The quality of the therapeutic alliance is a robust predictor of psychotherapy outcomes (Horvath, Del Re, Flückinger, & Symonds, 2011). Recent studies have shown that some therapists are consistently better at developing and maintaining alliances with their patients than others (Baldwin, Wampold, & Imel, 2007; Dinger, Strack, Leichsenring, Wilmers, & Schauenburg, 2008; Zuroff, Kelly, Leybman, Blatt, & Wampold, 2010), suggesting that alliance quality may be systematically related to certain therapist characteristics or behaviours. In this vein, recent research on the alliance has sought to more precisely clarify key therapist factors that contribute to alliance development, including how therapists identify and resolve alliance ruptures, i.e., tensions, strains, or breakdowns in the patient-therapist collaborative relationship (Safran & Muran, 2006). Unresolved alliance ruptures have been shown to relate to poorer outcomes and increased dropout rates, whereas the resolution of ruptures relates to better outcomes (Safran, Muran, & Eubanks-Carter, 2011).

Research on alliance rupture and resolution has important implications for the study of the alliance in psychotherapy for borderline personality disorder (BPD). BPD is a complex mental health disorder characterized by pervasive patterns of emotional instability, disturbed interpersonal relationships, identity disruption, and behavioral dyscontrol. The interpersonal difficulties associated BPD often manifest with treatment providers, leading to an increased likelihood of alliance ruptures (McMain, Boritz, & Leybman, 2015 Shearin & Linehan, 1992; Waldinger & Gunderson, 1984). Dialectical Behavior Therapy (DBT), one of the evidence-based treatments for BPD, was developed, in part, to address the challenges of engaging and retaining BPD patients in treatment. Nevertheless, dropout from DBT and other specialized BPD treatments remain high, ranging from 25% to 30% (Barnicot et al., 2012).

Consistent with the broader alliance literature, these studies have linked patient and therapist-rated alliance with treatment retention and outcome (Hirsh, Quilty, Bagby, & McMain, 2012; Spinhoven, Giesen-Bloo, van Dyck, Kooiman, & Arntz, 2007; Turner, 2000). In DBT specifically, the therapeutic alliance in sessions one through four has been shown to predict treatment outcomes, including dropout (McMain, Burckell, Links, & Guimond, 2009). However, there is limited research on more fine-grained observational assessments of therapist characteristics and in-session behaviors that contribute to the formation of a good alliance in BPD, including strategies for identifying and resolving alliance ruptures that may correlate positively or negatively with treatment outcomes for BPD patients.

In a recent study by Boritz, Barnhart, Eubanks, & McMain (2018), we conducted an exploratory analysis of alliance rupture and resolution processes in the early sessions of a small sample of clients (N=6) who underwent one year of standard DBT for BPD. Alliance rupture and resolution processes were coded using the observer-based Rupture Resolution Rating Scale (3RS; Eubanks, Muran, & Safran, 2015), which differentiates whether a client responds to tension, misunderstanding, or conflict in the therapy relationship by withdrawing from or confronting the therapist. Findings showed that unrecovered clients evidenced a higher frequency of withdrawal ruptures than recovered clients. Additionally, withdrawal ruptures tended to persist for unrecovered clients despite the degree of resolution in the prior session, unlike for recovered clients, for whom the probability of withdrawal ruptures decreased as the degree of resolution increased. This study suggests that alliance rupture and resolution processes in early treatment differ between recovered and unrecovered clients in DBT for BPD.

The present study was an effort to replicate and elaborate the findings from our exploratory study, with the following aims: (1) to determine whether alliance rupture and resolution processes predicted clinical outcomes in BPD, and (2) to assess the moderating effect of specific therapist baseline characteristics on alliance rupture and resolution processes and clinical outcomes.

Method

Sample. The sample was drawn from an ongoing RCT titled, “Faster Application of Suicidal Treatment—Evaluating Response to Dialectical Behavior Therapy” (FASTER-DBT; McMain et al., 2018). The FASTER-DBT trial assessed the clinical and cost-effectiveness of randomly assigned six months versus one year of treatment for chronically suicidal individuals diagnosed with BPD. In this study, 12 participants (six from the six-month arm, six from the one-year arm) were drawn as a simple random sample from the available participant pool of the FASTER-DBT study after the conclusion of its first year. Ethics for the FASTER-DBT Study were obtained from the Centre for Addiction and Mental Health (CAMH).

