connections over time.
Collapse
Affiliation(s)
- Simona Calugi
- Department of Eating and Weight Disorders, Villa Garda Hospital, Garda, Italy
| | - Laura Dametti
- Department of Eating and Weight Disorders, Villa Garda Hospital, Garda, Italy
| | - Mirko Chimini
- Department of Eating and Weight Disorders, Villa Garda Hospital, Garda, Italy
| | - Anna Dalle Grave
- Department of Eating and Weight Disorders, Villa Garda Hospital, Garda, Italy
| | | |
Collapse
|
8
|
Albano G, Cardi V, Kivlighan DM, Ambwani S, Treasure J, Lo Coco G. The relationship between working alliance with peer mentors and eating psychopathology in a digital 6-week guided self-help intervention for anorexia nervosa. Int J Eat Disord 2021; 54:1519-1526. [PMID: 34042206 PMCID: PMC8453826 DOI: 10.1002/eat.23559] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 05/14/2021] [Accepted: 05/14/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The quality of working alliance (WA) is associated with treatment outcomes across several types of psychiatric disorders and psychological interventions. This study examined the role of WA with peer mentors (people with lived experience of illness) and student mentors (graduated psychology students) in a 6-week, digital, guided self-help (GSH) intervention for anorexia nervosa. METHOD Ninety-nine patients rated weekly, for 6 weeks: (a) eating psychopathology using the short version of the Eating Disorder Examination Questionnaire (EDE-QS) and (b) WA with a student mentor (n = 14) or a peer mentor (n = 10). WA was assessed by asking patients the extent to which they felt comfortable working with their mentor and the extent to which they agreed with them on the goals for support. WA with mentors and the association with eating psychopathology change were measured on a session-by-session basis. The analysis involved a random intercepts cross-lagged panel model. RESULTS WA with peer mentors was slightly higher than WA with students (ES = 0.3). Peer mentors' WA in the previous session was significantly associated with eating psychopathology ratings in the next session. No significant relationship was found between the previous session's EDE-QS scores and peer mentor alliance in the following session. In the student mentor group, there were no session-by-session associations between WA and eating psychopathology. However, greater WA with the student mentor across sessions was associated with less eating psychopathology. DISCUSSION These findings suggest that clinical outcomes are in part associated with the characteristics of the mentor delivering guidance in an online GSH for eating disorders.
Collapse
Affiliation(s)
- Gaia Albano
- Department of Psychology, Educational Science and Human MovementUniversity of PalermoPalermoItaly
| | - Valentina Cardi
- Department of Psychological MedicineKings College LondonLondonUK,Department of General PsychologyUniversity of PadovaPadovaItaly
| | - Dennis M. Kivlighan
- Department of Counseling, Higher Education and Special EducationUniversity of MarylandCollege ParkMarylandUSA
| | - Suman Ambwani
- Department of PsychologyDickinson CollegeCarlislePennsylvaniaUSA
| | - Janet Treasure
- Department of Psychological MedicineKings College LondonLondonUK
| | - Gianluca Lo Coco
- Department of Psychology, Educational Science and Human MovementUniversity of PalermoPalermoItaly
| |
Collapse
|
9
|
Developing more efficient, effective, and disseminable treatments for eating disorders: an overview of the multiphase optimization strategy. Eat Weight Disord 2019; 24:983-995. [PMID: 30603927 PMCID: PMC6606403 DOI: 10.1007/s40519-018-0632-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 12/18/2018] [Indexed: 10/27/2022] Open
Abstract
The present manuscript describes the multiphase optimization strategy (MOST) and its potential applications to treatments for eating disorders (EDs). The manuscript describes the three phases of MOST, discusses a hypothetical case example of how MOST could be applied to developing a disseminable ED treatment, and reviews the pros and cons of the MOST approach. Outcomes from treatments for EDs leave room for improvement. However, traditional methods of treatment development and evaluation (i.e., the treatment package approach) make it challenging to determine how best to improve ED treatments. For example, testing full treatment packages in open trials and RCTs without systematic testing of each component is inefficient (as it is unknown which components are effective), and often does not provide concrete future directions for optimization of the treatment. Much stands to be gained by optimizing treatments in the early stages before testing them in open trials or RCTs. MOST is an alternative, engineering-inspired research framework that is well-suited to address the issues of inefficiency associated with the treatment package approach. MOST entails identifying the most promising treatment components for inclusion in interventions, then eliminating or deemphasizing less efficacious/inert components. This strategy results in a treatment comprised of only effective components that can then be tested via RCT. Though the MOST approach has limitations, it has the potential to greatly benefit ED treatment research and is worthy of application in the field.
