Clinician Reports of the Motivation to Change and the Therapeutic Alliance in Patients With Anorexia Nervosa: Countertransference as a Mediator

Objective: The motivation to change in patients with anorexia nervosa (AN) predicts both treatment outcomes and the therapeutic alliance (TA). In addition, different countertransference patterns have previously been related to the patient’s motivation to change and the TA. However, the mechanisms through which these relationships occur are unclear. In this study, we examine the therapists’ perspectives on the relationships between all three variables and whether countertransference patterns mediate the relationship between the stage of change and the TA. Method: One hundred and fifty-six AN therapists were recruited from eating disorders recovery centers, conferences, and associations. The participants completed a motivation to change questionnaire (the staging algorithm questionnaire), a countertransference questionnaire, and a TA questionnaire (working alliance inventory short revised), regarding the last patient with AN they had a session with. Results: Motivation to change, as rated by therapists, was strongly related to the TA and to countertransference patterns of hostility, helplessness, and positivity. Countertransference patterns that were hostile, helpless, positive, disengaged, or overwhelmed were related to the TA as rated by therapists. Additionally, three countertransference patterns (positive, hostile, and helpless) mediated the relationship between the motivation to change and the TA. Conclusions: Increasing patients’ motivation to change might facilitate alliance development. Furthermore, more attention should be given to therapists’ countertransference to account for the motivation to change–TA relationship as perceived by therapists.