A Closer Look at the Therapeutic Relationship: Moments of Disruptions in the Psychotherapy of Adolescents with Borderline Personality Pathology

This cumulative dissertation aims to study the ongoing therapeutic relationship and its moments of disruptions on a micro-level of investigation in psychotherapy of adolescents with borderline personality pathology (BPP). Patients with borderline personality disorder (BPD) have impairments in their identity and interpersonal functioning with pronounced affective and behavioral dysregulation. The BPD pathology results in difficulties in forming stable relationships with others, as well as with psychotherapists. Alliance ruptures are deteriorative moments in the collaboration regarding therapy goals, tasks, and strains in the affective bond. Silences are disruptions in the speaker-switch pattern between the patient and the therapist. Both events might be associated with beneficial and harming effects for the treatment outcome. This cumulative dissertation comprises five articles. The first article provides a theoretical review of the early detection of personality disorders in adolescence and its negative consequences of untreated personality disorders. Article two describes the study design of the overarching process-outcome study "Evaluation of AIT Study" (EAST) registered at clinicaltrials.gov (NCT02518906). In article three, we studied the trajectories of ruptures and resolutions of ten patients with BPP in 187 therapy sessions. In article four, we studied the mutual production of silence in the speaking patterns and its relation to the session evaluation from the perspective of the patient. The fifth article addresses the researcher-clinician gap with clinical recommendations for the handling of alliance ruptures and repairs in adolescents with BPP. The here presented research findings expand the existing evidence about moments of disruptions in psychotherapy with a clinically sensible and understudied sample of adolescents with BPP. Also, in the treatment of adolescents with BPP, alliance ruptures and resolutions might be associated with beneficial treatment effects. However, frequent and intensive alliance ruptures at the beginning of treatment might be associated with premature treatment termination. We found evidence for a mutual attunement between the patient and the therapist in their speaker switch pattern. However, adolescents with BPP are not in favor of sessions with frequent silences. Our findings demonstrated that alliance rupture-repairs and silence events are frequently occurring moments of disruptions. This supports a dynamic therapeutic relationship that is continuously negotiated between the patient and the therapist in psychotherapy with adolescents with BPP.