Exploring the role of patient personality and therapist emotional responses in determining therapeutic alliance when treating eating disorders

Introduction: Eating disorders (EDs) are characterized by persistent disturbances in eating or weight control behaviors and an overconcern with weight and shape. Clinical literature suggests that patients with eating disorders are very complex to treat, inducing in therapists a large spectrum of emotions that tend to exert a considerable impact on treatment process and outcome (Colli et al., 2015; Thompson-Brenner et al., 2012). Moreover, several studies regarding EDs treatment have showed that therapeutic alliance (TA) is a central factor in the psychotherapy process and outcome of EDs, given its association with treatment completion, weight gain, and symptomatic change. Regarding TA, literature has shown that clinicians tend to report negative perceptions, attitudes, and emotional responses towards their ED patients (Groth et al., 2020). Additionally, the egosyntonic dimension of EDs may reinforce patients’ ambivalence towards change and disagreement regarding treatment goals and tasks (Muzi et al., 2024). One factor that may influence therapists' emotional responses and TA, also playing a role in predicting treatment engagement and effectiveness in EDs, is the patient’s personality (Martinussen et al., 2017). Previous studies (e.g., Colli et al., 2015) have evidenced that the large spectrum of feelings likely to be evoked in therapists when treating ED patients can be influenced by patient’ personality styles. Thus, focusing on the role played by the therapists’ emotional responses and by therapeutic alliance in ED treatment, considering the potential association with ED patient characteristics seems crucial. Methods: A national sample of cisgender women with ED (n=178) was evaluated using the Structured Clinical Interview for DSM-5 (SCID-5-CV). The inclusion criteria were: (a) aged at least 18 years; (b) a pre-treatment diagnosis of DSM-5 anorexia nervosa (AN) or bulimia nervosa (BN) based on the SCID-5-CV; (c) presenting no organic syndromes, psychotic disorder, or syndrome with psychotic symptoms that could complicate the assessment of any variable in the study. In the present sample, 120 patients (67.4%) were diagnosed with AN, and 58 (32.6%) with BN. The Working Alliance Inventory to evaluate TA was fulfilled both by the patients (WAI-P) and therapists (WAI-T) within the first four therapy sessions. The Shedler-Westen Assessment Procedure (SWAP-200) was utilized to evaluate patients’ personality patterns, and the Therapist Response Questionnaire (TRQ) was assessed to evaluate clinicians’ emotional responses after the first month of treatment. The present study defined three hypotheses. Firstly, there will be differences between AN and BN patients in terms of therapists’ emotional responses and therapeutic alliance rated by both the therapist and the patient. Secondly, there will be significant associations between personality traits and therapists’ emotional responses and both therapist and patient-rated alliance. Finally, therapist emotional responses will mediate the relationship between ED patients’ overall personality functioning and both therapist and patient-rated alliance. Results: Findings showed that BN patients elicited more feelings of impotence/inadequacy and being overwhelmed/disorganized in therapists, while AN patients elicited more parental/protective responses. Regarding the TA, therapists reported higher levels of task, bond, and overall alliance with AN patients compared to BN patients, whereas no significant differences emerged between AN and BN in patients’ ratings of TA. Moreover, several associations emerged between SWAP PD scales and therapists' emotional responses. Specifically, positive/accepting therapists’ responses were negatively associated with all PD scales except for narcissistic and obsessive-compulsive PD scales. Conversely, hostile/angry therapists’ responses were positively associated with paranoid, narcissistic, and antisocial PD scales. Moreover, paranoid, schizoid, and schizotypal PD scales were negatively associated with lower levels of WAI-T and WAI-P, whereas avoidant, dependent and obsessive-compulsive PD scales were positively associated with higher scores of WAI-P and WAI-T. Additionally, the high-functioning PD scale was positively associated with higher levels of WAI-T and WAI-P. Furthermore, therapist emotional responses were found to mediate the relationship between ED patients’ personality functioning and both therapist - and patient-rated alliance, particularly in the hostile/mistreated and impotent/inadequate therapists’ responses. Conclusions: The present study enhances our understanding of the role of therapists’ emotional responses and TA and the complex interplay with ED patients’ personality. From a clinical perspective, interventions targeting and promoting therapists’ emotional responses and TA may address the need to overcome standard and symptom-oriented treatments for EDs. This evidence highlights the importance of tailored therapeutic approaches that consider the emotional dynamics between therapists and patients, potentially leading to more effective treatment outcomes and improved patient engagement.