New findings from a team of American researchers indicate that the strength of a client/therapist bond called the therapeutic alliance significantly impacts the success of treatment for borderline personality disorder. Borderline personality disorder (BPD) is often treated with dialectical behavior therapy (DBT), a form of psychotherapy specifically intended to reduce suicidal behavior in people affected by BPD. In a study published in March 2015 in the American Psychological Association journal Psychotherapy, researchers from two U.S. universities assessed the impact that the perceived strength of the therapeutic alliance has on the effectiveness of DBT as a borderline personality disorder treatment. These researchers concluded that both the therapist’s and the client’s perception of the therapeutic alliance can influence treatment outcomes.
Dialectical Behavior Therapy
Dialectical behavior therapy is an offshoot of another form of psychotherapy, called cognitive behavioral therapy, which focuses on producing real-world changes in the dysfunctional thoughts, emotions and behaviors that can appear in an individual in high-stress situations. The creators of DBT specifically modified cognitive behavioral therapy in order to address the suicidal behaviors and non-suicidal self-injuring behaviors that frequently appear in people affected by borderline personality disorder. Unlike practitioners of cognitive behavioral therapy, practitioners of dialectical behavior therapy ask their clients/patients to openly accept the presence of dysfunctional thoughts, emotions and behaviors before beginning the process of active therapeutic change. The idea behind this approach is that acceptance helps reduce the perceived difficulty of the self-change process. While dialectical behavior therapy was developed in the context of borderline personality disorder treatment, psychologists and other mental health professionals also used the therapy to treat other forms of mental illness. Specific, evidence-based potential treatment benefits of DBT include a reduction in the frequency of involvement in suicidal or self-injuring behaviors, a reduction in the seriousness of existing suicidal or self-injuring behaviors, enhancement of the basic motivation to change dysfunctional thoughts and actions, enhancement of the ability to function well in high-stress situations and improvement of the quality of treatment provided by therapists. While DBT participation often does not result in complete symptom remission, it tends to substantially improve the ability to maintain or regain day-to-day function.
The Therapeutic Alliance
All forms of psychotherapy require frequent interactions between the client/patient and the mental health professional conducting the therapy. If mutually respectful and supportive bonds form between therapist and client/patient, the overall quality and effectiveness of treatment may be substantially improved. Conversely, if respectful and supportive bonds don’t form, there may be a significant decline in the quality and effectiveness of treatment. Psychologists and psychiatrists commonly use the term therapeutic alliance to refer to the formation of healthy client-therapist bonds that may enhance treatment outcomes. Therapists and their clients/patients may have similar perceptions of the strength of the therapeutic alliance formed during treatment. However, their views of the health of the therapeutic alliance may also differ considerably.
BPD Treatment and the Therapeutic Alliance
In the study published in Psychotherapy, researchers from California Lutheran University and the University of Washington used a project involving 101 women to assess the importance of the therapeutic alliance in the successful use of dialectical behavior therapy as a treatment for borderline personality disorder. All of the women enrolled in the project had a BPD diagnosis; however, only some of the participants received DBT as part of their treatment. Over the course of a full year, the researchers asked the clients/patients and their therapists to make independent assessments of the strength of the therapeutic alliance on four separate occasions. The researchers also examined the outcomes of dialectical behavior therapy for each individual who received this treatment. The researchers found that both the therapists’ and clients’/patients’ assessments of the strength of the therapeutic alliance had a notable impact on the outcomes of DBT treatment. When clients/patients had favorable opinions of the strength of their alliances, they meaningfully reduced their levels of involvement in suicidal behavior. In addition, they meaningfully reduced their levels of involvement in non-suicidal self-injuring behavior. Conversely, when therapists had positive views of the strength of the therapeutic alliance, their clients/patients had a lower level of future involvement in suicidal behavior. The study’s authors concluded that the strength of the therapeutic alliance in DBT treatment does not have any measurable impact on borderline personality disorder-related depression symptoms or BPD-related symptoms of a form of dysfunctional psychological self-defense called introjection.