Dropping out from psychological treatment for eating disorders : an attachment perspective

Objective: The central objective of this thesis is to better understand factors affecting dropping out from psychological treatment using the specific case of eating disorders. Methods: Following critical reviews of the drop-out literature, it was suggested that dropping out should be thought of and studied as the product of interactions taking place within the treatment relationship. The majority of previous research has unsuccessfully attempted to predict dropping out based on pre-treatment patient characteristics in isolation from therapist or therapy characteristics. Attachment theory framed a series of studies using both qualitative and quantitative methods to explore engagement in the early treatment relationship. Two constructs were used: attachment as a pre-existing trait affecting attitudes toward treatment relationships, and attachment as a state resulting from feelings and perceptions occurring within the early relationship. Results: Attachment concepts may improve characterisation of dropping out: Attachment as trait: Case-note analyses of 2 independent patient series replicated a dose-effect relationship between some childhood traumatic experiences and dropping out (N=224). In multivariate analyses, parental break-up in childhood was predictive. However, the relationship between adult attachment style and dropping out remains unclear. Attachment style dimensions from the Vulnerable Attachment Style Questionnaire (VASQ) did not distinguish drop-outs from other treatment status groups in a prospective study. Attachment as state: 26 in-depth qualitative interviews revealed that therapists' attuned responsiveness in the early sessions was important to establishing a 'secure base', which patients needed to engage. The Therapy Relationship Questionnaire (TRQ) was designed to measure both patient and therapist views of the developing relationship over time (N = 110). Conclusions: Dropping out undoubtedly results from myriad interacting patient, therapist, and therapy factors. However, the therapy relationship underlies these, so measuring it dynamically may be the best way of understanding dropping out. Such an approach, informed by attachment theory, might lead to clinically useful interventions for improving engagement.