Collapse
|
10
|
Puls HC, Schmidt R, Hilbert A. Therapist adherence and therapeutic alliance in individual cognitive-behavioural therapy for adolescent binge-eating disorder. EUROPEAN EATING DISORDERS REVIEW 2018; 27:182-194. [PMID: 30334340 DOI: 10.1002/erv.2650] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 08/20/2018] [Accepted: 09/21/2018] [Indexed: 11/05/2022]
Abstract
To evaluate psychological treatments for adolescent binge-eating disorder (BED), reliable information on therapeutic process factors is needed. This study examines therapist adherence and therapeutic alliance and their associations in cognitive-behavioural therapy (CBT) for adolescents with BED. In a randomised-controlled efficacy trial, adherence and alliance were objectively determined based on 247 audio-taped CBT sessions from a sample of N = 64 adolescents with BED. Variability of adherence and alliance, explained by treatment module, patient, and therapist were examined using multilevel modeling. Although adherence and alliance were excellent and unaffected by treatment module and therapist, there was significant between-patient variability for both concepts. Adherence was negatively associated with patient's treatment expectation. Alliance was negatively associated with the number of loss of control eating episodes and positively associated with adherence. Excellent adherence supported the internal validity of CBT for adolescent BED. Associations between process factors and patient characteristics demand adequate supervision in CBT.
Collapse
Affiliation(s)
- Hans-Christian Puls
- Department of Medical Psychology and Medical Sociology, Department of Psychosomatic Medicine and Psychotherapy, Integrated Research and Treatment Center AdiposityDiseases, Leipzig, Germany
| | - Ricarda Schmidt
- Department of Medical Psychology and Medical Sociology, Department of Psychosomatic Medicine and Psychotherapy, Integrated Research and Treatment Center AdiposityDiseases, Leipzig, Germany
| | - Anja Hilbert
- Department of Medical Psychology and Medical Sociology, Department of Psychosomatic Medicine and Psychotherapy, Integrated Research and Treatment Center AdiposityDiseases, Leipzig, Germany
| |
Collapse
|
11
|
Outpatient CBT for Underweight Patients with Eating Disorders: Effectiveness Within a National Health Service (NHS) Eating Disorders Service. Behav Cogn Psychother 2018; 47:217-229. [DOI: 10.1017/s1352465818000449] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background: Underweight eating disorders (EDs) are notoriously difficult to treat, although a growing evidence base suggests that outpatient cognitive behaviour therapy for EDs (CBT-ED) can be effective for a large proportion of individuals. Aims: To investigate the effectiveness of CBT-ED for underweight EDs in a ‘real-world’ settings. Method: Sixty-three adults with underweight EDs (anorexia nervosa or atypical anorexia nervosa) began outpatient CBT-ED in a National Health Service setting. Results: Fifty-four per cent completed treatment, for whom significant changes were observed on measures of ED symptoms, psychological distress and psychosocial impairment. There was also a large effect on body weight at end-of-treatment. Conclusions: The results suggest that good outcomes can be achieved by the majority of those who complete treatment, although treatment non-completion remains a significant barrier to recovery. Future studies should focus on improving treatment retention, as evidence suggests that CBT-ED in ‘real-world’ settings is effective.
Collapse
|
12
|
Gumz A, Kästner D, Weigel A, Daubmann A, Osen B, Karacic M, Wollburg E, Voderholzer U, Löwe B. The change process in adult anorexia nervosa inpatient treatment: a path model. Eat Weight Disord 2018; 23:313-320. [PMID: 27826742 DOI: 10.1007/s40519-016-0341-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Knowledge on the change process in the treatment of anorexia nervosa (AN) is an important starting point for the improvement of treatment, yet very little evidence exists. In an exploratory analysis, we aimed to investigate the interdependencies between higher-rank change process factors, BMI and AN-specific cognitions and behaviours over the course of inpatient treatment. METHODS We included 176 female adult AN inpatients from three specialized centres. The temporal interdependencies between the change factors and the outcome variables over the course of treatment (t0: beginning, t1: mid-treatment, t2: end) were investigated using a path model. RESULTS The sample had a mean age of 27.1 years (SD = 8.9 years) and a mean BMI at admission of 15.0 kg/m2 (SD = 1.6 kg/m2). A greater basic need satisfaction and a greater emotional involvement and commitment to treatment at t0 positively influenced the BMI at t1. Furthermore, greater basic need satisfaction at t0 led to less AN-specific cognitions and behaviours at t2. CONCLUSIONS The results are discussed with respect to the self-determination theory and the consistency theory. Further research on the change process in AN treatment is recommended.
Collapse
Affiliation(s)
- Antje Gumz
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schön Clinic Hamburg Eilbek, Hamburg, Germany
| | - Denise Kästner
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schön Clinic Hamburg Eilbek, Hamburg, Germany.
