5 - (SYM 48) The Impact of Telehealth on Working Alliance, Treatment Credibility, and Treatment Fidelity in Family Based Treatment for Adolescents with Anorexia Nervosa

Background: Anorexia nervosa (AN) has a 4% lifetime prevalence and disproportionately affects women. Family Based Treatment (FBT) is the first line treatment for adolescent AN. During the COVID-19 related shutdown, a clinical trial examining the impact of an adjunctive intervention on FBT outcome moved to a fully telehealth format. This unexpected shift provided a unique opportunity to examine differences across in-person and telehealth delivery of FBT. We summarize key treatment modifications for telehealth delivery and report on differences in patient-rated treatment credibility, therapeutic alliance, and treatment fidelity.  

Methods: Youth (age 12-18) with AN and their caregivers (N=59 families) were randomized to FBT alone (n=20) or FBT with Parent (n=20) or Adolescent-Focused (n=19) Cognitive Remediation Therapy. Treatment included 15 sessions over 6 months. We measured treatment credibility and expectancy via the Credibility and Expectancy Questionnaire at baseline. The Working Alliance Inventory was completed at four weeks post-baseline. FBT treatment fidelity focused on Sessions 1 and 2 and is ongoing.  

Results: Youth were aged 15.5 years (SD=1.7), with 50 assigned female and 8 assigned male at birth. Mean BMI z‐score was -0.1 (SD=0.8); 42% of the sample met criteria for severe malnutrition. Average illness duration was 13.1 months at baseline (SD=14.7). 18 families began in-person and 39 families received only telehealth. Mothers were less likely to describe treatment as logical or believe it would be successful when delivered via telehealth (p < .05); we saw no difference in treatment credibility and expectancy across modality for adolescents or fathers. Compared to telehealth, youth reported greater bond (p < .01,  η_p² = .22) and goal-related alliance (p = .04, η_p²= .14] for in-person sessions  and mothers reported greater bond (p < .01, Hedge’s g=0.94) and goal-related alliance (p < .01, Hedge’s g = 0.94) during in-person sessions. We saw no differences perception of alliance by treatment modality (p > .05) across fathers. Per therapists, the Family Meal was most impacted by the move to telehealth. Fidelity coding is on-going; preliminary data review indicates no difference in treatment fidelity.

Conclusion: Adolescents, particularly girls, had higher therapeutic alliance in-person compared to those in telehealth. Mothers were less likely to find treatment logical, believe it would be successful, and had weaker therapeutic alliance in telehealth. More work may be required to engage families in telehealth-delivered FBT.