Effects of Therapeutic Alliance and Metacognition on Outcome in a Brief Psychological Treatment for Borderline Personality Disorder

Abstract

Objective: The therapeutic alliance is possibly a crucial factor in treatment for borderline personality disorder (BPD). Among predictors of therapeutic alliance, aspects that have not yet been considered are metacognition or the patient’s capacity to be aware of mental states. We therefore explored whether metacognition predicted alliance and if metacognition and therapeutic alliance together predicted outcome in brief treatment for BPD.

Method: In a secondary analysis of a randomized controlled trial, we included N = 36 patients with BPD in the current study. The original trial assessed the effects of a 10 session psychiatric standard treatment with or without the added the Plan Analysis and the Motive Oriented Therapeutic Relationship. We assessed the therapeutic alliance session by session (Working Alliance Inventory), metacognition at session 1 (using the Metacognitive Assessment Scale-Revised) and outcome (using residual gains on the Outcome Questionnaire-45.2 between sessions 1 and 10).

Results: A more differentiated capacity to understand the mind of the others at treatment onset predicted an increase of therapist-rated alliance over time. Therapist rated alliance was the only significant outcome predictor (B = −0.85, R Squared = .12).

Conclusions: More differentiated metacognition predicted therapeutic alliance which in turn affected outcome, thus making metacognition a relevant therapy target early in therapy for BPD. Future studies should expand this investigation to patients with better functioning, treated with different modalities and with longer treatments.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The present study was funded by the Swiss National Science Foundation (grants SNSF 100019_152685 and 100014_134562/1 to Dr. Kramer).

Notes on contributors

Giancarlo Dimaggio

Giancarlo Dimaggio, MD, is Senior Associate Editor of the Journal of Psychotherapy Integration, Associate Editor of Psychology and Psychotherapy: Theory, Research and Practice, and, beginning in 2020, will be Editor-in-Chief of the Journal of Clinical Psychology: In-Session.

Pauline Maillard

Pauline Maillardis a researcher at the Department of Psychiatry, Institute of Psychotherapy, University of Lausanne, Switzerland.

Angus MacBeth

Angus MacBeth, PhD, DClinPsy, is a researcher and HCPC-registered clinical psychologist. He is a Lecturer in Clinical Psychology and Postgraduate Research Director in the School of Health in Social Science, University of Edinburgh, Scotland.

Ueli Kramer

Ueli Kramer, PhD, is Privat-Docent, psychotherapy researcher and clinical psychotherapist according to Federal Law, at the Department of Psychiatry (Institute of Psychotherapy and General Psychiatry Service), University of Lausanne, Switzerland. He holds an adjunct appointment at the Department of Psychology, University of Windsor, Canada.