Psychotherapy © 2016 American Psychological Association

2016, Vol. 53, No. 2, 152–162 0033-3204/16/$12.00 http://dx.doi.org/10.1037/pst0000063

Therapeutic Interventions in the Treatment of Eating Disorders:

A Naturalistic Study

Antonello Colli Daniela Gentile, Annalisa Tanzilli,

‘Carlo Bo’ University of Urbino Anna Maria Speranza, and Vittorio Lingiardi
Sapienza University of Rome

This study used naturalistic data from psychodynamic (PD) and cognitive– behavioral (CB) clinicians in
the community to offer a portrait of treatments for eating disorder (ED) patients as provided in everyday
clinical practice. The research aims were (1) to examine the therapeutic interventions reported by PD and
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CB clinicians working with ED patients; and (2) to assess the impact of different variables (such as
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patient personality styles, ED symptomatology, and therapists’ theoretical orientation and experience) on
the technique use reported by clinicians. A national sample of PD and CB clinicians (N ⫽ 105) completed
the Shedler–Westen Assessment Procedure-200 (SWAP-200; Westen & Shedler, 1999a, 1999b) to assess
personality disorders of a female patient with EDs in their care, as well as the Comparative Psychother-
apy Process Scale—Bulimia Nervosa (CPPS-BN; Thompson-Brenner & Westen, 2005) to describe the
characteristic interventions used in their treatments. Results showed that PD clinicians tended to use
primarily PD interventions, while CB clinicians employed CB techniques supplementing them with a
wider range of PD strategies. However, clinicians from both theoretical orientations used adjunctive
treatment techniques for EDs at a similar level. In addition, use of PD interventions was strongly
associated with the personality styles of ED patients regardless of therapists’ orientation, primarily being
used more often when patients exhibited dysregulated and impulsive styles. Conversely, use of CB
interventions was primarily related to a clinicians’ CB orientation, patients with more explicit symptoms
of anorexia nervosa, and negatively related to clinicians’ years of experience. The clinical implications
of these findings were discussed.

Keywords: eating disorders, therapeutic interventions, therapist orientation, personality, CPPS-BN

Psychotherapies are crucial for the effective treatment of pa-
tients with eating disorders (EDs) although the comparative effec-
tiveness of different psychotherapeutic approaches is still contro-
versial. The results from some research on bulimia showed that
effect sizes for psychodynamic (PD) therapy were larger than
those reported for cognitive– behavioral (CB) psychotherapy and
nutritional counseling (Bachar, Latzer, Kreitler, & Berry, 1999).
Two other randomized controlled trials (RCTs) studies (Fairburn,
Kirk, O’Connor, & Cooper, 1986; Garner et al., 1993) revealed no
difference in primary outcome measure (bulimic episodes and
vomiting) between PD and CB, while differences in favor of CB
were found in secondary measures. In other research binge-eating,
PD was superior to a wait list control condition and as efficacious
as CB (Tasca et al., 2006). A recent RCT of 70 patients with BN,
receiving either 2 years of weekly PD or 20 sessions of CB over 5
months, was conducted to compare the outcomes of long-term PD
versus CB. Findings showed that CB was more effective in reliev-
ing binging and purging and generally faster in alleviating ED
Antonello Colli, Department of Humanistic Studies, ‘Carlo Bo’ Univer-
sity of Urbino; Daniela Gentile, Annalisa Tanzilli, Anna Maria Speranza,
and Vittorio Lingiardi, Department of Dynamic and Clinical Psychology,
Faculty of Medicine and Psychology, Sapienza University of Rome.
Correspondence concerning this article should be addressed to Antonello
Colli, Department of Humanistic Studies, ‘Carlo Bo’ University of Urbino,
via Saffi, 22, 61029 Urbino, Italy. E-mail: antonello.colli@uniurb.it
features and general psychopathology (Poulsen et al., 2014). How-
ever, these results should be considered in context because the
psychoanalytic psychotherapists of this study did not explore bing-
ing and purging symptoms unless the patients spoke about them
and by contrast, enhanced cognitive behavior therapy (CBT-E)
therapists focused primarily on binging and purging symptoms: as
the primary outcome was binge and purge remission, differential
results by treatment condition may not be surprising (Tasca,
Hilsenroth, & Thompson-Brenner, 2014).
Another recent study compared the efficacy of the focal PD
therapy (a manualized PD therapy characterized by a greater focus
on symptoms than PD therapy as usual), CBT-E and optimized
treatment as usual; no difference in weight gain was recorded by
the end of treatment between the study groups but patients allo-
cated to focal PD therapy had higher recovery rates compared with
those assigned optimized treatment as usual at 12 month follow-up
(Zipfel et al., 2014).
Recently, the scientific debate on the efficacy and effectiveness
of various forms of psychotherapy was characterized by bitter
controversies between researchers who favor the empirically sup-
ported treatment movement and consider RCT designs as the gold
standard for evaluating rigorously the treatment outcomes, and
researchers who are skeptical of this model (for a review, see
Carey & Stiles, 2016; Laska, Gurman, & Wampold, 2014; Laska
& Wampold, 2014; Norcross, Beutler, & Levant, 2005; Wampold
& Imel, 2015; Westen, Novotny, & Thompson-Brenner, 2004).
Indeed, several authors suggested that naturalistic studies may

