Alliance, technique, both, or more? Clinicians' views on what works in cognitive-behavioral therapy for eating disorders.

OBJECTIVE: This study examined clinicians' views of the roles of two elements of cognitive behavioral therapy (CBT) in explaining treatment outcomes-CBT techniques and the therapeutic alliance. METHOD: Ninety-eight clinicians who reported delivering CBT for eating disorders completed measures addressing their beliefs about what is effective in CBT, their use of specific techniques, and their own anxiety levels. RESULTS: Clinicians substantially overestimated the role of both therapeutic techniques and the alliance in explaining treatment outcomes in CBT. Weak but significant correlations were found between therapist anxiety levels and their beliefs about the value of therapeutic techniques or the alliance. However, these associations were in different directions, with higher levels of clinician anxiety associated with more belief in the effects of the alliance but with less belief in the role of CBT techniques. Belief in the role of the therapeutic alliance was associated with a lower likelihood of encouraging the patient to change their eating pattern, while belief in the role of techniques was linked to greater use of case formulation, cognitive restructuring, behavioral experiments and body image work. DISCUSSION: Clinicians overestimate the value of both the alliance and therapy techniques in explaining treatment outcomes in CBT for eating disorders. Their beliefs about the strength of these factors are related to their own anxiety, and to their choice of techniques. Clinicians and supervisors should attend to the evidence regarding the impact of a range of elements of therapy, and work with all of those factors to enhance outcomes.

Impact of education on clinicians' attitudes to exposure therapy for eating disorders.

It is well established that clinicians use exposure therapy far less often than the evidence would suggest is justified. This shortfall has been explained as being at least partly a result of clinicians' beliefs and attitudes about exposure and their trait anxiety. Recent studies have shown that attitudes to exposure therapy for anxiety disorders can be improved through a simple educational approach. This study aimed to determine whether a similar educational approach can improve therapists' attitudes to exposure therapy for the eating disorders, and whether clinician's pre-intervention characteristics influenced the impact of the training. Thirty-four eating disorder clinicians (30 female, four male; mean age = 39.0 years; 85.3% Caucasian) attended a 90-min didactic teaching session on the subject of the use of exposure in treatment of eating disorders. Their attitudes to exposure therapy were measured before and after the workshop, in a within-subject design. The outcome was a substantial improvement in attitudes, with a strong effect size (Cohen's d = 1.68) that was comparable to the outcome of a similar intervention among clinicians working with anxiety disorders. The improvement was not related to clinicians' anxiety levels, but was greater among those whose attitudes were more negative at the outset of the teaching. While this finding needs to be tested for long-term maintenance and its relationship to change in clinical practice, it adds to the evidence that a simple educational intervention is sufficient to result in substantial improvement in clinicians' attitudes to exposure therapy.