Therapists’ emotional responses, therapeutic alliance and therapy outcome in patients with eating disorders.

Aim: A growing body of evidence has shown that patients with eating disorders (ED) tend to evoke strong emotional responses (or countertransference patterns) in their treating clinicians, such as frustration, hopelessness, worry, or rage, but also intense protective feelings. This study aimed at investigating the predictive value of a broad spectrum of therapists’ emotional responses in determining patient and therapist ratings of therapeutic alliance (TA), as well as therapy outcome evaluated by the clinical significance criteria. Methods: A sample of 112 patients with anorexia nervosa and bulimia nervosa treated in a psychodynamic-oriented residential program were asked to complete the Eating Disorder Inventory-3 and the Outcome Questionnaire-45.2 at both intake and discharge. Clinicians completed the Therapist Response Questionnaire to evaluate their countertransference patterns. TA (both therapist- and patient-rated) was measured through the Working Alliance Inventory after the first month and during the last week of treatment. Results: Findings showed that, even when controlling for baseline ED symptoms and DSM-5 diagnosis, criticized/mistreated, helpless/inadequate and overwhelmed/disorganized responses predicted worse early therapist-rated TA, but not patient-rated TA. Similarly, helpless/inadequate and positive emotional responses emerged, respectively, as negative and positive predictors of both therapist- and patient-rated TA at treatment termination. On the other hand, warm/positive therapist emotional responses emerged as a predictor of clinically significant/reliable symptomatic change, whereas helpless/inadequate and overwhelmed/disorganized predicted no change/significant deterioration. Discussion: These results suggest the importance of clinicians monitoring their emotional responses in residential treatment settings for ED, especially those that may represent a clinical challenge in this difficult-to-treat population.