152
 THERAPEUTIC INTERVENTIONS FOR EATING DISORDERS
provide a relevant complement to findings from randomized trials
of psychotherapy (Ablon et al., 2006). Overall, research has dem-
onstrated that even under tightly controlled conditions, treatments
often share significant elements of process (Laska et al., 2014;
Wampold & Imel, 2015). These common elements can predict
positive outcomes for various patient populations. In other words,
the “active ingredients” of a specific therapeutic approach are not
necessarily those presumed by the theory or treatment model. For
this reason, RCTs that evaluate a therapy as a “package” may not
automatically provide support for its theoretical premises or the
specific interventions that derive from them (Shedler, 2010).
It is important to examine if there are substantial differences in
the way therapists work in clinical practice. Even in controlled
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studies designed to test the efficacy of manualized treatments, it
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seems that clinicians tend to interact with patients in a different
manner and provide therapeutic interventions that are not specified
by the treatment manuals (Ablon, Levy, & Katzenstein, 2006;
Boswell, Kraus, Miller, & Lambert, 2015; Elkin et al., 1989; Imel,
Baer, Martino, Ball, & Carroll, 2011; Zickgraf et al., 2015). In line
with this perspective, some studies that investigated the factors
promoting a good outcome in different types of psychotherapy
supported the view that these therapies may include unacknowl-
edged elements from alternative approaches (Ablon & Jones,
1998, 2002; Ablon, Levy, & Katzenstein, 2006; Barber, Crits-
Christoph, & Luborsky, 1996; Diener, Hilsenroth, & Weinberger,
2007; Gaston, Thompson, Gallagher, Cournoyer, & Gagnon, 1998;
Lingiardi, Colli, Gentile, & Tanzilli, 2011; McAleavey & Caston-
guay, 2014). Moreover, research examining audio-recorded psy-
chotherapy sessions of PD and CB showed that PD therapists
tended to use a notable amount of CB strategies supplementing PD
strategies in the treatment of patients with posttraumatic stress
disorder or depression (Ablon & Jones, 1998, 2002). A study
examining what therapists do in the community when treating ED
patients also suggest that few clinicians closely adhere to treatment
manuals with most practitioners using a wide array of ED thera-
peutic interventions drawn from treatments that have no RCT
support (Tobin, Banker, Weisberg, & Bowers, 2007; Waller et al.,
2012). The findings suggested that the implementation of specific
CB techniques was far lower than protocols would suggest, par-
ticularly for clinicians who were anxious or more experienced in
working with EDs (Waller, Stringer, & Meyer, 2012). This sup-
ports prior work from a naturalistic sample investigating the in-
fluence of patient characteristics, as well as the nature or severity
of their EDs (comorbidity with borderline personality disorder
[BPD] and Depressive Disorder [MDD]), on the techniques pro-
vided by CBT therapists in everyday clinical practice with patients
with BN (Thompson-Brenner & Westen, 2005). The results sug-
gested that CB clinicians treating ED patients without BPD or
MDD tended to employ primarily CB interventions; conversely,
when treating ED patients with BPD or MDD, they continue to use
many CB interventions, but they supplement them with an even
wider range of interventions, including several that are character-
istics of a PD approach. For example, they help patients to deal
with distressing thoughts and feelings they are avoiding, identify
maladaptive interpersonal problems, come to terms with past re-
lationships, as well as traumatic experiences.
Research has also examined the associations between ED pa-
tients with dysregulated and constricted personality styles using
interventions endorsed by CB and PD clinicians. Both groups of
153
clinicians used more adjunctive interventions (e.g., used conjoint
inpatient or day treatment; used conjoint psychopharmacology;
established and maintained rules for therapeutic engagement) and
tended to address traumatic experiences with more dysregulated
patients (who were more likely to have trauma histories). How-
ever, the most striking finding was the large correlation between
dysregulation and the use of PD interventions by the CB-oriented
clinicians. In addition, CB-oriented clinicians tended to use more
PD interventions with more constricted patients, although the
effect was less pronounced, centering on use of the therapeutic
relationship and encouraging the patient to experience and express
feelings he/she is inhibiting. PD-oriented clinicians, in contrast,
reported using more CB interventions with more constricted pa-
tients, becoming more didactic and directive (Thompson-Brenner
& Westen, 2005).
It is important to highlight that therapists’ treatment adherence
is not solely or primarily owing to inability or unwillingness of the
therapist to follow the treatment, and therapist responsiveness or
flexibility may also be an important factor in treatment success.
Empirical evidence seems to suggest that treatment adherence and
integrity are affected by some variables such as treatment type,
therapist characteristics, responsiveness and patient variables (Bo-
swell, 2015; Boswell et al., 2015; Imel et al., 2011; Owen &
Hilsenroth, 2014; Stiles, 2009; Stiles, Honos-Webb, & Surko,
1998; Wampold & Imel, 2015; Zickgraf et al., 2015).
The present study used naturalistic data to examine psychother-
apy interventions for patients with EDs as reported by applied
clinicians belonging to two main theoretical approaches: CB and
PD. The aims of this research were as follows: (1) to examine the
therapeutic interventions used in everyday clinical practice by CB
and PD clinicians treating ED patients; and (2) to assess the effects
of variables, such as patient personality styles, ED symptomatol-
ogy, therapist theoretical orientation and experience, on the tech-
niques provided by these clinicians. We intend to examine the
following hypothesizes designed to replicate and extend the prior
work of Thompson-Brenner and Westen (2005):
Hypothesis 1: Both groups of CB and PD clinicians will use
interventions from the alternative theoretical orientation and
similar levels adjunctive interventions. This technical integra-
tion will be more pronounced for more experienced clinicians.
Hypothesis 2: Greater use of CB interventions will be used by
all clinicians with patients having more explicit specific ED
symptoms.
Hypothesis 3: Greater use of PD interventions will be used by
all clinicians with more emotionally dysregulated patients.
Method
Sample
