See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/330545816

Battles of the Comfort Zone: Modelling Therapeutic Strategy, Alliance, and

Epistemic Trust—A Qualitative Study of Mentalization-Based Therapy for
Borderline Personality Disorder

Article in Journal of Contemporary Psychotherapy · September 2019

DOI: 10.1007/s10879-018-09414-3

CITATIONS READS

11 938

5 authors, including:

Espen Folmo Sigmund Karterud

Oslo University Hospital Oslo University Hospital
23 PUBLICATIONS 87 CITATIONS 178 PUBLICATIONS 3,445 CITATIONS

SEE PROFILE SEE PROFILE

Mickey Toftkjær Kongerslev Elfrida Kvarstein

Region Zealand Mental Health Services and University of Southern Denmark Oslo University Hospital/ University of Oslo
121 PUBLICATIONS 799 CITATIONS 34 PUBLICATIONS 381 CITATIONS

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Mentalization-based treatment in a specialist service View project

Cochrane review of psychological therapies for people with borderline personality disorder View project

All content following this page was uploaded by Mickey Toftkjær Kongerslev on 22 January 2019.

The user has requested enhancement of the downloaded file.

Journal of Contemporary Psychotherapy
https://doi.org/10.1007/s10879-018-09414-3

ORIGINAL PAPER

Battles of the Comfort Zone: Modelling Therapeutic Strategy, Alliance,

and Epistemic Trust—A Qualitative Study of Mentalization-Based
Therapy for Borderline Personality Disorder
E. J. Folmo1 · S. W. Karterud2 · M. T. Kongerslev3,4 · E. H. Kvarstein5,6 · E. Stänicke7

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
We propose a model for how therapeutic strategy, alliance, and epistemic trust interact to foster or hinder therapeutic pro-
cesses. 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.

Keywords Mentalization-based treatment (MBT) · Interpretative phenomenological analysis (IPA) · Strategic competence ·
Therapeutic alliance · Process research

Introduction

Mentalization refers to the ability to understand and inter-

pret behaviours of self and others as expressions of inten-
* E. J. Folmo tional mental states such as feelings, wishes, goals, desires
espfol@ous-hf.no
or needs (Fonagy et al. 2002). It develops from early infancy,
1
Norwegian National Advisory Unit on Personality through attachment relationships and care. The attachment
Psychiatry, Section for Personality Psychiatry, Oslo figure is a source for physical security, emotional support,
University Hospital, Ullevaal, Nydalen, PO Box 4956, mental attention, knowledge, and culture. Recently, the con-
0424 Oslo, Norway
cept of epistemic trust (Fonagy et al. 2018) was introduced
2
The Norwegian Institute for Mentalizing, Oslo, Norway to explain the relation between attachment and mentalizing.
3
Psychiatric Clinic Roskilde, Region Zealand Psychiatry, An attitude of epistemic trust, in contrast to epistemic freez-
Roskilde, Denmark ing, implies that the listener is ready to take in personally
4
Department of Psychology, University of Southern Denmark, relevant knowledge about the social world. The concepts
Odense, Denmark of mentalization and more recently, epistemic trust, have
5
Section for Personality Psychiatry, Oslo University Hospital, particularly been advocated in treatment of borderline per-
Oslo, Norway sonality disorder (BPD). The field of psychotherapy research
6
Institute of Clinical Medicine, University of Oslo, Oslo, lacks narratives of the phenomenology of different core
Norway components and how they may work together. In the present
7
Department of Psychology, University of Oslo, Oslo, Norway qualitative study of BPD therapy sessions displaying very

