Treatment manuals tell clinicians what to do in therapy. They outline the things that we think to be useful in helping someone suffering from an eating disorder. What is underemphasised in those manuals is the stance of the therapist that may be most helpful in making the most of the treatment manual.

Collaboration or Direction?

A ‘collaborative stance’ is central to most therapies. Josie Geller from Canada is one of the worlds leading investigators of stance in eating disorder treatment.  Geller defines a collaborative stance as one that is supporting or encouraging change, whilst also supporting the individuals and showing concern and caring that is not contingent upon the individual’s behaviour.  You are working collaboratively toward goals that are agreed upon by the clinician and the individual. An example of a collaborative stance may be “What do you think got in the way of completing that challenge? You mentioned last week you really wanted to face that fear. How can I help you with this?” This is an invitation to understand a barrier to change together. It shows an understanding that change is hard.

This is contrasted to a ‘directive stance’, which is thought about as offering intrusive facilitation or contingent praise in order to get the patient to eat more, exercise less or agree to something.  Examples of a therapist being directive would be “You just need to stick to the meal plan” or “You are not motivated enough to change.”

Both patients and clinicians rate a collaborative stance as more helpful in the treatment of eating disorders.  Collaboration is seen as more acceptable and likely to lead to treatment retention and adherence.  So it is a no brainer – we should all be using a collaborative stance. I would imagine that most therapists would tell you that they indeed do use a collaborative stance. However, Zatisoff et al. (2015) found that collaborative and directive approaches were equally likely to occur in clinical practice.

As clinicians we are not as collaborative as we think we are. What about carers?

Geller et al. (2016) ask the same question about carers. Are carers as collaborative as they think they are? This is important as a collaborative carer style has been associated with higher motivation for change (van der Kaap-Deeder et al., 2014).

The carers recruited by Geller were the family and friends of patients with a mean age of 29 years and an average duration of illness of 12 years.  Importantly, these were adult patients. The stance for carers for adolescents may need to be different.

Predictably, carers felt that a collaborative stance was more helpful than a directive stance, but when faced with a series of clinical vignettes the majority (60%) of responses were coded as directive. Like clinicians, carers are less collaborative than they think.

Carers who believed that taking a directive stance was more helpful would, understandably, use a more directive approach to caring. It may be that teaching carers about the disadvantages of a directive stance and the benefits of a collaborative stance may be beneficial.  Geller et al (2016) tentatively concluded that their sample who had attended some sessions about the potential drawbacks of a directive approach and who were introduced to the concepts of stages of change were more likely to endorse a collaborative stance.  Psychoeducation to carers may be vital in enhancing change.

Collaboration was also positively associated with a warmer and more understanding interpersonal style and the use of a combination of concern and encouraging stance.  Helping carers manage their own distress would again seem important in facilitating a more helpful collaborative stance.


Van der Kaap-Deeder J, Vansteenkiste M, Soenens B, Verstuyf J, Boone L, Smets J. Fostering self-endorsed motivation to change in patients with an eating disorder: The role of perceived autonomy support and psychological need satisfaction. Int J Eat Disord 2014; 47:585–600.

Zaitsoff S, Yiu A, Pullmer R, Geller J, Menna R. Therapeutic engagement: Perspectives from adolescents with eating disorders. Psychiatry Res 2015; 230: 597–603.