We recruited a random sample of clinicians with at least 3 years
of postlicensure psychotherapy experience from the rosters of the
two largest Italian associations of PD and CB psychotherapy, as
well as from centers specializing in the treatment of EDs. We
contacted this random sample of 781 clinicians by email. Of these,
176 (23%) indicated they were currently treating a patient with an
ED that met the inclusion criteria of our study and were therefore
 154 COLLI ET AL.
invited to participate. Of these invited participants, 105 returned
completed measures (60%). Clinicians received no remuneration.
Procedure
We asked therapists to select a female patient, at least 18 years
old with an ED, no psychotic disorder, and not taking medication
for psychotic symptoms, whom they had seen for a minimum of
eight sessions. To minimize selection bias, we directed clinicians
to consult their calendar to select the last patient they saw during
the previous week who met the study criteria. To minimize rater-
dependent biases (i.e., therapist effects), each clinician was al-
lowed to describe only one patient. We did not find significant
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differences between those clinicians who participated in the re-
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search and those who declined to participate across variables such
as sex (␹2 ⫽ 0.66, p ⫽ .73), discipline (␹2 ⫽ 0.10, p ⫽ .12), and
theoretical orientation (␹2 ⫽ 2.736, p ⫽ .25). All participants
provided written informed consent consistent with institutional
review board approval.
Therapists. The sample consisted of 105 clinicians (female ⫽
80; male ⫽ 25). Each described the treatment of one patient with
an ED. There were 47 psychiatrists and 58 psychologists. Regard-
ing theoretical orientation, 55.23% (N ⫽ 58) of clinicians identi-
fied themselves as PD and 44.76% (N ⫽ 47) as primarily CB.
Their average experience as psychotherapists was 10.89 years
(SD ⫽ 8.82; min ⫽ 3, max ⫽ 37). Of the therapists, 48.57% (N ⫽
51) practiced in private setting and 51.43% (N ⫽ 54) in mental
health institutions (private and public). The length of treatment
averaged 14 months (min ⫽ 3, max ⫽ 96).
Patients. The patient sample consisted of 105 Caucasian fe-
male patients with mean age 26 years (SD ⫽ 9.01; range 18 –56).
Of these, 43 (40.95%) had a DSM–IV–TR (APA, 2000) diagnosis
of anorexia (N ⫽ 24 with restricting anorexia nervosa (AN) and
N ⫽ 19 with binge-purge AN), 34 were bulimic (32.38%; 16
purging and 18 without purging), and 28 had eating disorder not
otherwise specified symptomology (EDNOS; 26.66%). The mean
Global Assessment of Functioning (GAF) was 59.87 (SD ⫽ 13.18,
range 45–90). Of the patients, 75.23% (N ⫽ 79) were in outpatient
treatment, 30.47% (N ⫽ 32) had a history of psychiatric hospital-
ization, 40.90% (N ⫽ 43) had a personality disorder diagnosis
(Axis II DSM–IV–TR), 35.23% (N ⫽ 37) had an Axis I diagnosis
(N ⫽ 11 anxiety disorders, N ⫽ 18 mood disorders, N ⫽ 8
psychosomatics disorders).
Measures
Clinical Questionnaire—Eating Disorder Form. We con-
structed a general clinical demographic questionnaire for clinicians
to provide general information about themselves, their patients,
and therapies (length of treatment and number of sessions). Clini-
cians provided basic demographic and professional data, including
discipline, theoretical approach, employment address, hours of
work, number of patients in treatment, and patients’ age, gender,
race, education level, socioeconomic status, and development his-
tory. Clinicians were asked also to rate each diagnostic criterion
for AN, BN, and EDNOS according to the DSM–IV–TR (American
Psychiatric Association, 2000). This procedure allowed for a di-
mensional evaluation of each ED diagnosis (counting the presence
of each diagnostic criterion for each ED diagnosis) as well as a
categorical diagnosis applying DSM–IV–TR diagnostic algorithms.
Clinicians also rated history of ED symptoms and adaptive func-
tioning variables such as history of psychiatric hospitalizations and
ratings of GAF (American Psychiatric Association, 1994). In ad-
dition, clinicians indicated the presence or absence of DSM–IV–TR
Axis I disorders commonly comorbid with EDs and the 10 DSM–
IV–TR Axis II diagnoses in checklist form with a 3-point Likert
scale (0 ⫽ absence; 1 ⫽ subclinical presence; 2 ⫽ presence).
Clinicians also assessed variables potentially related to etiology,
such as history of abuse. To more comprehensively measure per-
sonality pathology and patient problems, respondents rated the
presence or absence of a list of clinical problems and personality
characteristics such as dissociative symptoms, self-harm, problems
with intimacy or commitment in close relationships, difficulty
expressing anger or aggression, difficulty asserting oneself, and
authority problems.
Shedler–Westen Assessment Procedure-200. The SWAP-
200 is a psychometric system designed to comprehensively assess
personality and personality pathology (Shedler & Westen, 1998;
Shedler, Westen, & Lingiardi, 2014; Westen & Shedler, 1999a,
1999b). It consists of 200 items that the assessor sorts into eight
categories, from not descriptive to most descriptive of the person.
The SWAP-200 assessment furnishes (1) a personality diagnosis
expressed as the matching of the patient assessment with 10
personality disorder scales (PD scales), which are prototypical
descriptions of DSM–IV–TR axis II disorders; and (2) a personality
diagnosis based on the correlation of the patient’s SWAP descrip-
tion with 11 empirically derived personality types (Q factors). It
also includes a dimensional measure of psychological strengths
and adaptive functioning. SWAP-200 yields dimensional and cat-
egorical diagnoses. The dimensional diagnosis is derived by cor-
relating the single patient assessment with the personality disorder
scales (PD). These PD scores are expressed as T scores (M ⫽ 50,
SD ⫽ 10) based on a large clinical outpatient sample of individuals
with DSM–IV–TR personality disorder diagnoses (Westen & Sh-
edler 1999a, 1999b, 2000). The categorical diagnosis can be as-
signed when the SWAP assessment identifies one or more PD
higher than T ⫽ 60 and when the high functioning factor is under
T ⫽ 60. Previous studies that applied SWAP-200 to EDs used
Q-analysis to identify three personality types: dysregulated (under-
controlled and impulsive); overcontrolled (constricted, inhibited, and
interpersonally avoidant); and high functioning (perfectionistic;
Thompson-Brenner & Westen, 2005; Westen & Harnden-Fischer,
2001). In this research, we applied the Italian version of the SWAP-
200, which has been validated and found reliable in previous works
(Shedler et al., 2014).
