Alliance rupture and repair processes in borderline personality disorder: A case study using dialogical sequence analysis

Objective: This study examined alliance rupture and repair processes in borderline personality disorder (BPD) and how the content of sessions interacts with the quality of the alliance. Design: A mixed methods single case study design was employed incorporating quantitative and qualitative measures of process and outcome. Methods: This case study examined a 22-year-old female with BPD who received 16 sessions of Cognitive Analytic Therapy. Measures of alliance, symptoms and global functioning were taken across multiple time-points. Selected sessions were analysed using dialogical sequence analysis (DSA), a theory-driven method of psychotherapy research that analyses utterances according to their author, addressee and referential object. Results: Quantitative data indicated symptom reduction without functional improvement. DSA demonstrated that the first exchanges in therapy were reflective of key relational themes. The case suggests that, rather than simply negotiating tasks and goals, repairing ruptures involves systematically linking the manifest topic to the client's core problems. Conclusions: This case study points to the mediating role that the content of sessions has on alliance quality. Results underline the importance of the therapist stance, the need for a shared formulation to make sense of relational processes and the use of responsively timed interventions to decrease desperation and improve self-reflection.