| | - Angelika Weigel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schön Clinic Hamburg Eilbek, Hamburg, Germany
| | - Anne Daubmann
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | - Ulrich Voderholzer
- Schön Clinic Roseneck Prien, Prien am Chiemsee, Germany.,Department of Psychiatry and Psychotherapy, University Hospital Freiburg, Freiburg im Breisgau, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf and Schön Clinic Hamburg Eilbek, Hamburg, Germany
| |
Collapse
|
13
|
Mander J, Neubauer AB, Schlarb A, Teufel M, Bents H, Hautzinger M, Zipfel S, Wittorf A, Sammet I. The therapeutic alliance in different mental disorders: A comparison of patients with depression, somatoform, and eating disorders. Psychol Psychother 2017; 90:649-667. [PMID: 28497909 DOI: 10.1111/papt.12131] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 02/23/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The therapeutic alliance is intensively investigated in psychotherapy research. However, there is scarce research on the role of the specific diagnosis of the patient in the formation of the therapeutic alliance. Hence, the aim of this study was to address this research gap by comparing the alliance in different mental disorders. DESIGN Our sample comprised 348 patients (mean age = 40 years; 68% female; 133 patients with depression, 122 patients with somatoform disorders, and 93 patients with eating disorders). METHODS Patients completed the Working Alliance Inventory and measures of therapeutic outcome in early, middle, and late stages of inpatient psychotherapy. We applied multivariate multilevel models to address the nested data structure. RESULTS All three disorder groups experienced positive alliances that increased across the course of therapy and showed similar alliance-outcome relations that were of comparable strengths as in current meta-analyses. However, we found perspective incongruence of alliance ratings from patient and therapist in the three disorder groups. CONCLUSIONS Our results generally indicate that the working alliance is of importance irrespective of the specific mental disorder. Perspective incongruence feedback of working alliance experiences could help to strengthen coordination between patient and therapist and thereby improve the therapeutic process. Further implications of these findings are discussed. PRACTITIONER POINTS We found no differences in the strengths of alliance ratings and alliance-outcome associations in depressive, somatoform, and eating disorder patients. This indicates that the working alliance is of general clinical importance irrespective of the disorder group and should be a central target in all therapies. We found perspective incongruence in alliance ratings between patient and therapist in all three disorder groups. Perspective incongruence feedback of working alliance experiences could help to strengthen coordination between patient and therapist and thereby improve the therapeutic process.
Collapse
Affiliation(s)
- Johannes Mander
- Department of Psychosomatic Medicine and Psychotherapy, University of Tuebingen, Germany.,Center for Psychological Psychotherapy, University of Heidelberg, Germany
| | | | - Angelika Schlarb
- Department of Clinical Psychology, University of Bielefeld, Germany
| | - Martin Teufel
- Department of Psychosomatic Medicine and Psychotherapy, University of Tuebingen, Germany
| | - Hinrich Bents
- Center for Psychological Psychotherapy, University of Heidelberg, Germany
| | - Martin Hautzinger
- Department of Clinical and Developmental Psychology, University of Tuebingen, Germany
| | - Stephan Zipfel
- Department of Psychosomatic Medicine and Psychotherapy, University of Tuebingen, Germany
| | - Andreas Wittorf
- Department of Psychiatry and Psychotherapy, University of Tuebingen, Germany
| | - Isa Sammet
- Department of Psychosomatic Medicine and Psychotherapy, University of Tuebingen, Germany
| |
Collapse
|
14
|
Zugai JS, Stein-Parbury J, Roche M. The nature of the therapeutic alliance between nurses and consumers with Anorexia Nervosa in the inpatient setting: A mixed-methods study. J Clin Nurs 2017; 27:416-426. [DOI: 10.1111/jocn.13944] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Joel S. Zugai
- Australian Catholic University; Banyo QLD Australia
- University of Technology Sydney; Ultimo NSW Australia
| | | | | |
Collapse
|
15
|
Graves TA, Tabri N, Thompson-Brenner H, Franko DL, Eddy KT, Bourion-Bedes S, Brown A, Constantino MJ, Flückiger C, Forsberg S, Isserlin L, Couturier J, Paulson Karlsson G, Mander J, Teufel M, Mitchell JE, Crosby RD, Prestano C, Satir DA, Simpson S, Sly R, Lacey JH, Stiles-Shields C, Tasca GA, Waller G, Zaitsoff SL, Rienecke R, Le Grange D, Thomas JJ. A meta-analysis of the relation between therapeutic alliance and treatment outcome in eating disorders. Int J Eat Disord 2017; 50:323-340. [PMID: 28152196 DOI: 10.1002/eat.22672] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/12/2016] [Accepted: 12/12/2016] [Indexed: 12/11/2022]
Abstract
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, βs = 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.
