Discussion
BPD, PTSD, substance abuse
PATHOLOGY
The purpose of this study was to investigate whether early patient-rated therapeutic alliance is related to dropout in a residential DBT treatment. It is a follow-up to a previous study which showed that a change of therapist between DBT-briefing and -treatment increased the dropout rate of DBT [Our results support the importance of therapy process variables, and therapeutic alliance in particular, as predictors of therapy dropout in borderline pathology. Patients who demonstrated a stronger therapeutic relationship at baseline had a lower risk of dropout over the course of treatment. This finding extends the existing literature finding that a poor therapeutic alliance predicts dropout in DBT [In order to [DBT claims to have a specific influence on the therapeutic alliance, that is, to particularly enhance the state-like alliance. In a study by Bedics et al. [Furthermore, regular monitoring of the therapeutic alliance may be useful to improve treatment. In a multilevel meta-analysis, feedback on patients’ progress (including the therapeutic alliance in some of the studies reviewed) to the therapists has been found to improve treatment and decrease dropout rates [Different from what we expected, the strength of the therapeutic relationship was not significantly related to a change of therapist in our study. This result could mean that the change of therapist puts less strain on the therapeutic relationship than primarily assumed. However, the proportion of patients for whom change of therapist was necessary due to organizational reasons on our ward was higher in the present study (75%) than in our previous study [Comparable to previous studies, dropout rate was not associated with socio-demographic variables [A strength of this study is that we captured reasons for treatment discontinuation. Dropout on part of the patient and on part of the therapeutic team is relatively equally distributed. This result is comparable to our previous study [The study has several limitations, some of which are associated with the naturalistic setting of the study. First, only clinical diagnoses were made; no detailed diagnostics were performed using diagnostic interviews and independent raters. Therefore, previously known predictors such as PTSD, substance abuse and the number of BPD symptoms may not have been picked up. The sample is naturally very heterogeneous. We only used self-report measures, also for capturing the therapeutic relationship. This makes missing values more likely.Moreover, the therapeutic relationship was recorded one-sidedly by the patients. However, in psychotherapy research, the patient’s (not the therapist’s) judgment of the therapeutic alliance is particularly important. Not all patients chose to participate in the study and complete the questionnaires. Patients who chose not to participate may have special characteristics that affect the generalizability of the results. Furthermore, the sample size is very small; the results require replication. In addition, an impact of the COVID pandemic on dropout rates and reasons for dropout cannot be ruled out.Future research should replicate and further examine the effects of the therapeutic relationship rated by both patients and therapists on dropout and also treatment outcome in a larger sample. In addition, the improvement of the therapeutic relationship in general or certain aspects of it (e.g., subscale of the WAI) through feedback of the patient-rated therapeutic relationship to the therapists in DBT should be examined. Beyond that, other treatment process variables, such as expectations of treatment, should be included.