Resolving threats to the therapeutic alliance in cognitive analytic therapy of borderline personality disorder: a task analysis.

Background: Alliance ruptures and premature drop out from psychotherapy are very common with patients who have a diagnosis of borderline personality disorder, limiting the clinical effectiveness of treatment.

Aim: To test and refine a model of how therapists successfully resolve threats to the therapeutic alliance involving enactment of problematic relationship patterns in the cognitive analytic therapy of borderline personality disorder.

Method: Task analysis (Greenberg, 1984a) of 107 enactments from 66 sessions in four good outcome cases, compared with 35 enactments from 16 sessions in two poor outcome cases. This systematically compares a rational model of process with empirically coded transcripts of therapy sessions where independent raters have identified an alliance threat event.

Results: The process stages of the rational model were observed, and 20 refinements were made, including a new process stage, heuristic principles and 'when-then' steps. Therapists were found to cycle between stages. Therapists in good outcome cases recognized the majority of these enactments and focused attention to them in contrast to poor outcome cases where therapists usually failed to notice or draw attention to the alliance threat and did not adhere to the model.

Conclusion: Competent resolution of alliance-threatening events is crucially dependent on therapists' ability to recognize them, and secondarily on their adherence to the principles in the refined model. The model is consistent with prior research and can be used in supervision and quality improvement strategies.