Understanding the working alliance between clients diagnosed with anorexia nervosa and

403 Pages·2016·2.86 MB·English

by  Laura M. Oyer

University of Northern Colorado
Scholarship & Creative Works @ Digital UNC
Dissertations Student Research
8-1-2013
Understanding the working alliance between
clients diagnosed with anorexia nervosa and
therapists in individual psychotherapy: a
phenomenological approach
Laura M. Oyer
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Recommended Citation
Oyer, Laura M., "Understanding the working alliance between clients diagnosed with anorexia nervosa and therapists in individual
psychotherapy: a phenomenological approach" (2013).Dissertations.Paper 222.
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UNIVERSITY OF NORTHERN COLORADO

Greeley, Colorado

The Graduate School

UNDERSTANDING THE WORKING ALLIANCE BETWEEN CLIENTS
DIAGNOSED WITH ANOREXIA NERVOSA AND THERAPISTS IN
INDIVIDUAL PSYCHOTHERAPY: A PHENOMENOLOGICAL
APPROACH

A Dissertation Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Philosophy

Laura M. Oyer

College of Education and Behavioral Sciences
Department of Counseling Psychology

August, 2013
This Dissertation by: Laura M. Oyer

Entitled: Understanding the Working Alliance between Clients Diagnosed with Anorexia
Nervosa and Therapists in Individual Psychotherapy: A Phenomenological Approach

has been approved as meeting the requirement for the Degree of Doctor of Philosophy
in College of Education and Behavioral Sciences in Department of Counseling
Psychology

Accepted by the Doctoral Committee

Mary Sean O’Halloran, Ph.D., Research Advisor

Stephen L. Wright, Ph.D., Committee Member

Jennifer L. Murdock, Ph.D., Committee Member

Maria K. E. Lahman, Ph.D., Faculty Representative

Date of Dissertation Defense _________________________________________

Accepted by the Graduate School

_________________________________________________________
Linda L. Black, Ed.D., LPC
Acting Dean of the Graduate School and International Admissions
ABSTRACT

Oyer, Laura M. Understanding the Working Alliance Between Clients Diagnosed with
Anorexia Nervosa and Therapists in Individual Psychotherapy: A
Phenomenological Approach. Published Doctor of Philosophy dissertation,
University of Northern Colorado, 2013.

The therapeutic working alliance is a vital ingredient to psychotherapy,
specifically with clients diagnosed with Anorexia Nervosa (AN) as progress is often slow
and treatment difficult. This phenomenological study investigated the experiences of
eight clients with AN and seven therapists who work with this population regarding how
the working alliance was formed and challenged in the process of individual
psychotherapy. Data were gathered through semi-structured interviews. Findings
revealed overarching themes among all the participants as well as themes unique to
clients and therapists. The findings are discussed in the context of working alliance
theory. Implications for therapists when forming the working alliance with clients with
AN include remain patient while clients develop trust and motivation, maintain
awareness of personal reactions and seek consultation/supervision, be active and directive
at the beginning of treatment, use caution when creating therapy goals, collaborate with
other treatment providers and family, implement basic counseling skills (e.g.,
unconditional positive regard, validation, authenticity), utilize appropriate self-disclosure,
balance setting boundaries and portraying care, create a warm office environment, and
have/gain experience treating this population. Additionally, implications for clients are
discussed.
iii
TABLE OF CONTENTS

CHAPTER I. INTRODUCTION TO THE RESEARCH PROBLEM .......................... 1

Introduction ........................................................................................................ 1
Background and Context.................................................................................... 1
Statement of the Problem ................................................................................... 5
Purpose of the Study .......................................................................................... 5
Primary Research Questions .............................................................................. 6
Research Approach ............................................................................................ 6
Assumptions ....................................................................................................... 8
Rationale and Significance ................................................................................ 9

CHAPTER II. LITERATURE REVIEW .................................................................... 11

Overview .......................................................................................................... 11
Common Factors .............................................................................................. 11
The Working Alliance ...................................................................................... 12
Anorexia Nervosa ............................................................................................ 42
Literature Summary and Conclusions .............................................................. 57
Implications and Future Directions .................................................................. 58

CHAPTER III. METHODOLOGY ............................................................................. 61

Introduction ...................................................................................................... 61
Researcher’s Stance ......................................................................................... 62
Research Model and Paradigm ........................................................................ 65
Trustworthiness ................................................................................................ 81
Ethical Considerations ..................................................................................... 84

CHAPTER IV. FINDINGS: CLIENTS’ AND THERAPISTS’ EXPERIENCES ...... 86

Individual Client Participants .......................................................................... 87
Individual Therapist Participants ................................................................... 133
Conclusion ..................................................................................................... 171

CHAPTER V. FINDINGS: COMPOSITE EXPERIENCE ....................................... 172

Client Participants’ Overarching Themes ...................................................... 172
Therapist Participants’ Overarching Themes ................................................. 202

iv
Comparison of Clients’ and Therapists’ Overarching Themes...................... 221
Conclusion ..................................................................................................... 233