Comparative Psychotherapy Process Scale–Bulimia
Nervosa. The CPPS-BN is an adaptation for EDs of the Com-
parative Psychotherapy Process Scale (CPPS; Hilsenroth,
Blagys, Ackerman, Bonge, & Blais, 2005; Thompson-Brenner
& Westen, 2005; see Appendix). The CPPS-BN has 41 items,
each rated on a 7-point scale. The authors to maximize rele-
vance to EDs added to the original version of the CPPS inter-
ventions from the CB manual for BN (Fairburn, Marcus, &
Wilson, 1993), and interventions commonly employed for par-
ticular personality problems of relevance to patients with EDs.
Factor analysis identified three factors, “psychodynamic,”
“cognitive– behavioral,” and “adjunctive treatments,” that were
robust across different factor solutions and estimation proce-
 THERAPEUTIC INTERVENTIONS FOR EATING DISORDERS
dures and showed minimal cross-factor loadings. The PD factor
(15 items) included seven interventions identified by Blagys
and Hilsenroth (2000) as characteristic of PD therapies (e.g.,
addressing the patient’s avoidance of important topics and
shifts in mood) and eight items added by the authors. The CB
factor (11 items) included seven items identified by Blagys and
Hilsenroth (2002) as characteristic of this form of therapy (e.g.,
teaching the patient specific techniques for coping with his/her
symptoms) and four items added by the authors based on the
manual by Fairburn and colleagues (1993) (e.g., prescribing
regular eating patterns). The adjunctive treatments factor (five
items) included interventions such as psychiatric hospital ad-
mission not specific to any single theoretical approach. In the
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present study the internal consistencies of the three subscales
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were similar to reliabilities of the original factors (Thompson-
Brenner & Westen, 2005). We obtained the following Cron-
bach’s alpha values: .87 for PD treatment subscale, .93 for
Cognitive-Behavioral treatment subscale, and .62 for Adjust-
ment treatment subscale.
Statistical Analysis
All statistical analyses were performed with SPSS 20 for Win-
dows. Group differences between PD and CB clinicians on the
self-reported use of CPPS-BN therapeutic interventions (PD, CB,
and adjunctive treatment) were analyzed using Multivariate Anal-
ysis of Variance (MANOVA). Second, to provide the composite
descriptions of individual therapeutic interventions used by PD
and CB therapists treating ED patients, the CPPS-BN item scores
were averaged analyzing data both separately for PD (N ⫽ 58) and
CB (N ⫽ 47) clinicians as well as for the entire sample (N ⫽ 105).
The 10 highest-rated interventions (i.e., the items with highest
means) from the CPPS-BN were considered as the most charac-
teristic of ED treatments provided by PD, CB and all clinicians.
Finally, hierarchical (block) multiple regression analyses were
conducted to investigate if the CPPS-BN intervention strategies
could be predicted by some clinicians’ variables, ED symptom-
atology (number of DSM–IV–TR criteria met for each diagnosis of
AN, BN, and EDs not otherwise specified), and the SWAP-200
personality styles cutting across ED diagnoses (dysregulated, over-
controlled, and high functioning; Westen & Harnden-Fischer,
2001). All the multiple regressions, one for each type of therapeu-
tic intervention (PD, CB, and AT subscale scores) as the dependent
variable, were estimated in three steps. The first step (i.e., block)
contained clinicians’ theoretical orientation and years of experi-
ence. ED symptoms (AN, BN, EDNOS) were added in the second
Table 1
Differences in Therapeutic Intervention Ratings by PD and CB Clinicians Treating ED Patients
(MANOVA)
PD clinicians
(N ⫽ 58)
CPPS-BN subscales M (SD)
Psychodynamic treatment 4.36 (.91)
Cognitive-behavioral treatment 1.57 (1.01)
Adjunctive treatment 2.12 (1.32)
Note. PD ⫽ psychodynamic treatment; CB ⫽ cognitive-behavioral treatment; CPPS-BN ⫽ Comparative
Psychotherapy Process Scale—Bulimia Nervosa.
155
step. ED personality styles were entered in the third step. This
specific order allowed for verifying the impact of each step on the
three types of therapeutic interventions, providing the very con-
servative test for personality styles (given that it controlled for all
of ED diagnoses that may reflect in part personality processes). We
took into account the assumption that personality is a significant
diathesis for psychopathology (Westen, Gabbard, & Blagov, 2006)
and, using this order, it was possible to consider the specific
contribution of personality, net of the variability explained by all
the previous predictors. Changes in R2 were taken into account to
evaluate how much predictive power all the variables entered into
each step had, while the total R2 was considered as a measure of
variability accounted for by all the predictors of the three steps.
The F test, which is referred to as the F-change, was used to test
if R2 improvement was statistically significant (with a significance
level of p ⱕ .05)
Results
Differences in Therapeutic Interventions Used by PD
and CB Clinicians Treating ED Patients
The first aim of this research was to compare the self-reported
interventions of PD and CB clinicians used in the treatment of ED
patients. The results of the MANOVA showed a statistically sig-
nificant effect of the clinicians’ orientation on the techniques
employed in therapy, Wilks’s ␭ ⫽ .53, F(3, 101) ⫽ 29.54, p ⬍
.001, ␩2 ⫽ .47, Cohen’s d ⫽ 1.88. Specifically (see Table 1), there
was a significant difference between the PD and CB therapists on
the use of CB interventions, F(1, 103) ⫽ 70.02, p ⬍ .001, Cohen’s
d ⫽ 1.65. A trend toward significance was found comparing
therapists’ groups in the use of PD interventions, F(1, 103) ⫽ 3.12,
p ⫽ .080, Cohen’s d ⫽ 0.35. Finally, similar levels of AT inter-
ventions were detected in clinicians from both theoretical orienta-
tions, F(1, 103) ⫽ 1.79, p ⫽ .184, Cohen’s d ⫽ 0.26.
To offer a deeper understanding of the specific techniques
provided by CB and PD therapists, we created composite descrip-
tions of therapeutic interventions used in treatment of ED patients
by both clinician groups. We present the 10 most descriptive items
of treatment techniques used by PD (see Table 2) and CB clini-
cians (see Table 3).
It is important to note that PD clinicians working with ED
patients tended to use primarily PD interventions, while CB clini-
cians used CB techniques as well as several PD strategies. More in
detail, PD clinicians reported encouraging the patients to experi-
CB clinicians
(N ⫽ 47)
M (SD) F p ␩2 Cohen’s d
4.02 (1.03) 3.12 .080 .03 .35
3.52 (1.37) 70.02 .000 .41 1.65
2.49 (1.54) 1.79 .184 .02 .26
 156 COLLI ET AL.

