Is the therapeutic alliance overvalued in the treatment of eating disorders?
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.
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TA is fundamental in building adherence or engagement with therapy.
“TA is fundamental in building adherence or engagement with therapy (24, 54, 55).”
From Digital Therapeutic Alliance With Fully Automated Mental Health Smartphone Apps: A Narrative Review (2022) · cites this paper as [54]
The real value of a strong alliance may lie in its capacity to promote therapeutic engagement as opposed to contributing to clinical improvement.
“it has recently been proposed that the real value of a strong alliance may lie in its capacity to promote therapeutic engagement as opposed to contributing to clinical improvement [11].”
From Therapeutic alliance with a fully automated mobile phone and web-based intervention: secondary analysis of a randomized controlled trial (2016) · cites this paper as [11]
Relations between therapeutic alliance features and program engagement are potentially reciprocal, such that a strong alliance predicts increased program interactions and vice versa.
“relations between therapeutic alliance features and program engagement are potentially reciprocal, such that a strong alliance predicts increased program interactions and vice versa [11].”
From Therapeutic alliance with a fully automated mobile phone and web-based intervention: secondary analysis of a randomized controlled trial (2016) · cites this paper as [11]
Users may engage with an Internet intervention to the extent that they experience a collaborative partnership that is working well, just as in face-to-face therapy.
“suggesting that users may engage with an Internet intervention to the extent that they experience a collaborative partnership that is working well, just as in face-to-face therapy [11].”
From Therapeutic alliance with a fully automated mobile phone and web-based intervention: secondary analysis of a randomized controlled trial (2016) · cites this paper as [11]
Positive associations have been found between the therapeutic alliance and treatment engagement.
“Positive associations have also been found between the therapeutic alliance and treatment engagement [11,12].”
From Therapeutic alliance with a fully automated mobile phone and web-based intervention: secondary analysis of a randomized controlled trial (2016) · cites this paper as [11]
Cites
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Alliance predicts patients' outcome beyond in-treatment change in symptoms.
Barber, J. P., Connolly, M. B., Crits-Christoph, P. F., Gladis, L., & Siqueland, L. (2000) · Journal of Consulting and Clinical Psychology · doi:10.1037//0022-006x.68.6.1027 · Cited by 348 · see citing works
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Tang, T. Z., & DeRubeis, R. (1999) · Journal of Consulting and Clinical Psychology · doi:10.1037//0022-006x.67.6.894 · Cited by 284 · see citing works
Alliance predicts patients' outcome beyond in-treatment change in symptoms.
Barber, J. P., Connolly, M. B., Crits-Christoph, P. F., Gladis, L., & Siqueland, L. (2000) · Journal of Consulting and Clinical Psychology · doi:10.1037/0022-006x.68.6.1027 · Cited by 229 · see citing works
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The research–practice Gap: Bridging the schism between eating disorder researchers and practitioners
Lilienfeld, S. O., Ritschel, L. A., Lynn, S. J., Brown, A. P., Cautin, R. L., & Latzman, R. D. (2013) · International Journal of Eating Disorders · doi:10.1002/eat.22090 · Cited by 59 · see citing works
Self-citationTherapeutic alliance and weight gain during cognitive behavioural therapy for anorexia nervosa
Brown, A., Mountford, V., & Waller, G. (2013) · Behaviour Research and Therapy · doi:10.1016/j.brat.2013.01.008 · Cited by 48 · see citing works
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Waller, G., & Turner, H. (2016) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.12.005 · Cited by 256 · see citing works
Self-citationTremain, H., McEnery, C., Fletcher, K., & Murray, G. (2020) · JMIR Mental Health · doi:10.2196/17204 · Cited by 193 · see citing works
Graves, T. A., Tabri, N., Thompson‐Brenner, H., Franko, D. L., Eddy, K. T., Bourion‐Bedes, S., Brown, A., Constantino, M. J., Flückiger, C., Forsberg, S., et al. (2017) · International Journal of Eating Disorders · doi:10.1002/eat.22672 · Cited by 196 · see citing works
Digital Therapeutic Alliance With Fully Automated Mental Health Smartphone Apps: A Narrative Review
Tong, F., Lederman, R., D'Alfonso, S., Berry, K., & Bucci, S. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.819623 · Cited by 106 · see citing works
“TA is fundamental in building adherence or engagement with therapy (24, 54, 55).”
BackgroundClarke, J., Proudfoot, J., Whitton, A., Birch, M.-R., Boyd, M., Parker, G., Manicavasagar, V., Hadzi-Pavlovic, D., & Fogarty, A. (2016) · JMIR Mental Health · doi:10.2196/mental.4656 · Cited by 86 · see citing works
Waller, G. (2016) · Current Psychiatry Reports · doi:10.1007/s11920-016-0679-0 · Cited by 83 · see citing works
Turner, H., Bryant-Waugh, R., & Marshall, E. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.08.006 · Cited by 45 · see citing works
Mander, J., Neubauer, A. B., Schlarb, A., Teufel, M., Bents, H., Hautzinger, M., Zipfel, S., Wittorf, A., & Sammet, I. (2017) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12131 · Cited by 27 · see citing works
Olofsson, M. E., Vrabel, K. R., Hoffart, A., & Oddli, H. W. (2022) · Journal of Eating Disorders · doi:10.1186/s40337-022-00566-1 · Cited by 11 · see citing works
“However, while the alliance quality has repeatedly proven to be a reliable predictor of moderate size for treatment outcome across disorders and orientations [21, 22], its role in ED treatment has been unclear [23, 24].”
Background
- Authors
- Brown, A., Mountford, V. A., & Waller, G.
- Affiliations
- King's College London (GB)
- University of Sheffield (GB)
- Venue
- International Journal of Eating Disorders
- Publisher
- Wiley
- Published
- 2013-08-28
- Volume
- 46
- Issue
- 8
- Pages
- 779-782
- ISSN
- 0276-3478 (ISSN-L)
- 1098-108X
- OpenAlex
- W2148525742
- Cited by
- 39
- References
- 14
- Citations by year
- 2026: 1 · 2025: 4 · 2024: 1 · 2023: 2 · 2022: 7 · 2021: 2 · 2020: 1 · 2019: 2 · 2018: 2 · 2017: 4 · 2016: 5 · 2015: 7 · 2014: 1
- FWCI
- 4.82
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- International Journal of Eating Disorders (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Keywords
- therapeutic relationship, eating disorders, treatment outcomes, causal relationship, psychotherapy, cognitive behavioral therapy
- MeSH terms
- Feeding and Eating Disorders, Humans, Interpersonal Relations, Professional-Patient Relations, Psychotherapy, Research Design, Reproducibility of Results, Treatment Outcome, Benchmarking
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