13
Vol.:(0123456789)
 Journal of Contemporary Psychotherapy

high and low ratings of adherence and competence, we aim therapeutic competence has considerable relevance. For
to elaborate on aspects of therapist strategy, alliance, and unknown reasons, some therapists seem able to nurture
epistemic trust. and negotiate therapeutic alliances significantly better than
others (Lemma et al. 2011). Across therapy approaches,
Borderline Personality Disorder and Specifically therapists will apply “strategic competence” (Killingmo
Tailored Psychotherapy et al. 2014) to navigate and structure sessions. We under-
stand strategic competence as the totality of the therapist’s
Patients with borderline personality disorder (BPD) are understanding of psychotherapy, knowledge of the diagnosis
characterized by insecurity in close attachment relation- and the patient, and the specific relation. Rønnestad (2016)
ships, problems of emotional regulation, and a reduced identifies a combination of a deep engagement in the client’s
ability to mentalize (Bo et al. 2017). Currently, there are welfare, together with a willingness and capacity to confront
eight specific, evidence-based treatments for BPD (Stof- the client’s dysfunctional behaviour as one of six important
fers et al. 2012). These treatments are all extensive, highly characteristics of clinical expertise. In treatment of poorly
structured, and target core aspects of BPD. One of these functioning patients with BPD a willingness to confront
is mentalization-based treatment (MBT). Its efficiency for maladaptive patterns, may be crucial. However, such con-
BPD is established in several studies, of which three are frontation is challenging for both therapist and patient, may
randomised controlled trials from UK (Bateman and Fon- represent an interpersonal or emotional “battle of the com-
agy 2001, 2009; Rossouw and Fonagy 2012), and two are fort zone”, and needs to be managed with care.
naturalistic comparisons replicating positive results in set-
tings outside UK (Bales et al. 2015; Kvarstein et al. 2015).
Treatment manuals specifying the style of intervention and Therapeutic Alliance Challenged
reliable integrity measures for therapist interventions exist by Countertranference
for both the individual (Karterud et al. 2013) and group com-
ponents (Folmo et al. 2017). Countertransference reactions may be of particular impor-
tance in psychotherapy for BPD (Betan et al. 2005), and are
The Impact of Therapeutic Alliance Across Specific also relevant in structured therapies, such as MBT (Morken
Approaches et al. 2014). Negative countertransferences in therapists can
include feeling helpless, overwhelmed or overinvolved (Colli
Research focusing on mechanisms of change in psycho- et al. 2014). Rønnestad (2016) has indeed called for more
therapy, has emphasized qualities of the therapist-patient in-depth investigations of treatments with “difficult to treat
dyad. A therapist’s ability to form and maintain a therapeutic clients”. Specifically structured treatments aim to represent
alliance (goals, tasks, and personal bond; Bordin 1979) is helpfull strategies in the management of poorly functioning
reckoned as a robust predictor of outcome in psychotherapy. patients. The specified model may then serve as a potential
It is known to predict more variance in outcome than the vehicle for the therapeutic alliance.
application of a technique, strategy or (bona fide) treatment
approach alone (Wampold and Imel 2015). However, the
process and outcomes of therapy are a result of a complex Therapeutic Alliance and Therapist Model Fidelity
interplay between therapeutic factors, and specific types of
therapy may differ in their involvement and dependence of In an MBT study of BPD patients with substance abuse,
aspects of alliance (Nissen-Lie et al. 2015). The therapeutic Möller et al. (2017) reported that high therapist fidelity was
dyad clearly also depends on the patient’s ability to form a associated with an increase in the patients’ reflective func-
personal bond to the therapist, create goals and understand tioning (operationalization of mentalization; Fonagy et al.
the mutual tasks of therapy. Typical aspects of the relational 2002) during therapy sessions. In this case, high competence
problems in BPD are hostility, insecure attachment, and dis- in MBT was seen to induce a productive process of change
turbed epistemic trust (Bo et al. 2017). These are factors in core pathology. Nevertheless, little research has focused
which may severly challenge the therapeutic alliance. It is on how the therapists in evidence-based treatments tailor
of interest to understand how a therapeutic alliance can be the specific technique to the patient; how therapists using a
formed and fostered in such circumstances. certain method, may facilitate alliance and epistemic trust.
Hence, there is a pressing call to investigate how (skilled)
Therapeutic Alliance and Clinical Expertise therapists adapt their specific therapeutic method to the indi-
vidual patient and thus, integrate the potentially conflict-
The mere “relationship” with a therapist is, in itself, ing perspectives—specific treatments and common factors
insufficient (Laska et al. 2014) for positive outcome, and approaches (Laska et al. 2014).