Collapse
Affiliation(s)
- Tiffany A Graves
- Eating Disorders Clinical and Research Program (EDCRP), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Nassim Tabri
- Eating Disorders Clinical and Research Program (EDCRP), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Heather Thompson-Brenner
- Eating Disorders Clinical and Research Program (EDCRP), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Debra L Franko
- Eating Disorders Clinical and Research Program (EDCRP), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Kamryn T Eddy
- Eating Disorders Clinical and Research Program (EDCRP), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | | | - Amy Brown
- Eating Disorder Service, South London and Maudsley NHS Foundation Trust, London, England, United Kingdom
| | - Michael J Constantino
- Department of Psychological and Brain Sciences, University of Massachusetts-Amherst, Amherst, Massachusetts, United States
| | - Christoph Flückiger
- Department of Psychology, University of Wisconsin-Madison, Madison, Wisconsin, United States and Institute fur Psychologie, University of Bern, Bern, Switzerland
| | - Sarah Forsberg
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, United States
| | - Leanna Isserlin
- Division of Child & Adolescent Psychiatry, University of Ottawa, Ottawa, Ontario, Canada
| | - Jennifer Couturier
- Pediatric Eating Disorders Program, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | | | - Johannes Mander
- ZZP Center for Psychological Psychotherapy, University of Heidelberg, Heidelberg, Germany
| | - Martin Teufel
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, Tuebingen, Germany and Clinic for Psychosomatic Medicine and Psychotherapy, University of Duisburg-Essen, Essen, Germany
| | - James E Mitchell
- Neuropsychiatric Research Institute, Fargo, North Dakota, United States and University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota, United States
| | - Ross D Crosby
- Neuropsychiatric Research Institute, Fargo, North Dakota, United States and University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota, United States
| | | | - Dana A Satir
- Department of Psychiatry, University of Colorado Denver, Denver, Colorado, United States
| | - Susan Simpson
- School of Psychology, Social Work, and Social Policy, University of South Australia, South Australia, Australia
| | - Richard Sly
- School of Nursing Science, University of East Anglia, Norwich, Norfolk, United Kingdom
| | - J Hubert Lacey
- Department of Health and Social Care Sciences, St. George's, University of London, London, England, United Kingdom
| | - Colleen Stiles-Shields
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine and The School of Social Service Administration, University of Chicago, Chicago, Illinois, United States
| | - Giorgio A Tasca
- Brain and Mind Research Institute, University of Ottawa and the Ottawa Hospital, Ottawa, Ontario, Canada
| | - Glenn Waller
- Department of Psychology, University of Sheffield, Sheffield, United Kingdom
| | - Shannon L Zaitsoff
- Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Renee Rienecke
- The University of Michigan Comprehensive Eating Disorders Program, Ann Arbor, Michigan, United States
| | - Daniel Le Grange
- Department of Psychiatry, University of California, San Francisco, California, United States
| | - Jennifer J Thomas
- Eating Disorders Clinical and Research Program (EDCRP), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, United States
| |
Collapse
|
16
|
Danielsen YS, Årdal Rekkedal G, Frostad S, Kessler U. Effectiveness of enhanced cognitive behavioral therapy (CBT-E) in the treatment of anorexia nervosa: a prospective multidisciplinary study. BMC Psychiatry 2016; 16:342. [PMID: 27716162 PMCID: PMC5053175 DOI: 10.1186/s12888-016-1056-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 09/29/2016] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Anorexia nervosa (AN) is a debilitating psychiatric disorder associated with a wide array of negative health complications and psychiatric comorbidity. Existing evidence for AN treatment in adults is weak, and no empirically supported treatment has been reliably established. The primary objective of this study is to gain knowledge about the effectiveness of enhanced cognitive behavioral therapy (CBT-E) for anorexia nervosa delivered in a public hospital setting. Baseline predictors of treatment outcome and dropout are studied. Furthermore, there will be collected blood and stool samples for a general biobank to be able to initiate research on possible pathophysiological mechanisms underlying AN. METHODS The study will assess the potency of outpatient CBT-E in a sample of patients suffering from AN (age >16) admitted to the Section for Eating Disorders at the Department for Psychosomatic Medicine, Haukeland University Hospital in Bergen, Norway. The study has a longitudinal design with five main assessment time points: before treatment, at 3 months, at the end of treatment, at 20 weeks, and at 12 months follow-up including biobank samples. A control group without an eating disorder will also be recruited. DISCUSSION Treatment research in a public hospital setting is important for gaining knowledge about the transportability of treatments evaluated in research clinics into ordinary clinical practice. Furthermore, biological material from the thoroughly described patient cohort will serve as a basis for further research on the pathophysiological mechanisms in AN. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02745067 . Registered 14 April 2016. .
Collapse
Affiliation(s)
- Yngvild S. Danielsen
- Department of Clinical Psychology, University of Bergen, Christiesgt.12, Po.box. 7800, 5021 Bergen, Norway
| | - Guro Årdal Rekkedal
- Division of Psychiatry, Haukeland University Hospital, Haukelandsveien.22, Po.box. 1400, 5021 Bergen, Norway
| | - Stein Frostad
- Division of Psychiatry, Haukeland University Hospital, Haukelandsveien.22, Po.box. 1400, 5021 Bergen, Norway
| | - Ute Kessler
- Division of Psychiatry, Haukeland University Hospital, Haukelandsveien.22, Po.box. 1400, 5021 Bergen, Norway
| |
Collapse
|
17
|
van der Kaap-Deeder J, Smets J, Boone L. The Impeding Role of Self-Critical Perfectionism on Therapeutic Alliance During Treatment and Eating Disorder Symptoms at Follow-up in Patients with an Eating Disorder. Psychol Belg 2016; 56:101-110. [PMID: 30479431 PMCID: PMC5854110 DOI: 10.5334/pb.297] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study examines the impeding role of self-critical perfectionism at onset of treatment on therapeutic alliance during treatment and eating disorder symptoms at follow-up in patients with an eating disorder. Participants were 53 female patients with a mean age of 21.1 years treated for an eating disorder in a specialized inpatient treatment unit. Self-critical perfectionism was assessed at admission, therapeutic alliance was assessed during treatment (after three months of treatment), and eating disorder symptoms were assessed at admission, after three months and one year later. Self-critical perfectionism negatively related to treatment alliance with the therapist. Although self-critical perfectionism was not directly predictive of subsequent changes in eating disorder symptoms, it was indirectly related to less reduction in body dissatisfaction through the therapeutic alliance. These results point to the importance of self-critical perfectionism in the therapeutic alliance and in changes in body image problems. Treatment implications are discussed.
