Therapeutic alliance and predictive validity of reflective functioning in conjoint mentalization-based treatment for borderline personality disorder.

OBJECTIVE

Few studies have investigated the therapeutic alliance in treatment of patients with borderline personality disorder (BPD), particularly regarding alliance in group psychotherapy. This study aimed to investigate the development of therapeutic alliance in a 3-year outpatient mentalization-based treatment (MBT) program for BPD combining individual and group psychotherapy, and to examine whether reflective functioning (RF) predicted alliance development.

METHOD: Patients with BPD or significant sub-threshold borderline personality pathology were included, with baseline data from 47 patients and longitudinal data from 42. Baseline assessment comprised diagnostic interviews, self-report measures, and interview-based measures of RF. Patient-reported alliance was assessed every 6 months using the Working Alliance Inventory (subscales Bond, Task and Goal) for individual psychotherapy and the Group Questionnaire (domains Positive Bond, Positive Work and Negative Relationship with their respective subscales) for group psychotherapy. Main statistical method was linear mixed models.

RESULTS

In individual psychotherapy, initial alliance levels were satisfactory across all subscales. Over the course of treatment, the Bond level remained stable, whereas Task and Goal showed small but statistically significant increases. In group psychotherapy, Positive Bond was high initially and stable during treatment. For the Positive Work domain and its two subscales, initial levels were below the satisfactory range. During treatment, there was a small but significant increase in agreement on tasks and goals with the other group members but not with the therapists. For the Negative Relationship domain and its three subscales, all estimates except one were within the satisfactory range initially. Initial level of the subscale Group Members was outside the satisfactory range, indicating somewhat strained relationships with the other group members. Longitudinally, there were no improvements for the domain or subscales. RF at baseline had no significant effect on the therapeutic alliance in either treatment modality.

CONCLUSION

The study demonstrates overall satisfactory levels of therapeutic alliance in an MBT program for BPD but also indicates specific alliance-related challenges in the group psychotherapy component. Initial level of RF may not affect the therapeutic alliance in MBT treatment.

CLINICAL TRIAL REGISTRATION IF APPLICABLE: ClinicalTrials.gov ID NCT04157907.