13
Journal of Contemporary Psychotherapy

The Present Study emphasize treatment formulations and initial psychoeduca-

tion (Karterud 2012; Karterud and Bateman 2010).
The present study is a qualitative analysis aiming to explore For the qualitative process studies, video recordings of
therapeutic dialogues in therapy sessions in light of thera- the selected four sessions were transcribed, and personal
pists’ strategic competence, patients’ indication of epistemic data anonymized. Patients and therapists gave their written,
trust and the collaborative therapeutic alliance. For this pur- informed consent to participate in the project. The study was
pose, we investigated the specific approach, MBT, as a spe- approved by the Privacy Ombudsman at Oslo University
cific treatment for poorly functioning patients with BPD. Hospital.
We selected therapy sessions with high and low ratings of
MBT treatment fidelity (Karterud et al. 2013). In studying
the transcripts, we sought to understand what influenced the Qualitative Data Analysis
therapists in the sessions, how they maneuvered the topics,
how they handled difficult emotions, possible transferences Our intention was to investigate the phenomena beyond
and countertransferences, and the strength of the therapeu- concepts that are defined and operationalized in existing lit-
tic alliance. The results of the qualitative analysis led us to erature. We chose interpretative phenomenological analysis
suggest a model of the interaction between these different (IPA; Smith et al. 2009) as it allows a fundamental investiga-
aspects—alliance, strategy, and epistemic trust. tion of phenomena like alliance and strategic competence,
and has been employed in a number of papers in clinical
and counselling psychology (e.g., Østlie et al. 2016; Smith
Materials and Methods 2011). The transcripts were analysed according to the IPA
framework (Smith et al. 2009) in five steps:
Sessions were selected by purposeful sampling (Patton
1990). The four most deviant (extreme) sessions were sam- (1) The four sessions were transcribed and studied in detail,
pled from a total of 108 individual MBT sessions assessed and discussed in depth, in order to include as many
with the fidelity scale for MBT-I (Karterud et al. 2013). Rat- viewpoints as possible (therapist, patient, overarching,
ings were done as a regular, quality ensurance service proce- synthesis). During this process the first author was in
dure provided by the Quality Lab for Psychotherapy at Oslo contact with all other authors, discussing transcripts
University Hospital, Norway (http://www.mbt-lab.no). The in-depth with the second (SK) and fourth author (EK).
authors reached consensus after independent ratings of the (2) The first, fourth, and last author (EF, EK and ES) sought
sessions. Rater reliability (estimated on the basis of 30 fidel- to phenomenologically investigate the therapeutic alli-
ity ratings) was high (mean value, absolute G coefficients, ance (goals, tasks, and personal bond). Agreement on
adherence: 0.95, quality: 0.90). Two authors in this paper goals could be identified by indications of a mutual idea
(EF and SK) were raters. of achieving improvement. Agreement on tasks was
The fidelity ratings include MBT adherence and quality. interpreted from the patient’s willingness to engage in
Adherence ratings count the interventions compliant with therapy, participate in a mentalizing discourse or iden-
the 17 items of the fidelity measure. Quality is assessed for tify, accept and process problematic themes and behav-
each identified item on a 1–7 Likert scale. In addition, global iour patterns. The personal bond could be deduced by
adherence and quality scores are decided for the session as patient expressions indicating confidence in the thera-
a whole (overall clinical judgement). The cut-off for accept- pist being able to help (aspect of epistemic trust) and a
able MBT-fidelity is four or above. MBT interventions are degree of genuine relating, e.g., the patients’ trust that
predominantly characterized by a clear focus on exploration the therapist really cared and understood.
of mental states. (3) Emergent themes identified by (EF) were frequently
The investigated sessions were all part of MBT programs. discussed with the second (SK), fourth (EK) and last
Two sessions with high MBT ratings (Adherence: 7; Qual- author (ES). We looked for possible sequential patterns,
ity: 7), and two with low ratings (2/2) were selected from how interventions were timed, and identifiable strate-
Norwegian, Danish and Swedish MBT teams. At the time gies.
of video-recordings, treatments had lasted various lengths (4) The first (EF), fourth (EK), and last author (ES)
of time (range 6–24 months). The four therapists were affili- employed different theories and concepts (e.g., alliance,
ated within MBT teams, were experienced psychotherapists, common factors, strategic competence, MBT, psycho-
had advanced MBT training, and received regular MBT analytic theory, attachment theory) to illuminate the
supervision. Therapist age-range: 37–65 years. Standard perceived patterns.
MBT includes patients with personality disorders and core (5) In a final discussion, on the basis of steps 1–5: The
BPD pathology and combine individual and group therapy, first (EF), fourth (EK), third (MK) and last author (ES)

