Alliance processes in eating disorders with childhood maltreatment sequelae: Preliminary implications

Background Effective eating disorder (ED) treatments are drastically needed for patients with experiences of sustained and prolonged emotional, physical and sexual childhood maltreatment (CM) that often results in post‐traumatic sequelae such as severe, complex posttraumatic stress disorder (cPTSD). EDs with comorbid cPTSD (cPTSD‐ED) have protracted treatment courses and poorer prognoses. Aim To summarise the knowledge base on cPTSD‐ED with specific emphasis on disturbances in self‐organisation (DSO) in relation to therapeutic alliance (TA) processes. Method Expert opinions based on current relevant literature are critically examined. Results Preliminary insights on change and alliance processes suggest that neglecting to address emotional‐relational processes in the conceptualisation and treatment of cPTSD‐ED impedes treatment progress. Conclusion We hypothesise that the DSO construct inherent in cPTSD‐ED calls for a focus on TA processes in addition to traditional ED treatment elements such as nutritional rehabilitation and behaviour change, and regardless of ED treatment provided. More process research on a larger scale is urgently called for. Highlights A comprehensive literature suggests that eating disorders co‐occurring with complex posttraumatic stress disorder following childhood maltreatment interfere with favourable eating disorder outcomes. Disturbances in self‐organisation inherent in complex posttraumatic stress disorder seem to affect productive alliance formations. We propose that future integrated treatments for this patient group benefits from focussing on dysfunctional alliance processes alongside traditional eating disorder treatment elements, and hypothesise its potential role in a multi‐contextual model.