The effect of therapist interventions on the therapeutic alliance with borderline patients

The Therapeutic Alliance Over 10 Sessions of Therapy for Borderline Personality Disorder: Agreement and Congruence Analysis and Relation to Outcome

The authors examined whether alliance dynamics are affected by tailoring the therapeutic relationship to the individual patient in brief psychotherapy of borderline personality disorder. Sixty patients were randomized to 10-session Good Psychiatric Management (GPM-BV) or GPM combined with Motive-Oriented Therapeutic Relationship techniques (MOTR+GPM-BV). Patient- and therapist-rated alliance was assessed weekly. Self-reported symptomatic distress was assessed pre-, mid-, and posttreatment. In MOTR+GPM-BV, stronger therapist-rated alliance predicted lower symptomatic distress in the same timepoint, but not in a lag, whereas symptomatic distress predicted therapist-rated alliance in a lag. Therapist-rated alliance was lower than patient-rated alliance in GPM-BV but not in MOTR+GPM-BV. In MOTR+GPM-BV, higher agreement on strong alliance tended to predict lower symptomatic distress. Patient- and therapist-rated alliances were temporally congruent, but congruence did not predict outcome. Addressing the relationship needs of patients may partly exert its salutary effect by increasing agreement between patients' and therapists' experience of the alliance.

Flexing the frame: contemplating the use of multiple ports of entry in parent-infant psychotherapy

Multirelational interventions are well described in the psychoanalytic parent-infant literature. Daniel Stern (1995) originally suggested and described five "ports of entry" that may be employed to access the multiperson parent-infant clinical system. Other authors have elaborated and extended Stern's original list of ports of entry. The impact of using multiple ports of entry on the psychoanalytic frame, however, is largely neglected in the parent-infant psychotherapy literature. Danielle Quinodoz's (1992) four facets of the psychoanalytic setting are used to structure a discussion of how the multiplicities associated with parent-infant psychotherapy may impact the frame. The article argues strongly for a necessary flexing of the psychoanalytic frame to establish therapeutic alliances. A fifth facet, that of psychoanalytic mindfulness, is offered as a counterbalance to the risks associated with excessive flexing of the frame, particularly in relation to Quinodoz's fourth facet of "refraining from 'doing.'" This article relies on case material to illustrate the issues under discussion. Further engagement and debate are invited.

The relationship between agreeableness and the development of the working alliance in patients with borderline personality disorder

The working alliance between therapist and patient is an important component of effective interventions for borderline personality disorder (BPD). The current study examines whether client personality affects the development of the working alliance during the treatment of BPD, and whether this influences treatment effectiveness. Data was based on 87 patients with BPD who were participants in a randomized controlled trial comparing Dialectical Behavior Therapy (DBT) and general psychiatric management. Higher levels of trait Agreeableness were associated with steeper increases in working alliance throughout treatment, but only in the DBT condition. Increases in working alliance were in turn associated with better clinical outcomes. Mediation models revealed a significant indirect path from Agreeableness to better clinical outcomes, mediated through larger improvements in working alliance over time. These results highlight the role that patient personality can play during the therapeutic process, with a specific focus on the importance of Agreeableness for alliance development.

Interpretive work in milieu groups

Interpretive work in milieu psychotherapy groups aims to bring concealed and hidden material to the fore so that it can be discussed openly. A host of clinically important issues thrive in the milieu, about which the patients are fully aware, but are unable to discuss. Two types of interventions are described whose goal is to overcome resistance to discussion; they are clarifying interpretations and making a parallel statement. Clarifying statements help patients understand their experience in the milieu; they are interpretive when they bring avoided material into the open. In those instances where resistance to discussion is great, the subject first appears in metaphor, is worked with, and then emerges in a displaced form. Working indirectly with metaphor and displaced material can serve to overcome transference resistance. The therapist then need only ask a direct question or make a statement in order for the avoided material to emerge. The combination of working with displaced material followed by a question or statement that is framed in terms of that theme has an interpretative function.

A note on transference and alliance: II. Patterns of interaction

Conceptual and pragmatic difficulties are encountered in relating and differentiating transference from alliance. Transference and alliance, along with the real relationship, are component elements of the analytic relationship, and are mutually involved in intermingling and interaction at all points of the analytic process. Variants of transference, as discussed in a companion article (Meissner, 2001), are differentiated from and related to alliance components and functions. Transference and alliance can interact in oppositional terms, each undermining or obfuscating the other; an emphasis on alliance may subvert transference and, conversely, transference may act as one of the major sources of misalliance. They may also sustain and reinforce each other; alliance often serves as a vehicle for providing a safe context for emergence of difficult transference derivatives, and benign and mild forms of positive or idealizing transference can offer reinforcement to the analytic relationship, and in some degree, to the alliance. Some forms of transference, especially selfobject transferences, may enjoy significant overlap with alliance functions. Therapeutic implications and limits of these differentiations are considered.

Psychodynamic psychotherapy of borderline personality disorder: a contemporary approach

Recent trends in the economics of mental health care threaten to undermine the use of psychodynamic psychotherapy for the treatment of patients with borderline personality disorder. These trends are driven in part by the assumption that such treatment of these challenging patients is very expensive. The author highlights empirical research that supports both the usefulness and the cost-effectiveness of this treatment approach. He also reviews some effective clinical strategies with borderline patients.

Toward a conceptual alliance about therapeutic alliance: a voyage through the Inferno

I suggest that there is not a conceptual consensus in psychoanalysis regarding the therapeutic alliance. Some argue that the unobjectionable part of the transference should be facilitated; some argue that there is no unobjectionable part of the transference, that all parts should be subjected to analysis. There are those who argue that the therapeutic alliance exists in early treatment; others who argue that it exists later. I suggest using a classical text, Dante's Inferno, as a paradigm for a journey of self-discovery. By reviewing the moments of hesitation that Dante experiences with Virgil and how these are overcome, we cast light on our current problem on the nature of the therapeutic alliance and how to facilitate it. The components of the unobjectionable are related to Winnicott's idea of the maturational processes and Hartmann's (1958) ideas of the primary and secondary autonomous function. Based on their considerations, we make recommendations for use of the therapeutic alliance.

Assessment of therapeutic alliances in the psychiatric hospital milieu

The authors developed scales to assess long-term hospital patients' collaboration in milieu treatment and their working relationships with various staff members. A factor analysis of patients' ratings of their collaboration in several areas of treatment yielded three dimensions: Goal Orientation, Involvement, and Use of Structure. While each dimension of collaboration correlated positively with working relationships and progress, Goal Orientation was the most substantial contributor. Patients' and staff members' perceptions of their working relationships corresponded to a statistically significant-but modest-degree. Only nurses' ratings of progress related significantly to patients' ratings. The authors highlight divergent perceptions of the treatment process, and advocate that different perspectives be openly discussed and clarified in the service of improved collaboration.