Covert therapeutic micro-processes in non-recovered eating disorders with childhood trauma: an interpersonal process recall study

Malin E Olofsson; KariAnne R Vrabel; Asle Hoffart; Hanne W Oddli

doi:10.1186/s40337-022-00566-1

Covert therapeutic micro-processes in non-recovered eating disorders with childhood trauma: an interpersonal process recall study

J Eat Disord. 2022 Mar 21;10(1):42. doi: 10.1186/s40337-022-00566-1.

Authors

Malin E Olofsson¹, KariAnne R Vrabel^{2

3}, Asle Hoffart^{2

3}, Hanne W Oddli²

Affiliations

¹ Department of Psychology, University of Oslo, Forskningsveien 3A, 0373, Oslo, Norway. m.e.olofsson@psykologi.uio.no.
² Department of Psychology, University of Oslo, Forskningsveien 3A, 0373, Oslo, Norway.
³ Research Institute, Modum Bad, Vikersund, Norway.

Abstract

Method: To uncover therapeutic micro-processes from the perspectives of eating disorder (ED) treatment non-responders with childhood trauma (CT) late effects, we explored in-session experiences of poor long-term outcome patients. Female inpatients aged 28-59 (M = 40.2, SD = 5.0) from a randomised trial comparing Compassion Focused Therapy for EDs (n = 3) with Cognitive Behavioural Therapy for EDs (n = 3) were interviewed with video-assisted recall about a self-selected session. Data were analysed through Interpretative Phenomenological Analysis (IPA) with Grounded Theory (GT) elements.

Results: Covert patient strategies included self-effacement, regulating therapeutic distance to open up, and engaging with reflective rather than experiential interventions. First, self-effacement included submissive, passive or pretend responses to perceived criticising or violating therapist behaviours as well as other orientation and submission for approval. Second, some preferred a close patient-therapist alliance with therapist self-disclosure and reciprocity was a requirement for opening up; others required distance. Third, informants detached from experiential trauma work while engaging in joint reflection on post-trauma responses.

Conclusion: Informants were preoccupied with calibrating the emotional-relational landscape in session; we hypothesized that psychological insecurity and affective intolerance from CT limit their freedom to explore own in-session experiences.

Keywords: Eating disorders; Process research; Qualitative methods; Trauma; Working alliance.

Plain language summary

A patient perspective on individual ED treatment processes is scarce for difficult-to-treat eating disorders (EDs) with childhood trauma (CT). We therefore interviewed six poor long-term outcome inpatients through video-assisted recall about a self-selected therapy session. Patients’ covert in-session strategies included self-effacing behaviours in relation to their therapist, their respective preferences for closeness or distance to their therapist to be able to open up in session, and being more prone to engage in therapists’ reflective interventions rather than experiential. In sum, patients were preoccupied with calibrating the emotional–relational landscape between patient and therapist in session, which were strategies that went undetected. We hypothesized that a lack of psychological security and affective tolerance limit patients freedom to explore own experiences from the perspective of traumatic attachment and self-differentiation theory.