Collapse
Affiliation(s)
| | - Jos Smets
- Psychiatric nurse, Alexian Brothers Psychiatric Hospital (Unit Ter Berken), Tienen, Belgium
| | - Liesbet Boone
- Department of Developmental, Social, and Personality Psychology, Ghent University, Ghent, Belgium
| |
Collapse
|
18
|
Stiles-Shields C, Bamford BH, Touyz S, Le Grange D, Hay P, Lacey H. Predictors of therapeutic alliance in two treatments for adults with severe and enduring anorexia nervosa. J Eat Disord 2016; 4:13. [PMID: 27054037 PMCID: PMC4822323 DOI: 10.1186/s40337-016-0102-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 03/29/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Therapeutic alliance (TA) has been found to be a significant predictor of outcome for patients with severe and enduring anorexia nervosa (SE-AN), accounting for more variance than treatment type. To better understand how to promote TA for this population, the aim of the current study was to investigate predictors of TA in adults with SE-AN. METHODS Participants were 63 adult females with SE-AN presenting to an outpatient, multi-site randomized controlled trial conducted at two clinical sites. Participants' perception of the quality of their therapeutic relationship, demographic information, and eating disorder symptomatology were assessed via interview and questionnaire measures. RESULTS Baseline ratings of how successful participants believed treatment would be for them was the only variable to significantly predict early (p = .01), mid (p = .009), and late treatment alliance (p = .03). No other variables investigated predicted the quality of patient rated TA at any point in treatment (ps > .57). CONCLUSIONS Results suggest instilling hope in treatment outcome may enhance TA, and in turn, outcomes for patients with SE-AN in outpatient therapy.
Collapse
Affiliation(s)
- Colleen Stiles-Shields
- />Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | | | - Stephen Touyz
- />University of Sydney, School of Psychology, Sydney, Australia
| | - Daniel Le Grange
- />Department of Psychiatry, University of California, San Francisco, San Francisco, CA USA
- />Department of Pediatrics, University of California, San Francisco, San Francisco, CA USA
| | - Phillipa Hay
- />Centre for Health Research, School of Medicine, Western Sydney University, Sydney, Australia
| | - Hubert Lacey
- />St. George’s, University of London, Eating Disorders Research Group, London, UK
| |
Collapse
|
19
|
Turner H, Marshall E, Wood F, Stopa L, Waller G. CBT for eating disorders: The impact of early changes in eating pathology on later changes in personality pathology, anxiety and depression. Behav Res Ther 2016; 77:1-6. [DOI: 10.1016/j.brat.2015.11.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/22/2015] [Accepted: 11/23/2015] [Indexed: 10/22/2022]
|
20
|
Waller G, Turner H. Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track. Behav Res Ther 2015; 77:129-37. [PMID: 26752326 DOI: 10.1016/j.brat.2015.12.005] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 12/08/2015] [Accepted: 12/13/2015] [Indexed: 12/22/2022]
Abstract
Therapist drift occurs when clinicians fail to deliver the optimum evidence-based treatment despite having the necessary tools, and is an important factor in why those therapies are commonly less effective than they should be in routine clinical practice. The research into this phenomenon has increased substantially over the past five years. This review considers the growing evidence of therapist drift. The reasons that we fail to implement evidence-based psychotherapies are considered, including our personalities, knowledge, emotions, beliefs, behaviours and social milieus. Finally, ideas are offered regarding how therapist drift might be halted, including a cognitive-behavioural approach for therapists that addresses the cognitions, emotions and behaviours that drive and maintain our avoidance of evidence-based treatments.
Collapse
Affiliation(s)
- Glenn Waller
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Western Bank, Sheffield, S10 2NT, UK.
| | - Hannah Turner
- Southern Health Eating Disorders Service, Southern Health NHS Foundation Trust, Southampton, UK
| |
Collapse
|
21
|
Vrabel KR, Ulvenes PG, Wampold B. Alliance and symptom improvement in inpatient treatment for eating disorder patients: A study of within-patient processes. Int J Eat Disord 2015; 48:1113-21. [PMID: 26340980 DOI: 10.1002/eat.22434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2015] [Indexed: 11/12/2022]
Abstract
OBJECTIVE This study examined the reciprocal relationship between alliance and symptoms during treatment for patients with eating disorders (ED). METHODS Ninety one patients with EDs received inpatient cognitive-behavioral therapy treatment over 14 weeks. The study used repeated measurements during treatment and collected alliance and symptom measures. The analysis separated the effects of alliance and symptoms into between- and within-patient effects in a multilevel analysis. RESULTS The results show a reciprocal relationship with between-patient alliance predicting ED symptoms and between-patient ED symptoms predicting alliance the subsequent weeks. However, for within-patient effects only alliance predicted ED symptoms the subsequent week. DISCUSSION The results nuance the effect of the alliance in this patient group, and paint a complex picture of alliance in the psychotherapy process.
