Samenvatting

Background: In face-to-face therapy for eating disorders, therapeutic alliance (TA) is an important predictor of symptomreduction and treatment completion. To date, however, little is known about TA during web-based cognitive behavioral therapy(web-CBT) and its association with symptom reduction, treatment completion, and the perspectives of patients versus therapists.Objective: This study aimed to investigate TA ratings measured at interim and after treatment, separately for patients andtherapists; the degree of agreement between therapists and patients (treatment completers and noncompleters) for TA ratings;and associations between patient and therapist TA ratings and both eating disorder pathology and treatment completion.Methods: A secondary analysis was performed on randomized controlled trial data of a web-CBT intervention for eatingdisorders. Participants were 170 females with bulimia nervosa (n=33), binge eating disorder (n=68), or eating disorder nototherwise specified (n=69); the mean age was 39.6 (SD 11.5) years. TA was operationalized using the Helping AllianceQuestionnaire (HAQ). Paired t tests were conducted to assess the change in TA from interim to after treatment. Intraclasscorrelations were calculated to determine cross-informant agreement with regard to HAQ scores between patients and therapists.A total of 2 stepwise regressive procedures (at interim and after treatment) were used to examine which HAQ scores predictedeating disorder pathology and therapy completion.Results: For treatment completers (128/170, 75.3%), the HAQ-total scores and HAQ-Helpfulness scores for both patients andtherapists improved significantly from interim to post treatment. For noncompleters (42/170, 24.7%), all HAQ scores decreasedsignificantly. For all HAQ scales, the agreement between patients and therapists was poor. However, the agreement was slightlybetter after treatment than at interim. Higher patient scores on the helpfulness subscale of the HAQ at interim and after treatmentwere associated with less eating disorder psychopathology. A positive association was found between the HAQ-total patientscores at interim and treatment completion. Finally, posttreatment HAQ-total patient scores and posttreatment HAQ-Helpfulnessscores of therapists were positively associated with treatment completion.Conclusions: Our study showed that TA in web-CBT is predictive of eating disorder pathology and treatment completion. Ofparticular importance is patients’ confidence in their abilities as measured with the HAQ-Helpfulness subscale when predictingposttreatment eating disorder pathology and treatment completion.