Development of therapeutic alliance in mentalization-based treatment—Goals, Bonds, and Tasks in a specialized treatment for borderline personality disorder

Abstract

Objective: Mentalization-based treatment (MBT) is an evidence-based long-term treatment for borderline personality disorder (BPD). Alliance is central for effective psychotherapies. Few studies have addressed aspects of working alliance in BPD evidencebased treatments. This study aimed to investigate alliance development in MBT therapies with different clinical outcomes. Method: The sample included 155 patients in an MBT programme. Clinical outcomes were based on Global Assessment of Functioning (GAF). The sample was divided in two subgroups according to GAF levels at the end of treatment (cut-off = 60). Working alliance was assessed by patient report (Working Alliance Inventory, subscales, Goals, Bonds and Tasks) and assessed repeatedly over 36 months. The method for statistical analyses was linear mixed models. Results: Initial levels of Goals, Bonds, and Tasks did not differ by subgroup, but change over time differed significantly by subgroup. In the good outcome subgroup, ratings of Goals, Bonds, and especially Tasks increased significantly over time. In the poor outcome subgroup, paranoid PD was associated with poorer alliance development over time. Conclusions: Good outcome therapies were characterized by a process where the working alliance grew over time. Results encourage an explicit focus on tasks in therapy particularly for patients with high levels of mistrust.

Learning the subtle dance: The experience of therapists who deliver mentalisation‐based therapy for borderline personality disorder

“…Also subsumed within this theme was therapists' commitment to MBT and the need to provide a strong therapeutic alliance. The alliance is a well‐evidenced common factor in psychotherapy (Wampold, 2015) and a potential mechanism of change in MBT (e.g., Folmo et al, 2021). Some therapists in our study talked about relational work with service users in the form of explicit discussion in the here and now about the therapeutic alliance (or mentalising relationship).…”

“…In addition to understanding therapists' general experiences of the therapeutic journey, it is important to understand common and specific mechanisms of change in MBT (e.g., the therapeutic alliance, enhanced mentalising, epistemic trust; Bateman & Fonagy, 2006; Folmo et al, 2021; Fonagy & Allison, 2014; Fonagy & Bateman, 2006), as perceived by the therapist. Drawing on therapists' own experiences of how their service users have changed or transitioned/adapted over the course of MBT could triangulate and extend the understanding we have gained from existing quantitative (De Meulemeester et al, 2018) and qualitative service user studies (e.g., Gardner et al, 2019) of the mechanisms of action, and thus guide future research into how MBT works.…”

The Group Questionnaire (GQ)—Psychometric properties among outpatients with personality disorders.

“…A recent study suggested high sensitivity to social exclusion as a predictor of poorer group alliance (Euler, Wrege, Busmann, Lindenmeyer, Kvarstein, 2018). Although not specifying group processes, a recent PD study highlighted interactions between the mutual agreement on aims and tasks in therapy and positive outcomes (Folmo, Stänicke, Johansen, Pedersen, et al, 2020).…”

Psychological flexibility and the moderating role of the therapeutic working alliance in Acceptance and Commitment Therapy in Daily Life (ACT-DL) in an early psychosis sample

“…Second, the alliance was measured at post-intervention. As such, we cannot preclude that the therapeutic alliance was not a moderator of improvements in PF, but that is was actually an outcome of improved PF in itself, given that previous process literature has shown that improvements in symptoms throughout therapy may lead to a better perceived therapeutic alliance (Ardito & Rabellino, 2011;Folmo et al, 2021). Third, the operationalization of our daily life PF measures consisted only of a limited number of ESM items, and our momentary measures focused solely on the open ACT processes.…”