Understanding the working alliance between clients diagnosed with Anorexia Nervosa and therapists in individual psychotherapy: A phenomenological approach

The therapeutic working alliance is a vital ingredient to psychotherapy, specifically clients diagnosed with Anorexia Nervosa (AN), as progress is often slow and treatment difficult. This phenomenological study investigated the experiences of eight clients with AN and seven therapists who worked with this population regarding what therapist factors aided in and challenged the working alliance formation in individual psychotherapy. Phenomenology was the methodology used to guide this study and data were gathered through semi-structured interviews. Findings revealed the following helpful therapist factors in alliance formation: strong basic counseling skills, strengthsbased approach, collaboration with external systems, appropriate self-disclosure, expertise and experience treating eating disorders, individualizing treatment, willingness to be contacted outside of session, warm and safe office environment, awareness of personal reactions toward the client, and seeking supervision. Unhelpful therapist factors included lack of attunement to clients’ needs, judgmental/invalidating attitude, failure to individualize treatment, lack of confidence and competence, and lack of objectivity. 344 THERAPIST FACTORS INFLUENCING THE WORKING ALLIANCE IN INDIVIDUAL PSYCHOTHERAPYWITH ANOREXIA NERVOSA Introduction I realize that this is a very deadly disease. I realize that we are literally starving to death and that our lives are literally on the table, but if you move too fast, we just run harder and die faster. People don’t realize that if they run in, wanting to save our lives, they end up struggling because they move too quickly and scare us. It’s like a horse. You don’t go running up to a horse in a pasture; it spooks them. Kelly (client participant) Anorexia Nervosa (AN) is a serious psychiatric disorder with a lifetime prevalence rate of approximately . 5% and an estimated long-term mortality rate of over 10% (American Psychiatric Association [APA], 2000). Females with AN have a 58 times greater suicide rate than do healthy females; 3 to 20% of those with AN attempt suicide (Warren, Crowley, Olivardia, & Schoen, 2009). Additionally, because AN involves a reduced intake of food, semi-starvation characteristics can affect these individuals, e.g., problems with the individual’s major organ systems, anemia, dehydration, osteoporosis, cardiovascular and gastrointestinal abnormalities, and even death (APA, 2000; Wright, 2010). Due to the increased rate of physical problems, suicide, and death, it is clear AN is a serious disorder. Treating clients diagnosed with AN can be difficult as progress is often slow and prognosis usually poor (Franko & Rolfe, 1996). In a meta-analysis of outcome studies, Steinhausen (2002) discovered approximately 46.9% of clients with AN fully recovered, 33.5% improved, and 20.8% developed a chronic course of the disorder. There are several reasons treatment could be difficult with this population including, but not limited to, high dropout rates, difficulties with cognitive processing due to low body weight and malnourishment (Tchanturia & Hambrook, 2010), the ego-syntonic nature of the disorder 345 that inhibits the client from seeing themselves as sick (Vitousek, Watson, & Wilson, 1998), and comorbidity with other disorders such as obsessive-compulsive personality disorder (Satir et al., 2011), anxiety disorders, and substance abuse disorders (Steinhausen, 2002). Furthermore, forming a working alliance with this population is often complicated due to clients’ difficulties trusting the therapist (Warren et al., 2009) and high prevalence of insecure attachment styles often found in this population (Wechselblatt, Gurnick, & Simon, 2000). Working Alliance Several terms have been used to refer to the relationship between the client and therapist: therapeutic alliance, working alliance, helping alliance, and therapeutic relationship (Horvath & Luborsky, 1993). The most commonly used conceptualization of the working alliance was defined by Bordin (1979). He described it as a collaborative relationship between the client and therapist comprised of three different components: agreement on the goals of therapy, agreement on the tasks of therapy, and the relational bond between client and therapist. Since Bordin (1979) offered this pantheoretical definition, researchers have investigated how the alliance affects therapeutic outcome and have used a variety of measures to evaluate these constructs. For example, in a recent meta-analysis on alliance and outcome, Horvath, Del Re, Flückiger, and Symonds (2011) analyzed 201 outcome studies using over 30 different types of alliance measures. Additionally, when measuring outcome, researchers have used a variety of constructs, e.g., global ratings of satisfaction and improvement, target complaints and symptom checklists, pre-and post-counseling changes, and session evaluations (Horvath & Luborsky, 1993; Kivlighan, 2007). 346 Although there is much variability among the assessments used to measure alliance and outcome, researchers found alliance to correlate moderately with outcome--it is one of the most robust predictors of outcome (Safran, Muran, Samstag, & Stevens, 2002). Helpful Therapist Factors on Alliance Formation Research demonstrates that several therapist factors have been helpful in alliance formation. The therapist-offered conditions of empathy, genuineness, respect, and unconditional positive regard have been associated with developing and maintaining a positive working alliance (Gelso & Carter, 1985; Lambert & Barley, 2002). Therapists who were compassionate and portrayed a willingness to help their client face his or her problems also contributed to better therapeutic relationships (Gelso & Carter, 1985). Wei and Heppner (2005) reviewed several studies and concluded therapist flexibility and credibility were associated with the strength of the alliance. Additionally, therapists who were more challenging, thematically focused, and here-and-now oriented had stronger alliance ratings than did therapists who attempted to clarify or obtain information, explored feelings, or offered support and encouragement (Sexton & Whiston, 1994). Other therapist characteristics that contributed a strong working alliance included trustworthiness, warmth, honesty, integrity, confidence, and openness (Hersoug, Høglend, Havik, von der Lippe, & Monsen, 2009). Hersoug, Høglend, Monsen, and Havik (2001) and Hersoug et al. (2009) found that therapists who had more perceived social support and a higher degree of comfort in close interpersonal relationships also had higher-rated working alliances.