Trajectories of alliance ruptures in the psychotherapy of adolescents with borderline personality pathology: timing, typology and significance

Abstract

Jeremy Safran and his research group suggest that rupture-repair processes are important for the therapeutic change in patients with personality disorders. In this exploratory study, we describe alliance ruptures and resolutions on a session-by-session basis in a clinical sample of adolescents with Borderline Personality Pathology (BPP). Three research questions are addressed: i) Is there a typical trajectory of alliance ruptures over treatment time? ii) Which rupture and resolution markers occur frequently? iii) Which rupture markers are most significant for the therapeutic alliance? Ten patients who presented with identity diffusion and at least three Borderline Personality Disorder criteria were studied and treated with Adolescent Identity Treatment. Alliance ruptures and resolutions were coded in 187 therapy sessions according to the Rupture Resolution Rating System. Mixed-effect models were used for statistical analyses. Findings supported an inverted U-shaped trajectory of alliance ruptures across treatment time. The inspection of individual trajectories displayed that alliance ruptures emerge non-linearly with particular significant alliance ruptures appearing in phases or single peak sessions. Withdrawal rupture markers emerged more often compared to confrontation markers. However, confrontation markers inflicted a higher impact or strain on the immediate collaboration between patient and therapist compared to withdrawal markers. Clinicians should expect alliance ruptures to occur frequently in the treatment of adolescents with BPP. The findings support the theory of a dynamic therapeutic alliance characterised by a continuous negotiation between patients and therapists.

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 ).…”

Silence in the psychotherapy of adolescents with borderline personality pathology.

“…The summing of these events by session can only provide an idea of an overall effect (which would not as such be reflected in a single event). The problem could be attenuated by correlating silence with significant therapeutic events such as ruptures and resolutions or change moments (Krause et al, 2007; Schenk et al, 2019; Zimmermann et al, 2018), thus narrowing down the meanings of silence episodes to more specific contexts. In addition, the definition of silence as absence of speech for at least 3 s is arbitrary and was based on existing literature (Daniel et al, 2018).…”

The Evidence-Base for Psychodynamic Psychotherapy With Children and Adolescents: A Narrative Synthesis

“…Pre-post analyses showed that 39.3% of the patients were remitted by the end of treatment, in addition to significant improvements on a range of other measures. Likewise, Schenk et al ( 2019 ) conducted a small exploratory study of psychodynamic therapy, involving 10 adolescents (aged 14–18) with identity diffusion and BPD symptoms. Results showed a significant reduction in psychopathology and an improvement in psychosocial functioning over time.…”