Testing an Alliance-Focused Dialectical Behaviour Therapy Training for Borderline Personality Disorder

Borderline personality disorder is a severe psychological disorder characterized by a pattern of emotional dysregulation, interpersonal difficulties, and impulsivity. The therapeutic alliance is the cornerstone of effective psychotherapy with clients with BPD and is positively associated with treatment retention and clinical improvement. However, the therapeutic alliance in BPD treatments can be difficult to form and maintain. BPD symptoms such as emotional instability, heightened emotional reactivity, greater susceptibility to negative emotions, and interpersonal sensitivity can impact the establishment of a strong therapeutic alliance. Additionally, when clients are emotionally dysregulated or presenting with high-risk behaviors, therapists are especially vulnerable to becoming reactive and engaging in therapy-interfering behaviors that can elicit or exacerbate alliance ruptures (i.e., tension, strain, or breakdown in the therapeutic alliance). Research suggests that therapists' abilities to effectively repair alliance ruptures when they occur is critical for positive clinical outcomes in BPD treatments.

Despite the importance of alliance rupture responsiveness in BPD treatments, many of the current methods employed in psychotherapy training do not adequately develop these therapeutic skills. Psychotherapy training typically focuses on the therapeutic relationship in an unstructured, non-systematic way, using instructional or supervision-based methods despite evidence that suggests this type of passive learning is ineffective for skill development. Recent advancements in psychotherapy training have begun to focus on improving therapists' skills in navigating alliance rupture and repair, however these trainings are often time intensive and do not sufficiently target the unique client needs and therapist challenges that emerge in BPD treatments.

The primary aim of this pilot randomized controlled trial is to evaluate the feasibility, acceptability, and effect sizes of two alliance-focused DBT training interventions to improve therapists' abilities to recognize and respond to alliance ruptures with BPD clients. Additionally, we will examine whether specific therapist characteristics moderate the impact of training. Up to eighty psychotherapists will be randomly assigned to receive either a 4-week training as usual, which includes alliance-focused training plus reflective practice or a 4-week alliance-focused training plus deliberate practice training. Both trainings include the same content but employ different training methods (i.e., deliberate practice versus reflective practice). Change in skill acquisition related to recognizing and responding to alliance ruptures will be assessed based on a set of performance tasks (interpersonal facilitative skills, process recognition, emotion recognition). Therapist characteristics of emotion regulation, empathy, emotional reactivity, and humility will be assessed by self-report to determine change in emotion regulation, humility, interpersonal reactivity, and empathy, and the moderating effects of these characteristics on training outcome. Finally, participants will be asked about the feasibility and acceptability of the training interventions.