Using a Therapeutic Alliance to Predict Weight Gain in Young AN Patients

Anorexia nervosa (AN) is one of the most disabling diseases among adolescents who seek mental health care. For clinicians, determining a prognosis for and time to reaching ideal body weight for young patients are extremely difficult. A group of French researchers sought to predict the time it would take for these young patients to achieve their target weights by using the concept of therapeutic alliance. The therapeutic alliance is an all-encompassing term for therapy that emphasizes the collaborative nature of the partnership between counselor and client. This partnership incorporates client preferences and goals into treatment and outlines methods for accomplishing those goals.

Dr. Stephanie Bourion-Bedes and colleagues conducted a prospective cohort study of adolescents who were screened consecutively in the impatient and outpatient departments of psychiatry and pediatrics at Nancy Hospital, University of Nancy, Metz, France. To be included in the study, patients had to be between 9 and 20 years of age and to have a DSM-IV-TR diagnosis of AN. Patients’ parents and therapists were also included in the study. Treatment combined an individual therapy and a supportive program aimed at improving eating patterns and weight. Oral refeeding was used to achieve a target weight and if the patient refused to eat, nasogastric feeding might be required. The weight gain expectation was monitored and the target weight was 90% of ideal body weight.

Medical interviews and self-administered questionnaires were used for assessment of eating behaviors. The therapeutic alliance was evaluated with the French version of the Helping Alliance Questionnaire for Child, Parents, and Therapist (Can J Psychiatry 2006; 51:913). The child and parent versions include 15 items, 13 of which cover basic aspects of interpersonal relationships between patients and staff, as well as the degree of common understanding and the capability to provide or receive needed help. The remaining items are positive statements that explore the overall psychological state of the patient. Patients also completed the Eating Attitudes Test-26, and sociodemographic and clinical profiles were developed for each participant.

The final group included 108 patients and their therapists and 85 parents. Most patients were female (94.4%) and the mean age was 15.3 years. The mean duration of having the eating disorder before care was given was 11.2 months. Mean body mass index (BMI) at inclusion was 15.1 kg/m². In all, 23 therapists were included: 3 worked in both inpatient and outpatients settings, and two-thirds were female. All were working with patients with eating disorders.

An inpatient setting worked best

Eighty-six participants were clinically recovered and 26 were from the outpatient setting and 60 from inpatient settings; those from inpatient settings had a shorter time to recovery then those from outpatient settings. Nearly 80% of the patients achieved target weights. The researchers chose early and repeated measures designed to see how therapy worked for the patients. The results showed that the therapeutic alliance was better over the course of time of therapy than with early therapeutic alliance. An inpatient setting was the most important predictor of time to achieve a target weight in the short term—this is probably due to the relatively intensive treatment in the inpatient unit, which provided intensive care 24 hours a day, 7 days a week. Being very underweight at admission was associated with a longer time to achieve target body weight, as has been shown in previous studies.

The authors concluded that patients’ perception of an early therapeutic alliance is a good predictor of achieving a target weight. And, because therapeutic alliance is a modifiable construct, they feel it could be a target for intervention in young AN patients.