EVIDENCE-BASED CASE STUDY Alliance-Focused Therapy for Anorexia Nervosa: Integrative Relational and Behavioral Change Treatments in a Single-Case Experimental Design Dana A. Satir Boston University David M. Goodman Lesley University Rebecca M. Shingleton Boston University John H. Porcerelli Wayne State University Bernard S. Gorman Nassau Community College Elizabeth M. Pratt, David H. Barlow, and Heather Thompson-Brenner Boston University Evidence supporting outpatient treatments for anorexia nervosa (AN) is severely lacking, due to low retention and poor outcome. One explanation for drop-out is weak treatment alliances. A single-case experimental analysis accompanied by in-depth qualitative description is presented for Ms. O, who received a novel treatment for AN called Alliance Focused Treatment (AFT) that attends to ruptures in the alliance, interper- sonal difficulties and emotional avoidance. At intake Ms. O met diagnostic criteria for AN, Major Depressive Disorder, and Social Phobia. She was characterized as having symptoms of Obsessive Compulsive, Avoidant, and Depressive personality disorders. Treatment began with a Baseline followed by the experimental (AFT) and comparison treatments (Behavioral Change Treatment [BCT]) using a replicated experimental single-case phase change design. Graphs of slopes of kilocalorie and alliance change facilitated observation of treatment effects. Ms. O participated in 16 sessions of AFT and 8 sessions of BCT with specific benefits. Ratings of the treatment alliance were consistently high and she evidenced significant changes in weight, quality of life, and personality pathology. Associations between rupture/repair episodes and kilocalorie increases were observed. The utility of the treatment relationship in facilitating emotional expression was evident. At posttreatment, Ms. O endorsed cognitive AN symptoms, although these were not explicitly treated. This study provides preliminary support for the feasibility and effect of AFT and BCT, and highlights the importance of the alliance in treating adults with AN. Further research on emotion regulation in AN and its effect on the treatment relationship are needed. Keywords: anorexia nervosa, treatment alliance, single-case design, relational and behavioral psycho- therapy Anorexia nervosa (AN) is a serious psychiatric disorder with com- monly poor treatment outcome and high lifetime mortality rates (Crow et al., 2009; Herzog et al., 2000). AN is defined by a refusal to maintain a normal body weight for one’s age and height, intense fear of weight gain, disturbance in one’s body shape or weight, and a lack of recognition of the seriousness of low-weight (American Psychiatric Association [DSM–IV–TR], 2000). Treatment outcome data for adults with AN are described as “sparse and inconclusive” (Bulik, Berkman, Brownley, Sedway & Lohr, 2007, p. 10). Multiple reviews conclude that the majority of participants in treatment trials either drop out, show minimal improvement, or relapse following treatment (e.g., Agras et al., 2004; Attia & Walsh, 2009; Strober, 2004; Walsh et al., 2006; Wilson, Grilo, & Vitousek, 2007). No treatments have been established as “efficacious” in the treatment of adults with AN (Fairburn, 2005; McIntosh et al., 2005), and prominent researchers point to high drop-out rates in clinical trials as a serious limitation to existing research (Halmi et al., 2005). Given the high drop-out rates and poor outcome, novel treat- ments that promote retention and improvement are much needed. Treatment Alliance The treatment alliance is considered an essential aspect of successful psychotherapy across diagnostic categories (Horvath, Dana A. Satir, Rebecca M. Shingleton, Elizabeth M. Pratt, David H. Barlow, and Heather Thompson-Brenner, Center for Anxiety and Related Disorders (CARD) at Boston University; David M. Goodman, Psychology and Applied Therapies, Lesley University; John H. Porcerelli, Deptartment of Family Medicine & Public Health Sciences, Wayne State University; Bernard S. Gorman, Department of Psychology, Nassau Community College. This work was supported by a grant from the Fund for Psychoanalytic Research. Correspondence concerning this article should be addressed to Dana A. Satir, Eating Disorders Program, Department of Psychiatry & Behavioral Sciences, Children’s Hospital Colorado, 13123 E. 16th Avenue, Aurora, CO 80045. E-mail: dana.satir@gmail.com Psychotherapy © 2011 American Psychological Association 2011, Vol. 48, No. 4, 401– 420 0033-3204/11/$12.00 DOI: 10.1037/a0026216 401