Outpatient Treatment, from the Adolescent Patient's Viewpoint: Any progress involved trust.

Reprinted from Eating Disorders Review
May/June Volume 26, Number 3
©2015 IAEDP

When Swedish researchers evaluated adolescents' perceptions of their experience with outpatient treatment, two clear results stood out. The first was the importance of involving parents in treatment, particularly with anorexia nervosa (AN), and the second was the importance of trust. Dr. Katarina Lindsted and colleagues at Orebro University, Sweden, reported the results of their small study of 15 eating disorders patients recruited from four specialized eating disorder units. The researchers' goal was to develop an understanding of the treatment experience, this time from the patient's viewpoint (J Eat Disord. 2015; 3:9)

Dr. Lindsted and colleagues used a hermeneutic phenomenological approach with the subjects, which involves an attempt to understand how people give meaning to their experiences of significant events, and depends on narratives gained from interviews (M. van Manen, Researching lived experience: Human science for an action sensitive pedagogy, 2nd ed. Ontario: Althouse Press, 1997). The 15 patients enrolled in the study were 13 to 18 years of age; 6 had been treated for AN, and 9 had been treated for restrictive-type eating disorders not otherwise specified (EDNOS). Most had been in treatment for 1 to 2 years and had participated in 11 to 30 therapy sessions. Most of the authors' interviews were conducted 1 to 3 years after the individual had completed treatment. All interviews were recorded and transcribed verbatim; participants were allowed to read the transcripts and were invited to add or change any part of the transcript.

The interviewees were asked to speak openly about their treatment experience, and the interviewer started with the question, “Can you tell me about your time in treatment?” To carry the interview forward, the therapists had follow-on questions such as asking about the parents' role and the patient's relationship with the therapist. Most interviews lasted from 45 to 90 minutes.

Overall themes that emerged

According to the authors, the one overriding theme that emerged was the importance of family participation in treatment, especially at the very beginning of treatment. Most patients felt that they were more or less forced into treatment, and they had strongly ambivalent feelings about whether and how they should participate. Many reported that their first encounter with the therapist produced shame, relief, frustration, and exhaustion. Typically, parents brought their child to treatment, and many teens were angry and strongly resistant. Initially patients recalled having strong feelings of denial and resistance to change. Some also reported that they wished their siblings were involved in some way, since siblings were rarely involved in the family sessions.

Strong alliance was built on trust

As to be expected, a strong therapeutic alliance based on trust was very important to the outcome. The first meeting was especially significant, and the teens reported that the manner in which the therapist acted, spoke, and treated them made a huge difference in generating trust. They noted that when the therapist issued an invitation to cooperate, and continued to do so during their sessions, along with clarifying treatment goals and creating a shared view of the situation, there was a much greater chance of overall success. One notable finding was that focusing on weight gain as a goal for treatment did not sit well with the teens. Some felt unprepared to end treatment and expressed disappointment that the therapist was not more interested in their thoughts and feelings. 

Honesty and respect also emerged as important ingredients in the patient-therapist relationship; the teens needed to feel competent and to have their feelings validated. The results of these analyses reinforce the important role of nonspecific therapy factors in treatment outcome.