13
 Journal of Contemporary Psychotherapy

decided on the major recurrent themes/patterns in the Theme 3: Battles of the comfort zone. “How do we stay
sessions. on course? Can we challenge maladaptive patterns?” The
application of a specific technique, keeping it tailored to the
patient, goal, situation, and relation, was a challenge for all
therapists. The theme termed “Battles of the comfort zone”
Results emerged when assessing therapist’s effort to sustain strategic
competence.
In the selected sample, the high-rated sessions were char- Battles of the comfort zone were twofold. From the thera-
acterized by stable focus on mental states (mentalization). pist perspective, the persistence of a mentalizing focus, was
The interventions built logically on each other and seemed in some respects, a struggle against resigning to a perhaps,
guided by an overarching strategy: If one intervention failed, more “comfortable zone”, avoiding confrontation (e.g.,
the therapists pursued the same goal by another route. In merely providing supportive therapy). The strong impact of
the low-rated sessions, interventions were more seldom, the patient’s current mental states such as anger, pretend
and often lacked a clearly detectable plan or overarching mode (losing the emotional grounding), teleology (taking
pattern. The high rated sessions were characterized by the actions as evidence for inner states), psychic equivalence
therapists being more mentally involved, more active. They (taking own convictions for reality), and possibly also the
also seemed able to manage their own countertransference, therapist’s own wish for “good transferences”, seemed to
focus on affects, keep a mentalizing focus, and challenge the undermine the application of a focused technique and overall
patient in an emphatic and transparent way. In particular, it strategy. Battles of the comfort zone also include a patient
seemed that the ability to tolerate negative feelings and bring perspective. In high-rated MBT sessions, patients maladap-
up difficult themes with the patient distinguished high-rated tive behaviors, ways of thinking or relating could be identi-
from low-rated sessions. It seemed that high MBT fidelity fied and confronted. Avoidance of such confrontation might
implied therapies with more willingness for confrontation, be to let the patient reside within a (maladaptive) comfort
and as such, a willingness from both therapist and patient zone. In low rated MBT sessions, the main therapeutic pro-
to move beyond a perceivable “comfort zone”. Three major ject (theme 1) was abandoned, and these sessions did not
recurrent themes/patterns were thus identified: (1) Alliance; reveal relevant MBT therapeutic work. However, in a suc-
(2) Strategic competence; and (3) Battles of the comfort cessful, and repeated confrontative process, as illustrated
zone. Therapeutic alliance seemed to be fostered by both in the high-rated sessions, the alliance not only endured the
strategic competence and battles of the comfort zone. strain, but even seemed strengthened by the mutual effort.
Theme 1: Therapeutic alliance. “Where are we headed? Our two first identified themes (alliance and strategic com-
Do we cooperate?” Our first identified theme was well petence) seemed to work together and result in beneficial
defined by Bordin’s therapeutic alliance concept (goals, therapeutic work.
tasks, and personal bond; 1979). In MBT, the overall aim of
therapy is to increase the patient’s ability to mentalize. From Four Case Examples
the therapists point of view, the tasks in a therapy sessions
is to maintain a focus on mental states, promote a mental- Below we present our analysis of the three themes in the
izing dialogue, and explore mentalizing deficits. From the sessions.
patients point of view, tasks are to bring in, and be willing
to explore, personal issues within a mentalizing framework. Diane and Her Therapist: Losing Authority and Losing
A strong alliance indicates that the patient understands that Battles
increased mentalizing is the ultimate goal, that s/he agrees
to work towards this aim, and believes that the therapist can Diane was a woman in her late 20 s. Her therapeutic pro-
facilitate this process. ject (in the session) was not clear, and she displayed a wide
Theme 2: Strategic competence. “Given this patient, the repertoire of strategies to avoid working on her problems
goal, situation, and relation, how do we best bring about in therapy. By attacking, putting down, refuting, appealing
change?” Strategic competence provides the therapist the to, rejecting, and directly contradicting her therapist, she
broader roadmap of how to navigate, adjust, and tailor the focused her narrative on several themes, mostly in a pseudo-
MBT technique to the unique patient, relation, and situa- mentalizing way. She blamed others and her life-situation for
tion. Strategic competence partially overlaps with the qual- her problems, and wanted the therapist to support this view.
ity score of MBT—it includes the timing, precision and Diane opened the session by inquiring whether the thera-
relevance of the interventions. Skillful application of MBT pist had sent a health statement on her behalf: “Yes. Did you
includes an overarching ability to navigate (strategic com- send the statement?” Her tone was harsh and judgemen-
petence) not defined by the MBT manuals. tal. When the therapist turned defensive and uncertain, she

