Date of Award
Doctor of Philosophy (PhD)
Stephen M. Saunders
Ed de St. Aubin
Joan C. Russo, MaryAnne Siderits
The quality of the therapeutic alliance in psychotherapy has been found to be positively associated with many treatment outcome variables, such as client retention, client satisfaction in treatment, and improvement in symptoms. While some theorists assume that therapeutic alliance is established early in therapy and remains fairly stable across time in treatment, others such as Safran et al. (1990) suggest that the alliance quality fluctuates across time and is likely to be marked by frequent patterns of rupture and repair. In particular, individuals with Borderline Personality Disorder (BPD) have clusters of symptoms and interpersonal styles that are likely to present challenges to the formation and maintenance of a therapeutic alliance. The present study examines characteristics of the therapeutic alliance in Dialectical Behavioral Therapy (DBT), a comprehensive form of cognitive behavioral therapy that has received empirical support for the treatment of chronically suicidal and self-harming individuals with BPD. Clients in an outpatient DBT program at a community mental health center completed monthly self-report measures of therapeutic alliance quality and psychiatric symptoms (Beck Depression Inventory-II, Beck Hopelessness Scale, Brief Symptom Inventory), across one year of treatment. It was hypothesized that clients diagnosed with BPD would have greater variability in the therapeutic alliance across time, and would be more likely to have patterns of alliance reflecting rupture and repair sequences, as compared to clients not diagnosed with BPD. Results indicated that clients with a diagnosis of BPD did not have a broader range of alliance across time, but were significantly more likely to have acute episodes of alliance rupture and repair during the year of DBT treatment. Treatment outcome analyses suggest that the DBT program was effective in reducing depression, hopelessness, and general psychiatric symptoms. Clinical significance analysis, using the Jacobson and Truax (1991) methodology, was used to classify individual client outcomes, and results indicated that nearly half of the clients in the sample achieved clinically significant "Improvement" or "Recovery" after one year of DBT. Patterns of therapeutic alliance across time were not significantly associated with treatment outcome.