The influence of therapist actions, strategies and qualities on change processes in psychological therapies for eating disorders: grounded theory analysis

BACKGROUND: Therapist actions, qualities and strategies are a potentially modifiable factor influencing outcome in psychological therapies for eating disorders. This study aims to hear the perspectives of those with lived experience, to identify therapist actions and behaviours which were helpful or unhelpful in change and recovery, and to construct a theory of the processes by which these therapist actions might impact on recovery. METHODS: Eighteen participants who had undergone various psychological therapies for EDs took part in semi-structured interviews. They described helpful and unhelpful therapist behaviours, their emotional and cognitive impacts, and how these influenced recovery. Using a constructivist grounded theory approach, data were analysed through initial and focused coding, comparative methods, theoretical sampling, and memo-writing to develop a theoretical model. RESULTS: Participants described two interacting major categories of therapist actions, strategies and qualities: therapist 'style and stance' along with 'tasks of therapy'. These were described as having some direct pathways of influence on 'change processes and recovery', but also acted through three core categories of interacting intervening processes: 'the person seen heard and cared for', 'trust and openness to therapy' and 'turning towards change'. These processes are the core of the model, acting to catalyse (or block) change. CONCLUSIONS: Elements of therapist style and the tasks of therapy influence recovery both directly and through key intervening processes: feeling seen, heard and cared for; developing trust and openness to therapy; and turning towards change. The constructed model and categories are considered in light of psychotherapy theory. The identified aspects of therapist style and tasks are relevant to clinicians and can inform the co-production of guidance for future use in training and delivery of ED therapies.