13
Journal of Contemporary Psychotherapy

immediately followed up by saying: “It should have been something like why it is a bigger problem for you than for
sent two weeks ago”, in a way which indicated frustration others, that is what was maybe… that is what was…”. How-
with the therapist. Next, Diane confronted the therapist for ever, in response to Dianes confronting style, the therapist
mislabelling her feeling of anger in the previous session: gradually started to excuse him/herself for questioning her
“Last session, I got angry with you. You said I was irritated, position: “Yes. No, I was also thinking… it wasn’t right… it
but I wasn’t, I was angry!” The therapist misunderstood was foolish to say that… negative attitude and that, so… but
her, laughed, and again underestimated her feelings. Diane I still think that, OK, maybe other people have different…”
moved on to say that her problems stemmed from other peo- Towards the end of the session, Diane said she really needed
ple, and not from herself. After a while, the therapist vaguely to finish a paper over the next few days. The therapist then
suggested that the patient’s views were not necessarily the suggested that they should have kept the content of the ses-
only reality. Diane immediately refuted this perspective, stat- sion more superficial. Diane strongly rejected this argument,
ing that she took no responsibility for her problems: “… you leaving the therapist bewildered, still out of touch. Therapist:
made it only my experience and not an actual reality… then “We could have kept it a bit superficial here, but… Diane:
you are kind of placing responsibility on me for a situation What’s the point of that? Therapist: Yes, what’s the point
that is really not my responsibility.”At the end of the session of that. Right. More superficial or… More focused on the
the therapist offered Diane an extra session. Diane turned concrete, or… yes. I think it was very important that we
down this offer, saying that it would not help. spoke about this..”. The dialogue in this session, indicates
Alliance The patient exhibited little confidence in the that Diane was winning a battle of the comfort zone without
therapist and statements explicitly demonstrated a lack of resolving her maladaptive, prementalistic, modes of experi-
alliance. The emotional level was high. Diane was not able encing (pretend mode, psychic equivalence and teleology).
to understand or consider most of the therapist interventions. Diane: “This is not something I can do much about. And… I
Interventions did not address the actual relationship or thera- don’t see any point in having a positive attitude to something
peutic project (alliance level). In this case, the possibility for negative.”
battles of the comfort zone were lost on the alliance level.
Strategic Competence The therapist’s initial attempt to Monica and Her Therapist: Protecting the Patient
laugh away the theme of the patient being “angry and not from Therapy
irritated with him/her” was out of tune with Diane, and the
entire session was coloured by a lack of therapists’ direction, Monica, a woman in her early 20 s, had suffered a violent
authority and clarity. Interventions were vague, often only sexual assault and subsequently missed several sessions. The
initiated, but not followed up. Possible therapist strategies session was her first since the incident. She conveyed that
were outmaneuvered. The therapist missed several oppor- she lacked energy and did not sleep well. In the session, she
tunities to explore how Diane’s statements made sense, or seemed uninterested in resuming psychotherapy. The thera-
confront non-mentalizing. The most frequent intervention pist did not challenge the patient. The therapeutic strategy
was “Ehm”, suggesting an attempt to be warm and support- was resigned early in the session. The session included some
ive. Increasingly, the therapist seemed to strive for a pleasant enquiry, information and continued with a sequence about
climate (which often resulted in an even lower interpersonal Monica’s wish to buy a new dress. The patient finally wanted
temperature). At one crucial moment, Diane displayed per- to end the session five minutes early, “as they had nothing
sonal vulnerability in a relational context, but at that point, important to talk about”. The therapist agreed.
the therapist missed the invitation to explore mental con- Alliance Most interventions aimed for a positive per-
tent, and instead pursued a concrete detail. Diane: “Ehm… sonal bond. The relationship or therapeutic project was not
Because… I really felt that I wasn’t… seen, in a way, at all. addressed directly. Monica had one utterance addressing
By her. Ehm… Therapist: When did you…?” Diane: “Sat- alliance to the group “No, I am actually quite excited about
urday. Therapist: Saturday, OK. Yes, you said that. Yes”. getting back there, because it has been pretty much... a lot
Battles of the Comfort Zone Early in the session, the happening there.” However, she did not seem enthusiastic
therapist seemed outplayed by their own countertransference about the ongoing individual therapy session and took the
(e.g., feeling overwhelmed, helpless, and fearing Diane’s opportunity to end the session early. The alliance seemed
anger) and the therapists mentalizing capacity seemed weak.
effected. Less able to guide, challenge or question the Strategic Competence Monica’s therapist sought a warm,
patient’s mental states, the therapist gradually retreated to a gentle, considerate atmosphere throughout the session, asked
supportive and submissive stance. The therapist attempted to practical questions, validated responses, but largely avoided
challenge Diane when she talked about the other students at exploration and refrained from challenging the patient. Brief
her school being the cause of her problems: “Mm. You kind inquiries included details after the assault (had the rapist
of.. yes. Because what I was interested in understanding, was been caught: “You don’t know, or do you know that he hasn’t

