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. 2025 Dec;58(12):2378-2391.
doi: 10.1002/eat.24524. Epub 2025 Sep 24.

The Relationship Between Therapeutic Alliance, Early Symptom Change, and Outcome Among In-Patients With Anorexia Nervosa

Janina Werz  1   2 , Brunna Tuschen-Caffier  1 , Ulrich Voderholzer  3   4   5
Affiliations

The Relationship Between Therapeutic Alliance, Early Symptom Change, and Outcome Among In-Patients With Anorexia Nervosa

Janina Werz et al. Int J Eat Disord. 2025 Dec.

Abstract

Objective: Therapeutic alliance (TA) is an important process variable, evidence suggesting its influence on treatment outcome across several mental disorders. Yet, its role in treating anorexia nervosa (AN) remains under-examined. Previous research has yielded heterogeneous results, indicating a complex relationship between TA, early change, and outcome, potentially depending on contributing factors like age. This relationship was examined in a sample of 173 adult and adolescent inpatients with AN treated in a specialized clinic.

Method: Data were collected in weeks 2, 5, 9, and the week before discharge. Outcome was defined dimensionally (Eating Disorder Examination Questionnaire, Body Mass Index) and categorically (premature termination, weight status, remission status). Several potential influencing factors (e.g., duration of illness, previous therapy) were analyzed. The effect of TA on early change and outcome, and vice versa, was analyzed using regression analyses.

Results: TA was positively associated with greater early weight gain and overall general symptom change. Later TA predicted premature termination and remission status. The latter effect ceased when early change was considered. The TA subscale "task" played the most important role. Early change in ED symptoms predicted better TA later in treatment.

Discussion: In accordance with previous research, a complex bidirectional relationship between TA and outcome in AN patients was identified. The results indicate the importance of focusing on symptom improvement as well as establishing an agreement on therapeutic tasks. Future research should concentrate on the complexity and bidirectionality of TA and symptom change over the course of treatment, considering possible mediators.

Keywords: anorexia nervosa; early change; eating disorder; outcome; premature termination; therapeutic alliance; working alliance.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

FIGURE 1
FIGURE 1
Procedure: time points of measurement.
FIGURE 2
FIGURE 2
Flowchart.
FIGURE 3
FIGURE 3
Regression pathways.
See this image and copyright information in PMC

References

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