Collapse
Affiliation(s)
| | | | - Bruce Wampold
- Research Institute of Modum Bad, Vikersund, Norway.,University of Wisconsin-Madison
| |
Collapse
|
22
|
Gumz A, Kästner D, Raczka KA, Weigel A, Osen B, Rose M, Meyer B, Wollburg E, Voderholzer U, Karacic M, Vettorazzi E, Löwe B. Aggregating factors of the change process in the treatment of anorexia nervosa. Eat Behav 2015. [PMID: 26202211 DOI: 10.1016/j.eatbeh.2015.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE We aimed to reduce the large body of factors which may be associated with the change process in treatments for Anorexia Nervosa (AN) into a clinically and scientifically useful number of higher-rank dimensions. In addition, we examined the associations between the identified factors and eating disorder psychopathology and body mass index (BMI) in exploratory analyses. METHODS Within a naturalistic multicenter study we administered the Change Process Questionnaire (CPQ-AN) to inpatients with AN upon admission. The factorial structure of the CPQ-AN was explored via factor analysis. Multiple regression analyses were performed to examine the associations with BMI and eating disorder symptomatology (EDI-2). RESULTS In total 233 female inpatients with AN (mean BMI=14.9 kg/m(2), SD=1.7) participated. The factor analysis yielded four latent factors: basic need satisfaction, AN-specific cognitions and behavior, emotional involvement and commitment to treatment, and alliance and treatment confidence. Furthermore, greater basic need satisfaction and less AN-specific cognitions and behavior predicted lower EDI-2 scores. Higher alliance and treatment confidence were associated with higher BMI as well as a lower EDI-2 score. CONCLUSION The associations between the newly derived dimensions and BMI and AN-psychopathology provide evidence to support the clinical relevance of the identified change process dimensions. Future investigations could provide further insights to deepen our understanding of the change process in AN.
Collapse
Affiliation(s)
- Antje Gumz
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, and Schön Clinic Hamburg Eilbek, Hamburg, Germany.
| | - Denise Kästner
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, and Schön Clinic Hamburg Eilbek, Hamburg, Germany
| | - Karolina A Raczka
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, and Schön Clinic Hamburg Eilbek, Hamburg, Germany
| | - Angelika Weigel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, and Schön Clinic Hamburg Eilbek, Hamburg, Germany
| | | | - Matthias Rose
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, and Schön Clinic Hamburg Eilbek, Hamburg, Germany; Department of Psychosomatic Medicine and Psychotherapy, University Medical Center, Charité, Berlin, Germany
| | - Björn Meyer
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, and Schön Clinic Hamburg Eilbek, Hamburg, Germany; Department of Psychology, City University, London, UK
| | - Eileen Wollburg
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, and Schön Clinic Hamburg Eilbek, Hamburg, Germany; The Pennsylvania State University, Altoona, USA
| | - Ulrich Voderholzer
- Schön Clinic Roseneck Prien, Germany; Department of Psychiatry and Psychotherapy, University Hospital Freiburg, Germany
| | - Matislava Karacic
- Schön Clinic Roseneck Prien, Germany; Department of Psychiatry and Psychotherapy, University Hospital Freiburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, and Schön Clinic Hamburg Eilbek, Hamburg, Germany
| |
Collapse
|
23
|
Turner H, Bryant-Waugh R, Marshall E. The impact of early symptom change and therapeutic alliance on treatment outcome in cognitive-behavioural therapy for eating disorders. Behav Res Ther 2015; 73:165-9. [DOI: 10.1016/j.brat.2015.08.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/06/2015] [Accepted: 08/14/2015] [Indexed: 10/23/2022]
|
24
|
Multiple measures of rapid response as predictors of remission in cognitive behavior therapy for bulimia nervosa. Behav Res Ther 2015; 64:9-14. [DOI: 10.1016/j.brat.2014.11.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Revised: 10/02/2014] [Accepted: 11/05/2014] [Indexed: 11/18/2022]
|
25
|
Zaitsoff S, Pullmer R, Cyr M, Aime H. The role of the therapeutic alliance in eating disorder treatment outcomes: a systematic review. Eat Disord 2015; 23:99-114. [PMID: 25330409 DOI: 10.1080/10640266.2014.964623] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
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.
