We propose a model for how therapeutic strategy, alliance, and epistemic trust interact to foster or hinder therapeutic processes. Four individual mentalization-based treatment (MBT) sessions were subjected to an in-depth qualitative comparison and interpretative phenomenological analysis. Two sessions had high adherence and quality ratings, and two exemplified low evaluations. The sessions were from an MBT program for patients with borderline personality disorder. The high-rated therapists were more prone to strategically identify and investigate maladaptive patterns, were more challenging, and brought the patients out of their comfort zone. This therapeutic endeavour seemed to facilitate therapeutic alliance and a productive therapeutic process. Low-rated therapists seemed to be brought out of their own comfort zone (e.g. transferences/counter-transferences), and attempted to amend the relational atmosphere by being supportive. In these sessions, the therapeutic alliance seemed weak, and therapeutic progress was not observed. When therapists strategically and competently challenged problematic patterns, despite disclosing discomfort, alliance was strengthened. It seemed that a clear therapeutic strategy, and skilfull battling of the patients’ comfort zone, fostered the therapeutic process. We hypothesize that epistemic trust may develop as a product of a fruitful and persistent focus on tasks and goals in therapy.
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Thanks to Björn Phillips and Roland Pålsson at the Stockholm Centre for Dependency Disorders, Sweden, Samantha Karrebæk and Kirsten Aaskov Larsen at Psychiatric Clinic Roskilde, Denmark, and Turid Helene Bergvik at The Section for Personality Psychiatry, Oslo University Hospital, Norway for providing us with material to this study.
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None of the authors have any financial disclosure/conflict of interest related to this manuscript.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent: Informed consent was obtained from all individual participants included in the study.
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Folmo, E.J., Karterud, S.W., Kongerslev, M.T. et al. Battles of the Comfort Zone: Modelling Therapeutic Strategy, Alliance, and Epistemic Trust—A Qualitative Study of Mentalization-Based Therapy for Borderline Personality Disorder. J Contemp Psychother 49, 141–151 (2019). https://doi.org/10.1007/s10879-018-09414-3
- Mentalization-based treatment (MBT)
- Interpretative phenomenological analysis (IPA)
- Strategic competence
- Therapeutic alliance
- Process research