CHAPTER VI. DISCUSSION................................................................................... 234

Summary of the Study ................................................................................... 234
Discussion of the Findings ............................................................................. 238
Theoretical Application: Working Alliance Theory ...................................... 273
Limitations ..................................................................................................... 285
Implications.................................................................................................... 288
Future Research Directions ............................................................................ 293
Conclusion ..................................................................................................... 295

REFERENCES .......................................................................................................... 296

APPENDIX A. INSTITUTIONAL REVIEW BOARD APPROVAL ...................... 318

APPENDIX B. EMAILS TO THERAPISTS ............................................................ 320

APPENDIX C. LETTER TO CLIENT PARTICIPANT ........................................... 323

APPENDIX D. CONSENT FORM FOR HUMAN PARTICIPANTS IN
RESEARCH: THERAPIST IN PERSON ..................................................... 325

APPENDIX E. CONSENT FORM FOR HUMAN PARTICIPANTS IN
RESEARCH: THERAPIST SKYPE/PHONE ............................................... 328

APPENDIX F. CONSENT FORM FOR HUMAN PARTICIPANTS IN
RESEARCH: CLIENT SKYPE/PHONE ...................................................... 331

APPENDIX G. CLIENT AND THERAPIST DEMOGRAPHIC
INFORMATION SHEETS ............................................................................ 334

APPENDIX H. MENTAL HEALTH REFERRALS AND RESOURCES .............. 337

APPENDIX I. INTERVIEW GUIDE ........................................................................ 339

APPENDIX J. MANUSCRIPT DRAFT ................................................................... 342

v
LIST OF TABLES

1. Demographics of Client Participants ............................................................... 72

2. Demographics of Therapist Participants .......................................................... 73

3. Artifacts Reported by Client Participants ...................................................... 174

4. Helpful Therapist Factors Reported by Client Participants ........................... 181

5. Helpful Client Factors Reported by Client Participants ................................ 189

6. Unhelpful Therapist Factors Reported by Client Participants ....................... 190

7. Unhelpful Client Factors Reported by Client Participants ............................ 197

8. Artifacts Reported by Therapist Participants ................................................. 204

9. Helpful Therapist Factors Reported by Therapist Participants ...................... 208

10. Helpful Client Factors Reported by Therapist Participants ........................... 213

11. Unhelpful Therapist Factors Reported by Therapist Participants .................. 216

12. Unhelpful Client Factors Reported by Therapist Participants ....................... 218

13. Similarities Between Clients’ and Therapists’ Descriptions ......................... 222

14. Differences Between Clients’ and Therapists’ Descriptions ......................... 230

vi
LIST OF FIGURES

1. Elements of research ........................................................................................ 66

vii
CHAPTER I

INTRODUCTION TO THE RESEARCH PROBLEM

Introduction

Through this phenomenological study, I sought to explore perceptions and
experiences of clients diagnosed with Anorexia Nervosa (AN) and therapists who work
with AN with regard to how the working alliance was formed and challenged during the
process of individual psychotherapy. Through this exploration, I identified the essence or
essences of the working alliance in therapy with clients diagnosed with AN as well as
discovered factors that influenced its formation. Participants in this study included eight
clients diagnosed with AN and seven therapists who provided individual psychotherapy
to clients diagnosed with AN, resulting in 15 total participants.
In this chapter, I provide an overview of the background and context for the
current study, the statement of the problem, purpose of the study, and research questions.
Additionally, I present the research approach, assumptions, and a discussion of the
rationale and significance of the current study.
Background and Context
Researchers have investigated the process and outcome of psychotherapy for
many decades. While some researchers focused on specific techniques or theoretical
orientations with regard to therapeutic outcome, other researchers investigated elements
common to all types of therapy, also known as common factors (Lambert & Ogles,
2

2004). The most frequently mentioned common factor in the psychotherapy literature
was the relationship, or alliance, between the client and therapist (Wampold, 2001).
Several terms were used in the psychotherapy literature to refer to the relationship
between the client and therapist: therapeutic alliance, working alliance, helping alliance,
and therapeutic relationship (Horvath & Luborsky, 1993). For the purpose of this study,
the relationship between the client and therapist is referred to as the working alliance or
alliance. The most commonly used conceptualization of the working alliance was
defined by Bordin (1979). He described it as a collaborative relationship between the
client and therapist comprised of three different components: agreement on the goals of
therapy, agreement on the tasks of therapy, and the relational bond between client and
therapist. Prior definitions of the alliance were conceptualized from a primarily
psychoanalytic perspective, whereas Bordin’s definition was proposed as a pantheoretical
definition common to all forms of therapy.
Since Bordin (1979) offered this pantheoretical definition, researchers have
investigated how the alliance affects therapeutic outcome and have used a variety of
measures to evaluate these constructs. For example, in a recent meta-analysis on alliance
and outcome, Horvath, Del Re, Flückiger, and Symonds (2011) analyzed 201 outcome
studies using over 30 different types of alliance measures. Additionally, when measuring
outcome, researchers have used a variety of constructs, e.g., global ratings of satisfaction
and improvement, target complaints and symptom checklists, pre-and post-counseling
changes, and session evaluations (Horvath & Luborsky, 1993; Kivlighan, 2007).
Although there is much variability among the assessments used to measure alliance and
outcome, researchers found alliance to correlate moderately with outcome. Furthermore,