Alliance, technique, both, or more? Clinicians' views on what works in cognitive-behavioral therapy for eating disorders.

Objective: This study examined clinicians' views of the roles of two elements of cognitive behavioral therapy (CBT) in explaining treatment outcomes-CBT techniques and the therapeutic alliance.

Method: Ninety-eight clinicians who reported delivering CBT for eating disorders completed measures addressing their beliefs about what is effective in CBT, their use of specific techniques, and their own anxiety levels.

Results: Clinicians substantially overestimated the role of both therapeutic techniques and the alliance in explaining treatment outcomes in CBT. Weak but significant correlations were found between therapist anxiety levels and their beliefs about the value of therapeutic techniques or the alliance. However, these associations were in different directions, with higher levels of clinician anxiety associated with more belief in the effects of the alliance but with less belief in the role of CBT techniques. Belief in the role of the therapeutic alliance was associated with a lower likelihood of encouraging the patient to change their eating pattern, while belief in the role of techniques was linked to greater use of case formulation, cognitive restructuring, behavioral experiments and body image work.

Discussion: Clinicians overestimate the value of both the alliance and therapy techniques in explaining treatment outcomes in CBT for eating disorders. Their beliefs about the strength of these factors are related to their own anxiety, and to their choice of techniques. Clinicians and supervisors should attend to the evidence regarding the impact of a range of elements of therapy, and work with all of those factors to enhance outcomes.