13
 Journal of Contemporary Psychotherapy

been caught?”; was support from health care and judicial returning when someone had hurt her was painful for Elsa.
system sufficient), on post-traumatic symptoms (dreams/ She tried several strategies to avoid talking about the group
nightmares; fear of walking alone in the dark), and func- in the session.
tioning (was coming to two group sessions too much at the Alliance Elsa made seven statements that directly
moment, was she able to continue at school: “Have you addressed the alliance in highly positive terms. The second
managed to get back on your feet with regards to … school one occurred about 10 min into the session: “Yes, but. Fuck-
and… or have you…”; how was her social network,“Who ing good. How competent you are. Thank you.” From the
is close by you now?”; and how were other things in her context, it suggests a genuine sense of being helped (bond
life, e.g., “What else is happening to you?”). The therapist part of alliance) and it may indicate an aspect of epistemic
provided news from the group, advice on sleep medication, trust. One utterance captured some of her inner representa-
and normalized symptoms in light of the recent incident. tion of the therapist’s persistent stance: “Yes but I see, I see
Battles of the Comfort Zone The therapist had a strat- what you’re saying, I see what you know you see. YES.”Later
egy of not confronting the patient too much in the current in the session, Elsa gave a statement concerning the appre-
situation—it is unclear what was the patient’s perspective ciation of new learning: “It’s good that others see things as
as she had difficulties with elaborating on her own mental well, that I don’t see.” By the word “others” it is clear in this
state. This is captured by the therapist. Therapist: “But those context that it was the therapist she denoted, although she
thoughts that are coming in lots... those thoughts, what are... chooses a less personal and more general phrasing. Elsa’s
I would have liked to hear.” Monica: “Well, this is what I announcement also expresses gratefulness. She recognized
have been telling you”. Therapist: “Yes. But are there any her therapist as competent and appreciated his help. In this
more?” Monica: “No.” Therapist: “No.. no...?.. content, session the therapeutic dialogue between patient and ther-
no kind of depressive... no kind of wish that you were... no apist indicates that the alliance relates closely to patients
kind of...?” Monica: “No. I am more kind of indifferent, confidence (experience of new interpersonal learning about
really.” Therapist: “Indifferent.” Monica: “Yes”. Neverthe- herself stemming from the therapy) and enables the therapist
less, countertransference appear to be present, effecting the to keep a focused strategy.
quality of the session. The fact that Monica had not turned Strategic Competence The therapist kept a persisting
up to therapy for a while was brought up. However, the mentalizing stance insisting to talk about Elsa’s attendance
question was framed so it could be precieved rather as dif- to group therapy—a part of the MBT program. The thera-
ficult for the therapist, who had been worried, than care for pist’s core strategy was close to the MBT manual, with curi-
the patient. The therapist also brought up missed sessions osity about mental states, keeping focus on mental content,
of group therapy, but abandoned the theme when Monica and being transparent about their own mind. The therapist
explained her total lack of energy after the traumatic event. often started by exploring and clarifying a topic, summariz-
The therapist often seemed to lack curiosity for the answers ing or connecting to a larger framework of understanding,
to own questions and in one example, the therapist gave a and then employing a more challenging stance. For instance,
conclusion on behalf of the patient. Therapist: “”Who is after Elsa had agreed to return to the group, her therapist
close by you now?” Patient: “Right now it is S and Y, fam- concluded the theme by highlighting her own responsibility
ily.” Therapist: “Yes. But you are a little lonely….” The and agency: “No, and when I asked you about this, it was
struggle of the comfort zone in this case seems to end up not to criticize you, but to emphasize the problem with it.
with a dialogue devoid of any exploration of mental states, There is something that is making it difficult when we talk
both parts avoiding discomfort, which nevertheless seemed about it. But the only one who can persuade you to go to the
to be present. The therapist becomes increasingly careful, group is you, yourself.” In this session the focused therapeu-
avoidant of emotional themes, oversupportive perhaps, and tic strategy seems to relate closely to the therapists specific
the patient increasingly unmotivated, but possibly, left in a MBT competence.
vulnerable state. Implicitly, the therapist may have conveyed Battles of the Comfort Zone The session revealed Elsa’s
compassion, but coupled with possible unresolved counter- discomfort and her relational issues. She (quite correctly)
tranferences of helplessness or resignation. expected her therapist to challenge her, and tried to avoid
such interventions by laughing, distracting and opposing.
Elsa and Her Therapist: Leaning on the Alliance in the Battle Elsa’s strong appraisals of her therapist could also be inter-
of the Comfort Zone preted as a defensive strategy, (implicitly) implying that the
therapist should be gentle with her, as she was nice to the
Elsa was a woman in her early 50 s. She was also a former therapist. However, Elsa’s therapist was not led astray by
heroin addict. Recently, she had felt hurt in a group therapy her avoidance strategies. After several interventions, per-
session, and had avoided coming for 4 weeks. This was the sistently, negotiating a need for talking about the theme,
most salient subject in the session. The underlying theme of e.g., “I think we should talk about it now, and then we can

