How a Strong Therapeutic Alliance Improves Treatment Outcomes for Borderline Personality Disorder

The therapeutic process should be a journey into yourself that allows you to uncover that which keeps you from moving forward in positive ways and orient you toward a deeper understanding of both yourself and the world around you.

Your therapist’s role is to act as a guide on that journey, creating the conditions in which you are able to explore your inner self, your lived experiences, and your relationships with others. If you do not trust your therapist to be that guide, you cannot fully engage in the therapeutic process and your treatment outcome—regardless of modality—is severely compromised. This is particularly true when you are struggling with an illness for which psychotherapy is the mainstay of treatment; without a productive therapeutic alliance, you cannot receive the benefits of treatment. A positive therapeutic alliance, however, is one of the primary predictors of successful treatment, regardless of modality.

So what is the therapeutic alliance? “It is the trust between you and your therapist that allows you to work together effectively,” says Dr. Deborah L. Cabaniss. “It’s what helps you to believe that your therapist is trustworthy and has your best interests at heart – so even if you become angry or disappointed with your therapist, you can believe you can continue to work together productively.” Unfortunately, many people with borderline personality disorder have historically struggled to create healthy therapeutic alliances with their clinicians, due to both the symptomatology of the illness and the biases that have permeated the therapeutic community. As noted in the Journal of Psychotherapy Integration:

A positive therapeutic relationship is widely recognized as an important factor that contributes to the effectiveness of clinical outcomes in psychotherapy for borderline personality disorder (BPD). All psychotherapy approaches for the treatment of BPD emphasize the importance of the relationship, yet with BPD clients, a positive relationship is often slow to develop, inconsistent, and difficult to maintain. The interpersonal sensitivity and reactivity that characterize borderline pathology often evoke counter-therapeutic reactions in psychotherapists. Therapist contributions to the interaction frequently impede the development and maintenance of a positive relationship.

These “counter-therapeutic” conditions—which can take many forms—can be particularly harmful to people with borderline personality disorder precisely due to the “interpersonality sensitivity and reactivity” inherent to the illness. As a result, many suffering from BPD have sought treatment only to find themselves not only unable to get proper care, but becoming wary of engaging in treatment. As Dr. Donna S. Bender of Tulane University observes, “Strains and ruptures in the [therapeutic] alliance may lead to premature termination of treatment,” and can cause you to withdraw from therapy altogether.

In recent years, there have been significant efforts to destigmatize mental health disorders, both within mainstream culture and in the therapeutic community itself. While it has not yet enjoyed the successful destigmatization we have seen with disorders like depression, inroads are being made as we see public figures like Brandon Marshall coming out about their own experiences with BPD, helping to humanize the illness to those who don’t have it and give hope to those who do.

Simultaneously, the therapeutic community has come a long way from the days when BPD was considered essentially untreatable; new research is continuously being produced to help us refine how we support those living with BPD and lend evidence to the possibility of change. And what that research shows us again and again is that the quality of the therapeutic alliance has a measurable impact on patient experiences and treatment outcomes.

A 2015 study published in Psychotherapy examined the effects of the therapeutic alliance on treatment outcomes of 101 women with Borderline Personality Disorder over the course of a year. The researchers found that those women who reported more positive therapeutic alliances had significantly fewer suicide attempts as well as lower rates of self-injury. While strong therapeutic alliances did not impact rates of depression, the marked effect on self-harming behavior suggests that the therapeutic alliance allows for greater self-regulation and integration of coping skills that act as alternatives to self-harm. This may come about in part due to the validation and relief that come from a warm, supportive relationship with a therapist in which you are able to fully engage in the course of treatment to gain the insight and skills you need to make meaningful change.

But there is another reason the therapeutic alliance is particularly significant for people with BPD; symptoms of BPD often manifest during the therapeutic experience and within the therapeutic relationship. How these symptoms are handled during treatment can provide unique opportunities to address them in a trusting setting and serve as a model for healthier attitudes toward the self and toward others. As Drs. Skodol and Bender write, “The treatment relationship can be a potentially powerful vehicle for patient improvement, as it can provide a supportive environment for exploration and because issues that come up in this context can be processed in a very immediate and instructive way.” Indeed, for people with BPD, one of the most significant aspects of psychotherapy isn’t simply talking about symptoms happening outside of therapy, but providing direct intervention for contemporaneous symptoms occurring within therapy. These interactions can provide a blueprint for handling emotional and behavioral disturbances outside of the therapeutic setting, giving you a heightened sense of control and agency in your everyday life.