Alliance Ruptures and Resolutions in Personality Disorders

Abstract

Purpose of Review This review provides an overview of the state of research on alliance ruptures and resolutions in the treatment of personality disorders (PDs). We discuss frequently used instruments to measure alliance ruptures and resolutions. We discuss the effectiveness of rupture resolution processes and highlight possible avenues for research to explore. Innovative assessments with the potential to reveal the link of ruptures and resolutions and mechanisms of psychotherapeutic change are discussed. Recent Findings The assessment of alliance rupture and resolutions is heterogeneous. Instruments vary largely with respect to a direct or indirect assessment, the time resolution of assessment (integral therapy, phase, session, event), session sampling strategy and perspectives (patient, therapist, observer). The heterogeneity in the instruments and study designs impedes comparability and interpretation of the findings. Results support the hypothesis that ruptures are more frequent in PD. Results also point towards beneficial effects of rupture resolution patterns, early alliance quality, and resolution complexity. Few studies control findings for pretreatment factors. Summary Evidence points to the direction that rupture resolution processes can be considered a general principle of change in the treatment of PD. The concept of alliance ruptures and resolutions provides a useful tool for the management of the therapeutic alliance and its moments of deteriorations throughout the treatment course. Dimensional pretreatment personality functioning is considered a key variable in future studies to highlight what works for whom.

Movement Synchrony in the Psychotherapy of Adolescents With Borderline Personality Pathology – A Dyadic Trait Marker for Resilience?

“…As a sidenote, and to put previous findings in this sample into perspective, in a previous study on silence in psychotherapy, we showed that in the present sample, silence can be problematic for the psychotherapeutic process ( Zimmermann et al, 2020 ). A further study based on the same data showed that there is an increased risk of withdrawal ruptures ( Schenk et al, 2019 , 2020 ) during psychotherapy in youth with BPD. We believe that these phenomena (silence and ruptures) are part of the normal psychotherapeutic process but that they imply a risk of being detrimental to the psychotherapeutic process because they can rigidify the interaction and hinder synchronization of the dyad in a larger sense.…”

“…There are several psychotherapeutic approaches specifically developed for adolescent with BPD: e.g., dialectical behavior therapy for adolescents (DBT-A; Fleischhaker et al, 2011 ), mentalization-based treatment for adolescents (MBT-A; Rossouw and Fonagy, 2012 ), adolescent identity treatment (AIT; Foelsch et al, 2014 ), and schema-focused psychotherapy for adolescents ( Loose, 2015 ). The therapeutic process with BPD patients is often challenging because symptoms of BPD (e.g., rejection sensitivity) can hinder the construction of a good therapeutic relationship ( McMain et al, 2015 ) through an increased risk of ruptures of the therapeutic alliance ( Schenk et al, 2019 , 2020 ). Psychotherapy process research investigates active ingredients of therapeutic interventions and helps improve therapeutic approaches, as well as informing psychotherapists about the mechanisms of change and how they may leverage these actions ( Hardy and Llewelyn, 2015 ; Zimmermann et al, 2018 ).…”

Evaluating the Interactive Effect of COVID-19 Worry and Loneliness on Mental Health Among Young Adults

“…Emerging work investigating COVID-19 related worry (i.e., worry that is rooted in the uncertainty that surrounds the trajectory and consequences of COVID-19) has shown that worry about the pandemic is associated with poorer mental health (Kleinberg et al, 2020 ; Wang et al, 2020 ) and greater substance use (Rogers et al, 2020 ). Additionally, worry during the pandemic is related to higher anxiety, anxiety sensitivity, and depression (Baiano et al, 2020 ), and COVID-19 stress syndrome is conceptualized, in part, on the basis of the tendency to worry about pandemic-related factors (Taylor, 2020 ). Certain demographic factors (e.g., sex; Van der Vegt & Kleinberg, 2020 ) have been shown to influence the degree of experienced worry, but no work has evaluated the relation between individual differences in COVID-19 related worry and other emotional vulnerability factors that contribute to worse psychological outcomes among young adults.…”

Vulnerability of personality disorder during the Covid-19 crises – a multicenter survey of treatment experiences among patients referred to treatment

“…As demographic data demonstrate, the sample carries a high burden of distress and impairment of personality functioningcomparable to other descriptions of poorly functioning patients with PD [43]. Such burden represents considerable clinical and personal vulnerability [44] effecting treatment processes [45][46][47] and treatment ruptures [12]. As one of few PD specific studies, the present investigation addresses the extraordinary situation of treatment interruption inflicted by the global Covid-19 pandemic.…”

“…Emotional and relational difficulties like the capacity to trust and connect to other people, may impede regular treatment attendance and a stable treatment alliance [6][7][8][9][10]. In long-term therapies and treatments for PD, the alliance and management of alliance ruptures in early phases of treatment impact adherence and outcomes [11,12]. Studies of adolescents and young adults with PD have in particular, demonstrated considerable attachment insecurity [13,14].…”