13
Journal of Contemporary Psychotherapy

return to what we were talking about, all right?”, the thera- just become really aware of my feelings and my…everything
pist finally succeeded in this first step. In creating this situ- after I got my diagnosis.” Maria indicated that she was not
ation the therapist leaned on the therapeutic bond, which used to be challenged: “Ehm...so I haven’t…I haven’t neces-
seemed good enough to allow the persistence. S/he was then sarily had to face a lot of…anything in reality.” Inferably,
able to say more about why the group is so important for Maria nevertheless, here can be seen to accept this aspect
the patient, and how s/he felt somewhat stupid for “nagging of therapy. An important contributing factor may be that the
about it for the hundredth time”, when the patient did not therapist seemed highly emotionally attuned. Throughout the
attend the group even though she promised. The following session she was able to accurately identify the patient’s feel-
is an example of alliance and strategy working together. The ings. Consequently, it is likely that the patient felt held and
therapist is open about countertransferences. Therapist: “At understood in a contingent and congruent way. The treat-
the same time, I think like this: Now that we’re talking about ment was in its beginning, but the alliance already appeared
it, I try in a way, well..it...it is quite difficult, because I can’t strong.
hide that I think it’s good for you to go there. Just because Strategic Competence The therapist was highly adherent
I happen to think so?! But at the same time, I feel that I nag to the manual, had an impressive range of MBT interven-
you about this a lot. And then I think like this: Is it because tions, and awareness of the conjoint therapy aspect. The
I keep nagging you, that you say yes, that you want to go therapist validated, encouraged, and kept a steadfast focus on
there? Because you don’t go there. And then I feel...well, mental states throughout the session. This process seemed to
what am I doing..... and I feel disappointed in a way. We talk stimulate the patient’s ability to mentalize others, and facili-
about it and you say you will go there and then you don’t....” tated Maria in exploring the experience of the other group
Elsa and her therapist seemingly agreed on the goals and members: “Mm. Do you think that the others notice the feel-
tasks in the therapy, even though the patient resisted them. ing you have, that it doesn’t concern them?” and “What do
In this session, in contrast to the former examples of Diane you think made her say something like that?” In a playful
and Monica, the personal bond (established trust) enabled an and gentle way, she further encouraged Maria to mentalize
explicit battle of the comfort zone, and Elsa, who accepted her emotional reactions to the others in the group: “Did you
the struggle, thus achieved a therapeutic focus on her core get a little irritated by her not trying to see it from your
relational problems. In treatment of patients with severe rela- perspective… viewpoint? Maybe? The fact that it also could
tional problems, the concept “battles of the comfort zone”, be difficult for them? Do you think that is what made you
depicts a two-way tension within the therapeutic dyad. most irritated?” The therapist balanced being challenging
and supportive, and explored the patient’s resistance to the
Maria and Her Therapist: Using Empathic Focus to Carefully group therapy in great detail, while she semeed to validate
Battle Affect Avoidance Maria’s different difficulties in a transparent and clear way:
“Because it, I think, it could also be really difficult to be the
Maria was a woman in her early 30 s. She harboured strong new one and kind of have to get in to a group, that already
resistance to the conjoint group therapy. When she eventu- is going, and… try to find one’s feet there, and find a place
ally turned up in the group, she experienced skepticism. This in the group, and I suppose, that too can be really difficult”.
urged her to leave the group. The therapist asked if some of She also normalized Maria’s trouble in choosing themes for
her thoughts and feelings about this could be shared with the group, and actively encouraged her to talk about this in
the group. Maria responded that strangers should have no her individual therapy: “If there is any situation… well how,
access to her inner life. This reactivity echoed other relations you could bring something into the group. So we could try
in her life, and she had lately become rather isolated. The to look at that… what could be relevant for you. There are
therapist explored various barriers Maria raised in relation a lot of people who feel like that, that… what exactly do I
to the group in an empathic and steadfast way, which finally bring up… what kind of event one should talk about,… that
allowed Maria’s underlying sadness to emerge. is when you can use our sessions to look at, whether there
Alliance Maria provided 20 statements concerning alli- could be some relevant situations…”
ance. Six of these were connected to a plan of education. If it Battles of the Comfort Zone The main part of the session
proved impossible to combine with treatment, she stated that was spent exploring and gradually challenging Maria’s con-
she would choose treatment: “Yes. Yes, yes, and I am also cerns about the group, and reasons for not finding it fruitful.
prepared that, if it should be, that I cannot, so if it should be, The therapist was steadfast in her focus on mental states and
that, that my teacher does not want to give me dispensation, mentalizing of Maria’s attachment to and beliefs about the
then I am fully aware that I will have to drop the education.” group. This increasingly activated the patient, and resulted
We interpreted this statement as reflective of Maris’s com- in her being “irritated” at the therapist for being “poked”.
mitment to the treatment she was receiving. Maria felt diag- As Maria was brought out of her emotional comfort zone the
nostic assessments had been helpful: “Ehm... but I have only therapist asked: “But I’m wondering, what can you notice

