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theses

Background: Dialectical behavior therapy (DBT) is an effective treatment for individuals with borderline personality disorder (BPD) and related problems, however, many individuals who begin DBT have limited engagement in therapy or prematurely dropout. Predictors of non-engagement and dropout are poorly understood. Low therapeutic alliance has been identified as a proximal predictor of dropout in DBT. Aims: This study explores 1) the trajectory of working alliance as perceived by clients and therapists during six months of DBT treatment, 2) the association of emotion indices with the strength of, and fluctuation in, working alliance ratings over time, and 3) the predictive association of working alliance factors with total engagement, average weekly engagement, and dropout. Method: Fifty-five adults with BPD and their therapists rated the working alliance (alliance) at the first four sessions, mid-treatment and post-treatment. At the end of the first four sessions, clients reported positive and negative state affect. Client attendance and homework completion were calculated to yield measures of their total engagement and average weekly engagement while in treatment. Results: Alliance ratings were high overall, and susceptible to within-person fluctuation throughout treatment. Positive affect was associated with client alliance ratings, while negative affect was negatively associated with therapist alliance ratings. Rates of engagement and dropout in this study were comparable to other studies, with 15 of 55 participants dropping out. Associations were found between alliance and 1) overall engagement, and 2) dropout. These associations were stronger when both client and therapist ratings were utilized, and the effects appear to be due to the Agreement factor of the alliance measure. Conclusions: This study suggests that the alliance factor measuring the extent to which clients and therapists agree on the tasks and goals of therapy is related to engagement and dropout in DBT. Attention to agreement on the goals and establishing the tasks of therapy may help identify clients at risk for low engagement or dropout, who may benefit from explicit interventions (e.g., commitment strategies, contingencies) aimed at promoting engagement and therapy completion.

ETD_8219

Psy.D.

Includes bibliographical references

by Marget C. Thomas

doi:10.7282/T3XP780B

ETD doctoral

The author owns the copyright to this work.