2025 Theses Doctoral

The Role of the Therapeutic Alliance in a Peer Mentorship Program for Individuals with Eating Disorders

Patmore, Jacqueline Marie

Purpose:
The therapeutic alliance is widely recognized as a critical component in successful psychotherapy outcomes. Peer mentorship programs leveraging mentors' lived experiences have shown promise in enhancing engagement and promoting recovery in individuals with eating disorders. However, the specific mechanisms through which therapeutic alliance operates within peer mentorship contexts remain unclear. This study examined the role of therapeutic alliance in facilitating engagement and improved clinical outcomes while exploring patient perception of helpful program elements in a peer mentorship program specifically designed for individuals with eating disorders.

Method:
Forty participants diagnosed with eating disorders were enrolled in a randomized controlled trial comparing a peer mentorship intervention (mentors with lived experience of eating disorders) against a social support intervention (mentors without eating disorder experience). Participants were explicitly informed about the difference between conditions regarding mentors' lived experience prior to their participation. Participants completed the Working Alliance Inventory–Short Revised (WAI-SR) to measure therapeutic alliance, alongside assessments of eating disorder symptoms (Eating Pathology Symptoms Inventory), anxiety (State-Trait Anxiety Inventory), depression (Patient Health Questionnaire-9), and eating disorder-related quality of life (Eating Disorder Quality of Life). Additionally, qualitative responses regarding the perceived helpfulness of the mentorship were analyzed using thematic analysis.

Results:
Participants in the peer mentorship group reported significantly stronger therapeutic alliances (p < .001, Cohen’s d = 1.48) compared to the social support group. A regression analysis controlling for group type found that higher WAI-SR alliance scores were associated with a greater reduction in depression scores (PHQ-9 symptom slope: B = –0.021, t(36) = –2.173, p = .036). In contrast, alliance scores were not significantly related to changes in anxiety symptoms (STAI slope: B = –0.029, t(36) = –1.732, p = .092) or in eating disorder symptoms (EPSI-BD slope: B = –0.008, t(36) = –0.760, p = .452). There was no significant relationship between alliance and change in eating disorder-specific quality of life (EDQOL slope: B = –0.001, t(36) = –0.490, p = .627). Therapeutic alliance was also significantly associated with increased participant engagement, including higher session attendance and longer participation duration. Qualitative analysis revealed key relational benefits unique to peer mentorship, notably emotional validation, authentic understanding, and recovery-oriented narratives, which participants identified as critical for fostering trust and engagement.

Limitations and Future Directions:
Several limitations should be noted, including the relatively small and homogeneous sample, reliance on self-report measures, and potential self-selection bias from participants opting into the study after waitlist assignment. Future research should employ larger, more diverse samples and incorporate objective clinical assessments alongside self-reports. Longitudinal studies investigating the durability of therapeutic alliance effects and hybrid models integrating peer mentorship with structured, evidence-based treatments are recommended to further understand and optimize mentorship interventions.

Conclusions:
Therapeutic alliance emerged as a central factor in improving depressive symptoms and enhancing participant engagement in peer mentorship programs for eating disorders, primarily driven by the relational benefits associated with mentors' lived experiences. These findings advocate for mentorship programs emphasizing relational competencies over precise diagnostic or demographic matching. Integrating peer mentorship's relational strengths with structured, evidence-based therapeutic interventions appears promising for effectively addressing both engagement and clinical symptom improvement, ultimately supporting sustained recovery trajectories for individuals with eating disorders.