Understanding the therapeutic relationship between people with

anorexia nervosa and their therapists

Alison Seymour, Dr Tina Gambling, Dr Gail Boniface

School of Healthcare Sciences, Cardiff University, Wales, UK.

Background to the study

Previously worked with people with eating disorders

The therapeutic relationship is known to be curative andhealing in its own right regardless of the type of therapy

(Rogers 1951, Horvath and Symonds 1991, Martin et al 2000)

Interest in the therapeutic relationship

People with eating disorders often experience relational problems within treatment

(Snell et al. 2010, Palmer 2014)

Health professionals also report ambivalence and

reluctance towards working with people eating disorders(Ramjan 2003, Jones and Larner 2004,

Woodrow and Fox 2010)

Ambivalence can impact on the development of

the therapeutic relationship (Hatcher 2010)

The therapeutic relationship is still viewed as an important aspect of

treatment by practitioners and service users in regards to quality and service user

satisfaction

(de la Rie et al 2008, Escobar et al 2010, Reid et al 2010).

So what are the experiences of

people with eating disorders?

What is a good therapeutic

relationship?

What do therapists do to develop a good

therapeutic relationship?

What sort of therapeutic

relationship do people value?

Overall aim of the study

To develop an in-depth understanding of the

process and nature of the therapeutic relationship

from the perspective of people with an eating

disorder and how this may impact on the

engagement and outcome of interventions.

Methods – combining qualitative online research methods and grounded theory

Online Research Methods (ORM)

Protects participant anonymity

Accesses participants from wide geographical area

Accesses hard to reach health populations

Asynchronous communication

(Gambling and Long 2012, James and Busher 2009, Walker 2013)

Constructivist Grounded Theory

Broad/open investigation

Concept driven analysis and theory development

Structured but flexible data gathering and analysis process

Reflexivity of the researcher

(Charmaz 2014, Birks and Mills 2015)

TherRel Website

Dedicated website

Used to communicate with participants

Anonymous email address and inbox

Participants could upload their stories anonymously

Updated throughout the phases of the study

Recruitment through Beat

Methods – phase 1, 2 and 3

Phase 1

Open to anyone with an eating disorder, open

questions about individual’s experiences

of working with therapists

Phase 2

Open to people with anorexia nervosa,

questions were developed from the initial and focussed coding from phase 1

Phase 3

Returned to previous participants with anorexia nervosa, questions were aimed at testing out the developing themes and

ideas from phase 1 and 2.

Emerging findings

Developing trust in the therapeutic

relationship

“They just got me”: feeling understood

and the role of empathy in the therapeutic

relationship

“One size doesn’t fit all”: taking an individual

approach in the therapeutic relationship and the

therapy process

Balancing the paradox of control

in the therapeutic relationship

It was essential for me to feel I had some control over my treatment, although I was

aware that control was one of the problems that had to

be addressed

I need to know that I have some control when it comes to interacting with medical

professionals, including those within a therapeutic

relationship. If I don’t feel in control, I won’t engage with

the process as well

Balancing the paradox of control in the therapeutic relationship

Developing trust in the therapeutic relationship

He treats me as a

person who has

worth…

I think the key thing for me in this

relationship was “trust”

(participant emphasis)...very simple

things helped to build trust…he

always turned up on time and

always followed up the things he

said he would

“They just got me”: feeling understood and the role of empathy in the therapeutic relationship

The therapist had a

fantastic gauge of me as

a person (not just as a

patient who needed

fixing)…..he understood

me and what made me

tick

Feeling that they understood

was a powerful moment. I had

never felt like that before and I

didn’t realise that I ever would. It

really makes you feel like

someone is on your side and

that you aren’t alone in whatever

it is you are going through

“One size doesn’t fit all”: taking an individual approach

I feel this approach was

tailor- made to my needs and

that if someone had needed

a more softly, softly

approach that’s what they

would have got. It felt as if

we were a team, trying to

reach the same goal

The therapist made an effort to ‘get to know me’

and allowed me to just speak and tell her ‘my story’

during the first session.

At the end of the first session, she went through

the main points of what we had discussed and

asked me what issues I would like to work on

first and explained that we would also have to

work on things like body image and the

importance I placed and status I gave to being

thin”.

Conclusions

Successful use of ORM to recruit

participants

On going process of theory development

Considering presence of a core category – person

centred practice.

Identified key components of helpful therapeutic

relationships

Acknowledgements and Thanks

SeymourA@Cardiff.ac.uk

Twitter: @aliseymour64

TherRel webformhttps://healthcarestudies.cf.ac.uk/therrel

Beat

All the participants

IT support at Cardiff University

William Morgan Thomas Fund, Cardiff University

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