Table 2
Highest-Rated Interventions Used by PD Clinicians (N ⫽ 58) Treating ED Patients

CPPS-BN items Subscale Mean

10 Most descriptive items reported by PD clinicians

13. Focused on the patient’s conflicting feelings or desires Psychodynamic 5.16
28. Preferred that the patient, rather than the therapist, initiate the discussion of significant issues, events,
and experiencesa 5.16
20. Encouraged the patient to experience and express feelings in the session Psychodynamic 4.86
37. Used the therapeutic relationship to offer the patient a different model for relationships than she had
previously experienced Psychodynamic 4.83
36. Focused on ways the patient deals with anger or aggression Psychodynamic 4.64
35. Encouraged the awareness and exploration of feelings the patient found uncomfortable or unacceptable Psychodynamic 4.57
29. Linked the patient’s current feelings or perceptions to experiences from the past Psychodynamic 4.55
8. Encouraged discussion of the patient’s wishes, fantasies, dreams, etc. Psychodynamic 4.45
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2. Focused on the influence of unconscious processes on behavior, emotions, or beliefsa 4.43

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27. Focused on similarities between the patient’s relationships and perceptions of relationships repeated
over time, settings, or people Psychodynamic 4.41
Note. PD ⫽ psychodynamic treatment; CPPS-BN ⫽ Comparative Psychotherapy Process Scale—Bulimia Nervosa.
a
Interventions that do not load on any CPPS-BN subscales (Thompson-Brenner & Westen, 2005).

ence and express emotions, explore their conflicting, uncomfort-
able, or unacceptable feelings or desires, link the current feelings
or perceptions to experiences from their past to identify repetitive
themes or patterns, as well as making use of the therapeutic
relationship for a corrective emotional experience. CB clinicians
reported teaching the patients specific behaviors or coping strate-
gies to deal with their symptoms and providing them with infor-
mation and facts about the current symptoms, disorder, or treat-
ment; likewise, they encourage the patients to express their
feelings and regulate intense emotions and identify maladaptive
interpersonal patterns and the thoughts, feelings, and motives
underlying them, as well as use the therapeutic relationship to offer
a different model of relationship than the ones they had previously
experienced.
To show the areas of integration between therapeutic interven-
tions used by PD and CB clinicians, we presented the 10 most
descriptive techniques of ED treatment for clinicians from both
theoretical approaches (see Table 4).
Predicting Therapeutic Interventions in Treatments of
ED Patients
Our second aim was to investigate the relationship among
different groups of therapeutic interventions in ED treatment,
patients’ ED symptomatology and personality styles, and thera-
pists’ therapeutic orientation and experience. A set of regression
analyses were performed to evaluate whether the use of distinct
clusters of therapeutic interventions (PD, CB, and adjunctive treat-
ment) predicted by clinicians’ orientation and years of experience
included in the first step, patients’ ED symptomatology entered in
the second step, and their personality styles added in the final step
(Tables 5, 6 and 7).
Findings showed that PD interventions were strongly associated
with the personality styles of ED patients. More in detail, dysregu-
lated/impulsive personality was the most robust predictor of these
therapeutic strategies, especially in the PD treatments (see Table
5). Conversely, CB interventions were not related to any particular

Table 3
Highest-Rated Interventions Used by CB Clinicians (N ⫽ 47) Treating ED Patients

CPPS-BN items Subscale Mean

10 Most descriptive items reported by CB clinicians

9. Encouraged the patient to practice behaviors or coping strategies learned in therapy between sessions Cognitive-behavioral 5.19
10. Encouraged the patient to become less self-critical or perfectionistic, or to “tone down” unrealistic
expectations of herself (either implicitly or explicitly)a 5.00
20. Encouraged the patient to experience and express feelings in the session Psychodynamic 4.91
12. Identified maladaptive interpersonal patterns and the thoughts, feelings, and motives underlying them Psychodynamic 4.79
11. Provided the patient with information and facts about her to current symptoms, disorder, or treatment Cognitive-behavioral 4.72
3. Encouraged the patient to assert herself or get her needs met in relationships Psychodynamic 4.66
4. Taught the patient specific techniques for coping with her symptoms Cognitive-behavioral 4.62
5. Helped the patient think of other ways to respond when she was feeling impulsive or self-destructive
(note : do not include binge eating here as a form of impulsivity or self-destructiveness)a 4.60
25. Helped the patient regulate intense emotions (e.g., anger, fear, etc.) Psychodynamic 4.53
37. Used the therapeutic relationship to offer the patient a different model for relationships than she had
previously experienced Psychodynamic 4.49
Note. CB ⫽ cognitive-behavioral treatment; CPPS-BN ⫽ Comparative Psychotherapy Process Scale—Bulimia Nervosa.
a
Interventions that do not load on any CPPS-BN subscales (Thompson-Brenner & Westen, 2005).
 THERAPEUTIC INTERVENTIONS FOR EATING DISORDERS 157

Table 4
Highest-Rated Interventions Used by All PD and CB Clinicians (N ⫽ 105) Treating ED Patients

CPPS-BN items Subscale Mean

10 Most descriptive items reported by all PD and CB clinicians

20. Encouraged the patient to experience and express feelings in the session Psychodynamic 5.01
13. Focused on the patient’s conflicting feelings or desires Psychodynamic 4.71
37. Used the therapeutic relationship to offer the patient a different model for relationships than she had
previously experienced Psychodynamic 4.68
28. Preferred that the patient, rather than the therapist, initiate the discussion of significant issues, events,
and experiencesa 4.68
12. Identified maladaptive interpersonal patterns and the thoughts, feelings, and motives underlying them Psychodynamic 4.53
36. Focused on ways the patient deals with anger or aggression Psychodynamic 4.44
35. Encouraged the awareness and exploration of feelings the patient found uncomfortable or unacceptable Psychodynamic 4.37
25. Helped the patient regulate intense emotions (e.g., anger, fear) Psychodynamic 4.35
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

23. Focused on the relationship between the therapist and patient. Psychodynamic 4.31
This document is copyrighted by the American Psychological Association or one of its allied publishers.

