Establishing a Better Therapeutic Alliance with Young Eating Disorders Patients

A focused, patient-centered approach to treating young patients with eating disorders helps minimize the need for coercion and intervention with resistant patients, according to Dr. Pierre Leichner, Director of the Eating Disorders Program at BC Children’s Hospital, Vancouver. Dr. Leichner notes that therapeutic efforts may stall when young patients are brought to a physician’s office by their parents at a time when they either don’t believe they have a problem, or when they are just becoming aware of it (BC Medical Journal 2005;47:23).

For young patients, Dr. Leichner uses the Stages of Change model developed by Prochaska and DiClemente (Am Psychol 1992;9:1102). This treatment approach recognizes that recovery is not straightforward and that relapses provide new chances for understanding and further change. In this model, six stages of change are defined: precontemplation, contemplation, preparation, action, maintenance, and relapse. According to the authors, clinicians cannot expect receptiveness to treatment to occur during the first three stages. It’s not until the Action stage that patients acknowledge the need to change (see Figure 1, page 2).

Dealing with Noncompliance

As Dr. Leichner notes, one of the most important principles in Motivational Enhancement Interviewing (MEI) is dealing with treatment resistance or noncompliance. This is usually a result of a mismatch between the state of change the patient is at and the caregiver’s expectations. Dr. Leichner also points out that most health-care professionals are trained to prescribe Action-stage activities and to assume that patients come for help when they are at the Preparation or the Action stage. In reality, Dr. Leichner’s ongoing research with youth with eating disorders shows that this is rarely the case—most patients are still at the Contemplation stage and are not ready to take any positive action at the time when they are referred (see figure).

When the patient is first seen

Active listening is essential when patients are still in the early stages of change, according to Dr. Leichner. The goal of active listening is to understand the patient’s perceptions of the situation, and to establish a therapeutic alliance with her. This takes patience and focus, says Dr. Leichner. For example, when a point is made that might need clarification, a simple reflection upon this or rephrasing by the clinician is a good starting point. He suggests using phrases such as “Help me understand…” or “I’m curious about…” to help young patients feel more comfortable and less fearful of being “interrogated.”

Taking the time to establish a therapeutic alliance cannot be underestimated, according to Dr. Leichner. More confrontational interventions that chal-lenge the patient should be used only after a good therapeutic alliance is well established.

After a good alliance has been established between therapist and patient, the clinician will find it easier to point out that getting better is often a long process that includes relapses, periods of doubt, and the challenges of dealing with difficult feelings.

Finally, he notes that in keeping with the Stages of Change model, the responsibility for change ultimately belongs with the patient, except in life-threatening circumstances. While most youths recover from eating disorders, it is rarely a straightforward process. Using Motivational Enhancement Interviewing can also help health-care professionals develop the essential therapeutic alliances that will help minimize battles for control.

Consider the Effects of Parents, Too

Battles for control can also involve the complex relationships between parents and children. Treatment may be delayed because of communication problems caused by the power relationship between parents and child. As researchers at the University of Leicester reported, parents of a child with an eating diosrder may assume an “executive role” that may make it difficult for the child to communicate directly and effectively with health-care professionals (BMJ 2003;326:305). Sometimes parents unknowingly interfere with the therapist who is trying to work directly with the child, according to the researchers. The key is for all parties—particularly the child—to have open lines of communication.