Collapse
Affiliation(s)
- Shannon Zaitsoff
- a Department of Psychology , Simon Fraser University , Burnaby , British Columbia , Canada
| | | | | | | |
Collapse
|
26
|
Gutiérrez E, Carrera O. Psychotherapy in anorexia nervosa: What does the absence of evidence mean? World J Transl Med 2014; 3:150-157. [DOI: 10.5528/wjtm.v3.i3.150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 09/01/2014] [Accepted: 10/10/2014] [Indexed: 02/05/2023] Open
Abstract
Psychological treatment in anorexia nervosa (AN) is disheartening. Psychotherapy is the “treatment of choice” for adults though this recommendation is grounded on the absence of good quality clinical studies. This paper seeks to address the question of why improvements in the psychological treatment of AN have been thwarted, and why one of the best treatments available for adult patients is specialist supportive clinical management that has entered the stage through the backdoor of nonspecific supportive treatments originally serving as a placebo treatment assigned in randomized clinical trials to control for non-specific aspects of true psychosocial treatments. The possibility that most of the psychopathological features that characterise the AN symptoms profile could be best understood as the direct consequences of emaciation would enhance the utility of research with animal models for generating new hypothesis to improve AN treatment.
Collapse
|
27
|
Brauhardt A, de Zwaan M, Hilbert A. The therapeutic process in psychological treatments for eating disorders: a systematic review. Int J Eat Disord 2014; 47:565-84. [PMID: 24796817 DOI: 10.1002/eat.22287] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 03/29/2014] [Accepted: 04/01/2014] [Indexed: 11/12/2022]
Abstract
OBJECTIVE For eating disorders, a vast number of investigations have demonstrated the efficacy of psychological treatments. However, evidence supporting the impact of therapeutic process aspects on outcome (i.e., process-outcome research) has not been disentangled. METHOD Using the Generic Model of Psychotherapy (GMP) to organize various process aspects, a systematic literature search was conducted on psychological treatment studies for anorexia nervosa, bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified. RESULTS Improved outcomes resulted for family-based treatment compared to individual treatment, for individual compared to group treatment, booster sessions, and positive patient expectations (GMP contract aspect); for nutritional counseling and exercising but not exposure with response prevention as adjunct interventions (therapeutic operations); for highly motivated patients and, to a lesser extent, for therapeutic alliance (therapeutic bond); as well as for rapid response and longer overall treatment duration (temporal patterns). Regarding other GMP aspects, studies on self-relatedness were completely lacking and in-session impacts were rarely investigated. DISCUSSION As most studies assessed only a limited number of process aspects, the ability to draw conclusions about their overall impact regarding outcome is rather limited. Therefore, future process-outcome research is needed beyond investigations of treatment efficacy for eating disorders.
Collapse
Affiliation(s)
- Anne Brauhardt
- Leipzig University Medical Center, Medical Psychology and Medical Sociology, Integrated Research and Treatment Center AdiposityDiseases, Philipp-Rosenthal-Strasse 27, 04103, Leipzig, Germany
| | | | | |
Collapse
|
28
|
Clinician and practice characteristics influencing delivery and outcomes of the early part of outpatient cognitive behavioural therapy for anorexia nervosa. COGNITIVE BEHAVIOUR THERAPIST 2014. [DOI: 10.1017/s1754470x14000105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractCognitive-behavioural therapy (CBT) can be effective for anorexia nervosa. However, there is evidence that the delivery of treatments for the eating disorders is inconsistent. This study examined evidence that clinician characteristics and practice can influence the effective implementation of CBT. The participants were 100 qualified clinicians who routinely offered outpatient CBT to adults with anorexia nervosa. They completed a survey of their demographic characteristics, level of anxiety, clinical practice in CBT for anorexia nervosa, and beliefs about the relationship between weight gain and therapeutic alliance in the early part of such treatment. Greater reported levels of weight gain were associated with the use of manuals, early focus on weight gain as a target, structured eating, and a belief that weight gain precedes a good working alliance. Clinician anxiety and early focus on the therapeutic alliance rather than structured eating were associated with poorer outcomes. These conclusions need to be tested within clinical and research settings. However, they suggest that clinicians should be encouraged to use manual-based approaches when treating anorexia nervosa using CBT, as focusing on techniques might result in the best possible outcome in this early part of treatment.
Collapse
|
29
|
Raykos BC, McEvoy PM, Erceg-Hurn D, Byrne SM, Fursland A, Nathan P. Therapeutic alliance in Enhanced Cognitive Behavioural Therapy for bulimia nervosa: Probably necessary but definitely insufficient. Behav Res Ther 2014; 57:65-71. [DOI: 10.1016/j.brat.2014.04.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 04/09/2014] [Accepted: 04/16/2014] [Indexed: 01/13/2023]
|
30
|
Turner H, Tatham M, Lant M, Mountford VA, Waller G. Clinicians' concerns about delivering cognitive-behavioural therapy for eating disorders. Behav Res Ther 2014; 57:38-42. [PMID: 24793719 DOI: 10.1016/j.brat.2014.04.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 04/05/2014] [Accepted: 04/09/2014] [Indexed: 12/29/2022]
Abstract
Despite research supporting the effectiveness of evidence-based interventions in the treatment of eating disorders, those interventions are under-utilised in routine clinical practice, possibly due to clinicians' concerns about delivering the relevant techniques. This study examined what elements of therapy clinicians worry about when delivering cognitive-behavioural therapy (CBT) for the eating disorders, and what clinician variables are associated with such concerns. The participants were 113 clinicians who used individual CBT with eating disorder patients. They completed a novel measure of concerns about delivering elements of CBT, as well as demographic characteristics and a standardised measure of intolerance of uncertainty. Clinicians worried most about body image work and ending treatment, but least about delivering psychoeducation. Their concerns fell into four distinct factors. Older, more experienced clinicians worried less about delivering the CBT techniques, but those with greater levels of prospective and inhibitory anxiety worried more about specific factors in the CBT techniques. Clinicians' capacity to tolerate uncertainty might impair their delivery of evidence-based CBT, and merits consideration as a target in training and supervision of CBT clinicians.