10. Encouraged the patient to become less self-critical or perfectionistic, or to “tone down” unrealistic
expectations of herself (either implicitly or explicitly)a 4.28
Note. PD ⫽ psychodynamic treatment; CB ⫽ cognitive-behavioral treatment; CPPS-BN ⫽ Comparative Psychotherapy Process Scale—Bulimia Nervosa.
a
Interventions that do not load on any CPPS-BN subscales (Thompson-Brenner & Westen, 2005).

patient’s personality subtype. They were positively associated with
clinicians’ CB orientation and patients’ explicit symptoms of an-
orexia, as well as negatively associated with clinicians’ years of
experience (see Table 6). Finally, the adjunctive treatment inter-
ventions were not associated with personality styles of ED pa-
tients, but were strongly predicted by their symptomatology,
mostly AN (see Table 7).
Discussion
The first aim of this research was to examine the similarities and
differences in the therapeutic interventions used in everyday clin-
ical practice by PD and CB clinicians working with ED patients.
We intended to examine whether CB therapists also used PD
interventions, likewise, did PD therapists use additional CB strat-
egies. Our results partially confirmed the hypotheses (see Table 1),
and support the findings of Waller and colleagues (2012). That is,
while CB therapists reported to use primarily CB techniques (e.g.,
teach the patient specific behaviors or coping strategies to deal
with their symptoms; prescribe more appropriate eating patterns;
help the patient to develop strategies for controlling impulses to
binge, purge, fast), they also incorporated a range of PD strategies.
Contrary to our expectations, PD therapists did not supplement
their PD interventions with CB ones to the same level as that of CB
clinicians (see also Table 2). However, both PD and CB ap-
proaches showed similar use of adjunctive treatment interventions
for EDs using conjoint inpatient or day treatment, encouraging the
patient to be weighed regularly or working with another profes-
sional in that role, and establishing and maintaining rules for
therapeutic engagement. More especially, CB therapists used PD
interventions that share a common focus on affect exploration
(e.g., encouraged the patient to experience and express feelings in
the session), interpersonal patterns (e.g., identified maladaptive
interpersonal patterns and the thoughts, feelings, and motives
underlying them), and the therapeutic relationship (e.g., used the
therapeutic relationship to offer the patient a different model for
relationships than she had previously experienced; Table 3). Given

Table 5
Hierarchical Multiple Regression Analyses Predicting Psychodynamic Interventions in ED Treatment From Clinicians’ Orientation
and Experience and Patients’ Symptomatology and Personality (N ⫽ 105)

F change (model)
Therapeutic intervention, clinician and patient variables R R2 Standardized ␤ or t (␤) (F) or (t) p

Criterion variable: CPPS-BN psychodynamic treatment

Step 1: Self-reported clinician orientation .220 .048 2.590 .080
Theoretical orientation (1 ⫽ PD; 2 ⫽ CB) ⫺.163 ⫺1.774 .079
Years of experience .065 .687 .494
Step 2: ED symptomatology .232 .054 .194 .900
Anorexia symptomatology ⫺.094 ⫺1.014 .313
Bulimia symptomatology ⫺.104 ⫺1.125 .263
EDNOS symptomatology ⫺.079 ⫺.865 .389
Step 3: ED personality subtypes .476 .227 7.141 .000ⴱⴱⴱ
Dysregulated/impulsive .368 3.659 .000ⴱⴱⴱ
Constricted/overcontrolled .077 .750 .455
High functioning perfectionistic .154 1.677 .097
Note. EDNOS ⫽ eating disorder not otherwise specified symptomatology; PD ⫽ psychodynamic treatment; CB ⫽ cognitive-behavioral treatment;
CPPS-BN ⫽ Comparative Psychotherapy Process Scale—Bulimia Nervosa.
ⴱⴱⴱ
p ⱕ .001.
 158 COLLI ET AL.

Table 6
Hierarchical Multiple Regression Analyses Predicting Cognitive-Behavioral Interventions in ED Treatment From Clinicians’
Orientation and Experience and Patients’ Symptomatology and Personality (N ⫽ 105)

F change (model)
Therapeutic intervention, clinician and patient variables R R2 Standardized ␤ or t (␤) (F) or (t) p

Criterion variable: CPPS-BN cognitive-behavioral treatment

Step 1: Self-reported clinician orientation .644 .415 36.208 .000ⴱⴱⴱ
Theoretical orientation (1 ⫽ PD; 2 ⫽ CB) .606 7.926 .000ⴱⴱⴱ
Years of experience ⫺.156 ⫺1.961 .050ⴱ
Step 2: ED symptomatology .676 .456 2.500 .064
Anorexia symptomatology .174 2.258 .026ⴱ
Bulimia symptomatology ⫺.049 ⫺.631 .530
EDNOS symptomatology .044 .583 .561
Step 3: ED personality subtypes .682 .465 .511 .676
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Dysregulated/impulsive .044 .526 .600

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Constricted/overcontrolled .067 .779 .438

High functioning perfectionistic ⫺.034 ⫺.446 .656
Note. EDNOS ⫽ eating disorder not otherwise specified symptomatology; PD ⫽ psychodynamic treatment; CB ⫽ cognitive-behavioral treatment;
CPPS-BN ⫽ Comparative Psychotherapy Process Scale—Bulimia Nervosa.
ⴱ
p ⱕ .05. ⴱⴱⴱ p ⱕ .001.

