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<p>The therapeutic alliance is a robust predictor of psychotherapy outcomes, but little is known about how alliance micro-processes unfold during sessions of specific evidence-based treatments for borderline personality disorder (BPD). In this qualitative study, we analyzed transcripts of 12 individual therapy sessions (six DBT and six MBT) conducted by four experienced therapists treating BPD patients. Using interpretative phenomenological analysis complemented by conversation analysis techniques, we identified two overarching themes that characterized alliance-building processes in the two treatments. The first theme was the therapist’s agenda for the session (sometimes referred to as the therapist’s agenda), capturing how therapists pursued and negotiated their therapeutic goals. The second theme was facilitating change through understanding and challenge, describing how therapists balanced empathy and confrontation when responding to patient emotions and behavior. Stylistic differences emerged between DBT and MBT. DBT was structured and goal-focused, while MBT was exploratory and patient-led: therapists often followed patient detours, adopted a curious “not-knowing” stance, focused on the patient’s subjective experience, immersed themselves in the patient’s affect, and used gentle, indirect questions to prompt insight. Despite these differences, both approaches forged strong alliances via distinct pathways aligned with their theories of change. These findings reveal model-specific alliance signatures in DBT and MBT and suggest that different therapeutic roads can lead to a robust alliance.</p>

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Unfolding the Micro-processes Characterizing the Therapeutic Alliance in DBT and MBT

  • 期刊论文

  • 发表日期：

    2025年8月7日

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  • Espen Jan Folmo,
  • Susanne Garred,
  • Elina Gough Maisey,
  • Anita Johanna Tørmoen,
  • Hanne Berit Weie Oddli

摘要

The therapeutic alliance is a robust predictor of psychotherapy outcomes, but little is known about how alliance micro-processes unfold during sessions of specific evidence-based treatments for borderline personality disorder (BPD). In this qualitative study, we analyzed transcripts of 12 individual therapy sessions (six DBT and six MBT) conducted by four experienced therapists treating BPD patients. Using interpretative phenomenological analysis complemented by conversation analysis techniques, we identified two overarching themes that characterized alliance-building processes in the two treatments. The first theme was the therapist’s agenda for the session (sometimes referred to as the therapist’s agenda), capturing how therapists pursued and negotiated their therapeutic goals. The second theme was facilitating change through understanding and challenge, describing how therapists balanced empathy and confrontation when responding to patient emotions and behavior. Stylistic differences emerged between DBT and MBT. DBT was structured and goal-focused, while MBT was exploratory and patient-led: therapists often followed patient detours, adopted a curious “not-knowing” stance, focused on the patient’s subjective experience, immersed themselves in the patient’s affect, and used gentle, indirect questions to prompt insight. Despite these differences, both approaches forged strong alliances via distinct pathways aligned with their theories of change. These findings reveal model-specific alliance signatures in DBT and MBT and suggest that different therapeutic roads can lead to a robust alliance.