The Predictive Ability of High Quality Therapeutic Alliance on

Outcome for Adolescents Undergoing Treatment for Anorexia

Nervosa. A Systematic Review.

Ms Andrea KoenigstorferSenior Psychotherapist, Insight Matters

&Mr Paul Keenan, Asst. Prof in Intellectual Disability Nursing, Trinity College Dublin

Context and Background

Therapeutic alliance: the relationship between client and therapist

Synonyms: helping alliance, therapeutic relationship, working alliance, helping relationship, or working relationship (Wright 2010)

Originated in psychoanalysis, further developed in client-centred, humanistic therapy models

Pantheoretical models: focused on the development of a collaborative, consensual working relationship (Horvath & Luborsky 1993)

Link between TA and outcome across a range of therapeutic approaches and client populations (Martin et al. 2000) Treatment of children and adolescents (Forsberg 2011) –

“conscripts” Treatment of eating disorders (Kaplan & Garfinkel 1999)

Changes in 21st century MH services provision -> more client or patient centred treatment approaches (Government of Ireland 2006)

Relationship of trust between all individuals involved in the process of recovery – a strong therapeutic alliance

Context and Background

Rationale

Evidence that suggests a connection between the TA and outcome in psychotherapy

Symptomatology of AN is a great burden on medical and social care resources – need for a successful and cost-effective treatment modalities

Research on this topic is scarce and not consistent

systematic review design

Question: How predictive is high quality therapeutic alliance for improved eating pathology and weight in adolescents with anorexia nervosa?

Aim: To determine the predictive ability of high quality therapeutic alliance on improved eating pathology and weight in adolescents with anorexia nervosa

Question & Aim

Objectives

Uncover gaps in current research

Provide evidence base for treatment development

Contribute to treatment improvement

Inform professionals

Disseminate findings to enhance standard practices and treatment outcomes

MethodsRetrieve, evaluate and synthesise studies

•Databases (PubMed, Web of Science, CINAHL and PsycINFO)

•Citation Indexes•Dissertations and theses databases

•Conference Abstracts or Proceedings

•Search String•Hand Searching

Search Applications

•Population•Exposure•Outcome Measures•Study Types

Inclusion and Exclusion Criteria

•Evaluate validity of the final selected articles

• Minimum quality threshold for the selection of studies

•Newcastle-Ottawa Scale

Quality Assessment

•Retrieve necessary information and findings from included studies

•Data collection form for intervention reviews for RCTs, developed by Cochrane Review Groups

Data Extraction

Results

• Results of the Search

• Included Studies• Excluded Studies

Description of Studies

• Selection• Comparability• Outcomes

Quality Assessmen

t• Outcome 1: Weight

• Outcome 2: Eating Disorder Pathology

Data Extraction

• Outcome 1: Weight

• Outcome 2: Eating Disorder Pathology

Data Analysis

ResultsStudy Selection Flow Chart

Results Quality Assessment

1 2 3 4 5 6 7 8 9Representativeness of the assessed cohorts

Do the authors provide a clear definition of TA?

Ascertainment of Exposure

Demonstration that outcome(s) of interest were below threshold for desired outcome at start of study

Comparability of cohorts based on design/analysis

Assessment of outcome(s)

Was follow-up long enough for outcomes to occur?

Adequacy of follow-up of cohorts

How many stars does this paper receive?

Based on the overall quality do you wish to include this paper?

Truly representative * Yes * Secure record * Yes * Age and other continuous factors *

Independent blind assessment *

Yes * Complete follow-up *

Somewhat representative *

No Structured questionnaire/scales *

No Other controlled factors *

Record linkage *

No Number of dropouts < 20% *

Selected group of users

Written self-report Statement of "No difference between groups"

Self-report Number of dropouts > 20%

No clear description No clear description Provision of statistical significance

No description No statement

Not applicableReference

Pereira, T. (2005) No clear description > 20% 8 Yes

Forsberg, S. (2011) 10 Yes

Modified Newcastle Ottawa Scale (NOS) - Quality Assessment of studies meeting the inclusion criteria for the systematic review on the predictability of the therapeutic alliance in the treatment of adolescents with anorexia nervosa

An overall quality score of 3 or lower will be excluded from the review

Modified Newcastle Ottawa Scale (NOS) Quality Assessment Tool

Results Data Extraction & Analysis

Problems: Only one of two studies or none of the studies

reported on the predefined outcomes The outcome measures in both studies were

different Source data for both studies not available

anymore This made it impossible to pool results for

the two studies Where possible, comparisons were calculated for

the two treatment groups in Study 2 (FBT and AFT)

Results Data Analysis

Outcome 1 – Weight:1. Overall weight change from BL to EOT

Pooling of results not possible, only one study reported on the results

Comparison of BMI%ile Change between the two treatment groups in study2 calculated in Review Manager – results not statistically significant

2. Overall weight change from BL to Early – no results to pool (neither of the studies reported)

Results Data Analysis

3. How sensitive/specific is high TA compared to low TA for predicting the achievement of target weight?

Calculation with VassarStats for Study 2 (http://vassarstats.net/)

Probability to correctly identify the No. of participants that reach Full Remission if TA is high is quite low in both treatment arms

Probability to correctly identify the No. of participants that achieve Partial Remission if the TA is low is relatively good for FBT and excellent for AFT

4. Are there differences in achieving target weight between different types of treatment? No results to pool (only Study 2 reported) Comparison of Remission Status between the two treatment

groups in Review Manager Statistically the results are non-significant

Results Data Analysis

Outcome 2 – Eating Disorder Pathology:1. Overall change in EDE Score from BL to Early