that emotional regulation and negative affect are core problems of
EDs (Lavender et al., 2015; Pedersen, Poulsen, & Lunn, 2015;
Racine et al., 2016; Vann, Strodl, & Anderson, 2013), it is not
surprising that the most used interventions are related to affect
exploration and to use of the therapeutic relationship seen as a
deeply meaningful and emotionally charged interpersonal experi-
ence (Colli & Lingiardi, 2009; Safran & Muran, 2000; see Table
4). Moreover, it is interesting to note that the interventions shared
by CB and PD therapists are more widely recognized as relevant
factors related to a good outcome of treatment and elaboration
depth (Diener & Hilsenroth, 2009; Diener, Hilsenroth, & Wein-
berger, 2007; Lingiardi, 2013; Lingiardi et al., 2011; Lingiardi,
Gazzillo, & Waldron, 2010).
The second aim of this research was to assess the effect of
different variables—such as patient personality styles, ED symp-
tomatology and therapists’ theoretical orientation, and experi-
ence— on the different clusters of therapeutic techniques provided
by the therapists. Consistent with previous research by Thompson-
Brenner and Westen (2005), our findings also demonstrated that
PD interventions were strongly associated with the personality
styles of ED patients, in particular, dysregulated/impulsive person-
ality. That is, among the personality styles associated with ED
patients characterized by lowest functioning personality level,
highest childhood sex abuse, and poorest outcome, was the most
robust predictor of PD interventions both for PD and CB therapists
(Thompson-Brenner & Westen, 2005). A possible explanation
might be that CB clinicians treating ED patients with difficulty
regulating emotions and impulses tended to tailor their interven-
tions to patient’s core problems and difficulties. Making greater
use of PD techniques, they focused on maladaptive patterns of
expression and regulation of emotions and impulses of these
patients, their aggressive and self-destructive behaviors, distress-
ing thoughts, or dysfunctional interpersonal relationships. In other
words, as suggested by Owen and Hilsenroth (2014), adherence
flexibility could reflect therapists’ efforts to be responsive to the
emerging context of therapy session, as well as the needs of clients

Table 7
Hierarchical Multiple Regression Analyses Predicting Adjunctive Treatment Interventions in ED Treatment From Clinicians’
Orientation and Experience and Patients’ Symptomatology and Personality (N ⫽ 105)

F change (model)
Therapeutic intervention, clinician and patient variables R R2 Standardized ␤ or t (␤) (F) or (t) p

Criterion variable: CPPS-BN adjunctive treatment

Step 1: Self-reported clinician orientation .131 .017 .887 .415
Theoretical orientation (1 ⫽ PD; 2 ⫽ CB) .120 1.249 .215
Years of experience ⫺.046 ⫺.466 .642
Step 2: ED symptomatology .395 .156 5.420 .002ⴱⴱ
Anorexia symptomatology .358 3.722 .000ⴱⴱⴱ
Bulimia symptomatology .058 .599 .551
EDNOS symptomatology ⫺.090 ⫺.940 .350
Step 3: ED personality subtypes .400 .160 .160 .923
Dysregulated/impulsive .033 .316 .752
Constricted/overcontrolled .017 .160 .873
High functioning perfectionistic ⫺.053 ⫺.554 .581
Note. EDNOS ⫽ eating disorder not otherwise specified symptomatology; PD ⫽ psychodynamic treatment; CB ⫽ cognitive-behavioral treatment;
CPPS-BN ⫽ Comparative Psychotherapy Process Scale—Bulimia Nervosa.
ⴱⴱ
p ⱕ .01. ⴱⴱⴱ p ⱕ .001.
 THERAPEUTIC INTERVENTIONS FOR EATING DISORDERS
by increasing or decreasing theory-specific techniques (e.g., Con-
stantino, Boswell, Bernecker, & Castonguay, 2013; Frank &
Frank, 1991; Stiles, 2009, 2013; Stiles et al., 1998; Wampold,
2001). Moreover, it is interesting to note that a recent RCT study
that examined an integrative cognitive affective therapy for BN
and found that individuals with higher affective lability may ben-
efit more from treatment with a greater focus on affective states
and self-regulation (Accurso et al., 2016).
Patients’ clear and exacerbated AN symptomatology was a
significant predictor of the use of both CB and adjunctive treat-
ment interventions for both PD and CB therapists. These results
suggests that when PD and CB clinicians engage with patients with
more severe ED symptoms, they increase the use of interventions
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
addressed to the symptoms monitoring, encouraging the patient to
This document is copyrighted by the American Psychological Association or one of its allied publishers.
be weighed regularly and using conjoint psychosocial treatment
such as nutritional counseling or group treatment and so forth. The
great relevance of adjunctive treatment interventions across ther-
apist approaches in the treatment of anorexic patients is not sur-
prising if we consider that treatment acceptance is a major chal-
lenge in the management of patients with AN, taking into account
their high ambivalence and lack of acceptance of the severity of
their illness. Thus, therapists not only have to cope with a fre-
quently difficult therapy process, but also must take responsibility
for management of physical and psychiatric complications of this
potentially lethal disorder (Dejong, Broadbent, & Schmidt, 2012).
Finally, the influence of therapists’ experience on the techniques
furnished by the therapists was examined. The results suggested
that more experienced CB therapists tended to use a greater
amount of PD techniques. Thus it is likely that less experienced
CB therapists tend to adhere to the cognitive treatment model more
rigidly, while those more experienced may feel free to be more
flexible, responsive, and tailor their interventions to an individu-
als’ needs according to patient (Castonguay, Goldfried, Wiser,
Raue, & Hayes, 1996; Owen & Hilsenroth, 2014; Stiles, 2009;
Stiles, Honos-Webb, & Surko, 1998). Overall, these results con-
firm the idea that what clinicians really do in their everyday
clinical practice could be different from what a specific treatment
model might suggest (Ablon et al., 2006). Our findings also
support the impact of patients’ core problems on therapists’ ap-
proach to treatment. In the future it will be necessary to further
investigate the interaction between clinicians’ treatment model,
experience and psychotherapy integration as well as patient’s
personality functioning and diagnosis in relation to treatment ad-
herence.
This study has some limitations that we are clearly aware of.
First, it is important to consider the absence of data about therapy
outcome. This lack does not allow us to examine the relevant
relationship between the adherence/flexibility and treatment out-
come. Future investigations should investigate what techniques
provided by therapists are associated with changes in symptoms
and personality functioning regardless of their theoretical orienta-
tion. Second, the use of self-report instrument to assess therapist
techniques and the use of a single informant (the therapist) may be
a source of measurement bias. A more rigorous research design
would include an independent evaluation of therapist techniques
from an observer point of view and with the use of audio/video
recordings or session transcripts. Additionally, in this research the
variable of therapist functioning in the relationship with the patient
was not included. A previous study on ED patients showed that
159
therapist adherence to CB protocol can be influenced by clinicians’
anxiety during the treatment (Waller et al., 2012). Future investi-
gations should examine the relevant role of clinicians’ emotional
responses to ED patients in the use of distinct intervention strat-
egies, taking into account that this patient population tends to
evoke intense reactions in their clinicians (Colli et al., 2015;
Lingiardi, Tanzilli, & Colli, 2015; Satir, Thompson-Brenner, Bois-
seau, & Crisafulli, 2009; Thompson-Brenner, Satir, Franko, &
Herzog, 2012).
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Appendix
Comparative Psychotherapy Process Scale—Bulimia Nervosa (Thompson-Brenner & Westen, 2005)