Collapse
Affiliation(s)
- Hannah Turner
- Southern Health Eating Disorders Service, Southern Health NHS Foundation Trust, Southampton, UK
| | | | - Marie Lant
- Barnsley Specialist Adult Learning Disability Health Service, South West Yorkshire Partnership NHS Foundation Trust, UK
| | - Victoria A Mountford
- South London and Maudsley Eating Disorder Service, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Psychiatry, King's College London, London, UK
| | - Glenn Waller
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Western Bank, Sheffield S10 2NT, UK.
| |
Collapse
|
31
|
Brown A, Mountford VA, Waller G. Is the therapeutic alliance overvalued in the treatment of eating disorders? Int J Eat Disord 2013; 46:779-82. [PMID: 23983066 DOI: 10.1002/eat.22177] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Revised: 04/17/2013] [Accepted: 07/20/2013] [Indexed: 11/06/2022]
Abstract
In this article, we make the case for a systematic program of research into the causal relationship between the therapeutic alliance and outcomes of psychological treatments for the eating disorders. To make that case, we need to begin by considering the validity of existing assumptions about that alliance-outcome relationship. We will then suggest what research is needed to allow clinicians to structure their work to best effect (e.g., should therapists focus on establishing a strong alliance even if it means not applying more therapy-specific techniques, or should they stress the application of those techniques even when the working alliance might seem likely to be weakened as a result). Although the authors have a background in cognitive-behavioral therapy (CBT), our aim is to suggest a research base that applies to a variety of psychotherapies, allowing for common or different conclusions about the alliance-outcome relationship, depending on what the proposed research indicates.
Collapse
Affiliation(s)
- Amy Brown
- Department of Psychological Medicine, Institute of Psychiatry, King's College London, United Kingdom
| | | | | |
Collapse
|
32
|
da Conceição Costa DL, Shavitt RG, Castro Cesar RC, Joaquim MA, Borcato S, Valério C, Miguel EC, Diniz JB. Can early improvement be an indicator of treatment response in obsessive-compulsive disorder? Implications for early-treatment decision-making. J Psychiatr Res 2013; 47:1700-7. [PMID: 23948637 DOI: 10.1016/j.jpsychires.2013.07.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 07/03/2013] [Accepted: 07/05/2013] [Indexed: 10/26/2022]
Abstract
UNLABELLED In major depression, early response to treatment has been strongly associated with final outcome. We aimed to investigate the ability of early improvement (4 weeks) to predict treatment response at 12 weeks in DSM-IV-defined obsessive-compulsive disorder (OCD) patients treated with serotonin reuptake inhibitors (SRI). We conducted an SRI practical trial with 128 subjects. INCLUSION CRITERIA age range 18-65 years-old, baseline Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score ≥ 16, and absence of previous adequate pharmacological treatment. Systematic assessments were performed at baseline, 4 and 12 weeks of treatment. Treatment response at 12 weeks was defined as a 35% or greater reduction in baseline Y-BOCS score. Stepwise logistic regression was used to test the relationship between early improvement and treatment response at 12 weeks, taking into account additional potential predictive factors. Different thresholds of early improvement were tested and their predictive power was calculated. Early improvement, defined as a 20% or greater reduction from baseline Y-BOCS score at 4 weeks, predicted response at 12 weeks with 75.6% sensitivity and 61.9% specificity. According to a logistic regression including demographic and clinical features as explaining variables, early improvement was the best predictor of treatment response (OR = 1.05, p < 0.0001). Only 19.8% of patients who did not improve at 4 weeks were responders after 12 weeks. In contrast, 55.3% of the individuals who showed early improvement were responders at 12 weeks (Pearson Chi-Square = 17.06, p < 0.001). Early improvement predicted OCD treatment response with relatively good sensitivity and specificity, such that its role in early decision-making warrants further investigation in wider samples. TRIAL REGISTRATION clinicaltrials.gov Identifier NCT00680602.
Collapse
|
33
|
Emotion regulation in broadly defined anorexia nervosa: Association with negative affective memory bias. Behav Res Ther 2013; 51:417-24. [DOI: 10.1016/j.brat.2013.04.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 04/17/2013] [Accepted: 04/17/2013] [Indexed: 11/24/2022]
|