No results available to pool – neither of the two studies reported

2. Overall change in EDE Score from BL to EOT No results to pool - only study 2 reported on the

overall Total EDE Score from BL to EOT Comparison of Total EDE Score changes between the

two treatment groups in Review Manager Statistically the results are non-significant

Discussion Outcomes

No calculation of a summary value - only comparison of the cohorts in Study 2:

FBT is a more directive, cognitive-behavioural approachAFT is a psychodynamic approachTA is important in achieving successful treatment outcome in this

particular clinical population – irrespective of the treatment approach

FBT: Higher odds ratio for achieving both Full and Partial Remission Status compared to AFT - focus in the early stage of FBT is on restoring weight (Forsberg 2011)

AFT: Higher effect values - focus on creation and development of the relationship between therapist and client

TA is an important factor towards recovery, but it is not sufficient on its own (consistent with DeRubeis et al. 2005)

Discussion Strengths & Limitations

Strengths:Examines the importance of the TA in two treatment

modalities for adolescents with AN with very different theoretical frameworks at the root

Recognised evidence-based treatments for adolescents with AN used in both studies

Alliance measured with tool developed for use with all types of therapeutic approaches (Horvath & Bedi 2002)

Limitations:Inconsistency of reported outcomes in search process

= many studies excludedPotential impact on statistical significance and actual

effect probabilityPrevented statistical meta-analysis of the two included

studies - data were too heterogeneous

Conclusion Implications for Practice

Lack of homogeneity in the identified studies - need for agreement on the key concepts in this area

Necessity for a more standardised process while respecting individual needs of the client

Harm reduction based services vs. traditional services focusing on "eliminating" a client's eating disorder - no clear definition of "successful outcome", "target weight", "improved eating disorder behaviour"

Both studies excluded participants that were severely underweight, acutely suicidal, or medically unstable and requiring hospitalisation, i.e. that would probably benefit most of a strong TA

Conclusion Implications for Future Research

Need for research: Do we need to identify different methods to develop and maintain the TA depending on treatment type

Examine the results in a different context (e.g. countries)

Influence of certain therapist and client characteristics on the TA; causal direction between symptom improvement and alliance score

TA does have a predictive value in relation to outcomes for this particular clinical population – irrespective of the treatment approach employed

The TA is not sufficient on its own to achieve successful outcome, but it does contribute towards better recovery

Bordin, E. (1994) Theory and research on the therapeutic working alliance: New directions. In A. Horvath, & L. S. Greenberg (Eds.), The Working Alliance: Theory, Research, and Practice (pp. 13-37). New York: John Wiley & Sons, Inc.

Couturier, J. L., & Lock, J. (2006) Denial and minimization in adolescents with anorexia nervosa. International Journal of Eating Disorders, 39(3), 212-216.

DeRubeis, R. J., Brotman, M. A., & Gibbons, C. J. (2005) A conceptual and methodological analysis of the nonspecifics argument. Clinical Psychology: Science & Practice, 12(2), 174-183.

Forsberg, S. (2011) The Relationship between Therapeutic Alliance and Treatment Outcome in a Comparative Study of Inividual and Family Therapy for Adolescent Anorexia Nervosa. Retrieved from ProQuest Dissertations & Theses : http://fulfillment.umi.com/dissertations/9bd12464abfee7aeff4dcaf1f28aa111/1394221143/3591823.pdf on March 4, 2014

Giordano, S. (2005) Understanding Eating Disorders. Conceptual and Ethical Issues in the Treatment of Anorexia and Bulimia Nervosa. Oxford: Oxford University Press

Government of Ireland (2006) A Vision for Change. Report of the Expert Group on Mental Health Policy. Dublin: Stationery Office.

 

References 1

Horvath, A. O., & Luborsky, L. (1993) The role of the therapeutic alliance in psychotherapy. Journal of Consulting and Clinical Psychology, 61(4), 561-573.

Horvath, A. O., & Symonds, B. D. (1991) Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38(2), 139-149.

Kaplan, A. S., & Garfinkel, P. E. (1999) Difficulties in treating patients with eating disorders: A review of patient and clinician variables. Canadian Journal of Psychiatry, 44(7), 665–670.

MacDonald, C. (2002) Treatment resistance in anorexia nervosa and the pervasiveness of ethics in clinical decision making. Canadian Journal of Psychiatry, 47(3), 267-270.

Martin, D. J., Garske, J. P., & Davis, M. K. (2000) Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68(3), 438-450.

Matusek, J. A., & Wright, M. O. (2010) Ethical dilemmas in treating clients with eating disorders: A review and application of an integrative ethical decision-making model. European Eating Disorders Review, 18, 434-452.

References 2

National Institute of Clinical Excellence. (2004) Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. Retrieved from http://www.nice.org.uk/nicemedia/pdf/CG9FullGuideline.pdf on November 20, 2012

Strober, M., & Freeman, R. (1997) The long-term course of severe anorexia nervosa in adolescents: Survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study. International Journal of Eating Disorders, 22(4), 339-360.

Vanderlinden, J. (2008) Many roads lead to Rome: Why does Cognitive Behavioural Therapy remain unsuccessful for many eating disorder patients? European Eating Disorders Review, 16, 329-333.

World Health Organisation (2001) The World Health Report 2001 - Mental Health: New Understanding, New Hope. Retrieved from http://www.who.int/whr/2001/en/whr01_en.pdf on November 20, 2012

Wright, R. W., Brand, R. A., Dunn, W., & Spindler, K. P. (2007) How to write a systematic review. Clinical Orthopaedics and Related Research, 455, 23–29. 

References 3