Not at all Very

Number Items description Subscale characteristic characteristic

1 Encouraged systematic self-monitoring of eating behavior (e.g., keeping a food diary). CB 0 1 2 3 4 5 6

2 Focused on the influence of unconscious processes on behavior, emotions, or beliefs. 0 1 2 3 4 5 6
3 Encouraged the patient to assert herself or get her needs met in relationships. PD 0 1 2 3 4 5 6
4 Taught the patient specific techniques for coping with her symptoms. CB 0 1 2 3 4 5 6
5 Helped the patient think of other ways to respond when she was feeling impulsive or 0 1 2 3 4 5 6
self-destructive (note: do not include binge eating here as a form of impulsivity or
self-destructiveness).
6 Actively initiated the topics of discussion and other therapeutic activities. 0 1 2 3 4 5 6
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

7 Encouraged the patient to reward or punish herself for adaptive and maladaptive 0 1 2 3 4 5 6
This document is copyrighted by the American Psychological Association or one of its allied publishers.

behaviors (e.g., giving herself something when she avoided purging).

8 Encouraged discussion of the patient’s wishes, fantasies, dreams, etc. PD 0 1 2 3 4 5 6
9 Encouraged the patient to practice behaviors or coping strategies learned in therapy CB 0 1 2 3 4 5 6
between sessions.
10 Encouraged the patient to become less self-critical or perfectionistic, or to “tone 0 1 2 3 4 5 6
down” unrealistic expectations of herself (either implicitly or explicitly).
11 Provided the patient with information and facts about her to current symptoms, CB 0 1 2 3 4 5 6
disorder, or treatment.
12 Identified maladaptive interpersonal patterns and the thoughts, feelings, and motives PD 0 1 2 3 4 5 6
underlying them.
13 Focused on the patient’s conflicting feelings or desires. PD 0 1 2 3 4 5 6
14 Helped the patient problem-solve current crises or difficult interpersonal situations. 0 1 2 3 4 5 6
15 Helped the patient deal with traumatic experiences. 0 1 2 3 4 5 6
16 Suggested specific activities or tasks for the patient to attempt outside of session. CB 0 1 2 3 4 5 6
17 Established and maintained rules for therapeutic engagement (e.g., managing extra AT 0 1 2 3 4 5 6
sessions, phone calls, boundaries, and safety issues).
18 Encouraged the patient to be weighed regularly, or worked with another professional AT 0 1 2 3 4 5 6
who played that role.
19 Explained the rationale behind the therapeutic technique or approach to treatment. CB 0 1 2 3 4 5 6
20 Encouraged the patient to experience and express feelings in the session PD 0 1 2 3 4 5 6
21 Helped the patient develop strategies for eating appropriately or controlling impulses CB 0 1 2 3 4 5 6
to binge, purge, fast, etc.
22 Addressed the patient’s avoidance of important topics and shifts in mood. PD 0 1 2 3 4 5 6
21 Helped the patient develop strategies for eating appropriately or controlling impulses CB 0 1 2 3 4 5 6
to binge, purge, fast, etc.
22 Addressed the patient’s avoidance of important topics and shifts in mood. PD 0 1 2 3 4 5 6
23 Focused on the relationship between the therapist and patient. PD 0 1 2 3 4 5 6
24 Challenged irrational or illogical conscious beliefs about food, diet, and eating. CB 0 1 2 3 4 5 6
25 Helped the patient regulate intense emotions (e.g., anger, fear). PD 0 1 2 3 4 5 6
26 Encouraged the patient to perform behaviors associated with anxiety in an effort to 0 1 2 3 4 5 6
overcome it (e.g., eating particular foods).
27 Focused on similarities between the patient’s relationships and perceptions of PD 0 1 2 3 4 5 6
relationships repeated over time, settings, or people.
28 Preferred that the patient, rather than the therapist, initiate the discussion of 0 1 2 3 4 5 6
significant issues, events, and experiences.
29 Linked the patient’s current feelings or perceptions to experiences from the past. PD 0 1 2 3 4 5 6
30 Interacted with the patient in a didactic or teacher-like way. CB 0 1 2 3 4 5 6
31 Prescribed regular eating patterns. CB 0 1 2 3 4 5 6
32 Offered explicit advice or suggestions. CB 0 1 2 3 4 5 6
33 Explored and addressed issues of sexuality. PD 0 1 2 3 4 5 6
34 Challenged irrational or illogical beliefs about issues other than food, diet, or eating. 0 1 2 3 4 5 6
35 Encouraged the awareness and exploration of feelings the patient found uncomfortable PD 0 1 2 3 4 5 6
or unacceptable.
36 Focused on ways the patient deals with anger or aggression. PD 0 1 2 3 4 5 6
37 Used the therapeutic relationship to offer the patient a different model for PD 0 1 2 3 4 5 6
relationships than she had previously experienced.
38 Helped the patient come to terms with her relationships with and feelings about PD 0 1 2 3 4 5 6
significant others from the past (e.g., mother, father).
39 Used conjoint psychosocial treatments, such as group treatment, nutritional AT 0 1 2 3 4 5 6
counseling, and family treatment
40 Used conjoint psychopharmacology. AT 0 1 2 3 4 5 6
41 Used conjoint inpatient or day treatment. AT 0 1 2 3 4 5 6
Note. PD ⫽ psychodynamic treatment; CB ⫽ cognitive-behavioral treatment; AT ⫽ adjunctive treatment.

Received April 12, 2016

Accepted April 14, 2016 䡲