All participants met DSM-IV diagnostic criteria for BPD, as assessed using the International Personality Disorder Exam (IPDE; Loranger, 1995). Inclusion criteria were the presence of at least two suicide attempts or non-suicidal self-injurious behaviours in the five years prior to study enrolment, with at least one of these episodes occurring in the previous three months. Exclusion criteria included DSM-IV diagnoses of psychotic disorder, bipolar I disorder, dementia, or IQ less than 70, chronic or serious physical health problems requiring hospitalization within the treatment year, or plans to move out of the treatment region during the study duration. The sample was comprised of seven women and five men, who had a mean age of 28 (range = 19 to 43).

Treatment. All participants received comprehensive Dialectical Behaviour Therapy (DBT), an evidence-based treatment for BPD developed by Marsha Linehan (1993). The four standard components of DBT treatment were delivered: individual therapy (one hour per week), group skills training (two hours per week), phone coaching (available 24 hours a day), and a therapist consultation team meeting (two hours per week). There were no restrictions on ancillary pharmacotherapy. Therapy sessions were videotaped. DBT adherence ratings were applied to randomly selected video recordings and the results indicated that therapists adhered to the treatment protocols (see McMain et al., 2018).

Measures

Process measures. This study examined four process measures: (1) Rupture Resolution Rating Scale (3RS: Eubanks et al., 2015); (2) Alliance Rupture-Resolution Section from the Post-session Questionnaire (PSQ; Muran, Safran, Samstag, & Winston, 1992); (3) Working Alliance Inventory Short Form (WAIS; Horvath & Greenberg, 1989); and (4) Kentucky inventory of mindfulness skills (KIMS; Baer, Smith, & Allen, 2004). The 3RS was applied to the first four treatment sessions. The PSQ was completed by patients and therapists following the first four treatment sessions. The WAIS completed by patients and therapists following the first four sessions, then at three and six months of treatment. The KIMS completed by therapists at baseline (pretreatment), then monthly through to the end of the follow-up phase (i.e., 24 months).

Outcome measures. This study examined three patient outcome measures: (1) the Symptom Checklist-90-Revised (SCL-90R: Derogatis, 1983); (2) Suicide Attempt and Self-Injury Interview (SASII; Linehan, Comtois, Brown, Heard, & Wagner, 2006); and (3) Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD; Zanarini et al., 2003). Clinical assessments occurred at baseline (pretreatment) and at three, six, and 12 months of treatment.

Anticipated Outcomes

Given the broader empirical and theoretical literatures that implicate the clinical importance of alliance quality and treatment outcome in BPD, we hypothesize that higher frequencies of unresolved alliance ruptures in early treatment (session one to four) will predict poorer outcomes at mid- and post-treatment. We further hypothesize that the association between the frequency of unresolved alliance ruptures in early treatment and outcome at mid- and post-treatment will be moderated by mindfulness. Specifically, unresolved alliance ruptures will have their most harmful impact when involving a less mindful therapist.

Analytic Plan

All research questions will be evaluated using multilevel modeling. Explicit testing of our hypotheses will be examined by testing the regression coefficients for the frequency of alliance ruptures and rupture-resolution episodes by time interaction, while controlling for baseline characteristics, across all outcome variables. Individual and joint Wald χ2 tests will be used. We will test for moderation effects by expanding the regression model to include the interactions of all baseline characteristics of interest by time, and then evaluating both the individual and joint effects of these variables. These tests will include individual and joint Wald χ2 tests and likelihood ratio tests of model parameters, as well as the evaluation of the reduction of unexplained variance in the variance components. Evaluation of model fit will be provided by statistical indices including Akaike’s Information Criteria (AIC) and Bayesian Information Criteria (BIC) and likelihood ratio tests.

Summary

Results from this study will highlight therapist characteristics and therapeutic strategies that are critical to enhancing therapeutic alliances with BPD patients. Such work can be used to improve DBT and other evidence-based therapies for BPD by enhancing training practices in light of research evidence for adaptive in-session behaviours and preexisting therapist characteristics.

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Tali Z. Boritz, Ph.D.

Tali Boritz is a psychologist and clinician scientist at the Centre for Addiction and Mental Health (CAMH), and an Assistant Professor in the Department of Psychiatry at the University of Toronto. She received her PhD from York University in Toronto, Canada, and completed her postdoctoral training at CAMH. She joined the Borderline Personality Disorder Clinic at CAMH in 2012. Her research primarily focuses on psychotherapy process and outcome, with particular emphasis on the treatment of personality disorders. Her current research program aims to elucidate mechanisms of change in personality disorders, including the successful negotiation of the therapeutic alliance.