13
 Journal of Contemporary Psychotherapy

right now, when you are sitting here telling me these things? depreciation, abstruseness, or stubbornness as well as the
What are you in contact with now?” Maria said she felt “irri- more austere atmosphere that arose when they pursued the
tated”. The therapist investigated this further by saying:“So patient’s problems.
me asking about things, and trying to understand some Our analysis suggests that the high rated clinicians were
things, and examining some things together with you, can willing to challenge the patients, even though it would
actually be experienced as irritating?” Maria confirmed that temporarily disharmonize the therapeutic relation. High
being “poked” like this by the therapist annoyed her, and rated therapists identified, investigated, and confronted the
then admitted that it was “not too comf… fantastic” to say patients’ problems in a clarifying process, which in turn, fur-
this aloud to the therapist—but she said it with a big smile. It ther promoted therapeutic alliance. In the low rated sessions,
was a relief for Maria to have ventilated her feelings towards the therapeutic alliance was interpreted as weak, and no
the therapist. It seemed to strengthen the bond. Her experi- positive progress was observed. Low rated therapists were
ence of being different and lonesome filled the last part of brought out of their own comfort zone (e.g., by transferences
the session, now with tears and sadness. She seemingly felt and/or counter-transferences), and attempted to amend the
seen, met and held by her therapist and her narrative became atmosphere by being overly agreeable and accommodating.
more open, personal and in contact with emotions. It seemed that a positive alliance and clear strategic com-
petence were two necessary, coacting components allowing
for what we conceptualized as “battles of the comfort zone”.
Discussion The therapist needs a willingness and capacity to confront
the client’s dysfunctional behaviour (Rønnestad 2016), and
This qualitative analysis of therapy sessions with high and a willingness to tolerate the discomfort (e.g., transferences
low-rated MBT fidelity including poorly functioning patients and counter-transferences) this may cause in the session. We
with BPD, highlights interactions between therapeutic alli- propose that, when administered with skill, such “battles
ance and therapists’ strategy. We suggest a model where of the comfort zone” may evoke an even stronger alliance.
alliance and strategic competence work together, and enable In our sessions, the more there was a sense of genuine
focused, but challenging work with highly sensitive patients warmth (personal bond) in the relation, despite struggles,
and their psychopathology. Further, we postulate that such the more it seemed possible for the therapist to challenge the
a process may have the potential of increasing the patient’s patient even further. This general sense of a “warm climate”,
epistemic trust. A central theme was depicted in the concept similar to what Sandler (1960) termed background of safety,
“battles of the comfort zone”. in the high-rated sessions seemed to enable work on sensi-
tive, but core relational or personal issues. In our analysis, a
Battles of the Comfort Zone: Expanding the Front crucial part of this warmth or background of safety is most
Line of the Therapeutic Relationship accurately seen as trust: It is reasonable that such trust is an
accumulated asset built from assimilated experiences of the
The low rated MBT sessions highlighted how counter-trans- therapist being able to help.
ferences of being useless, judged/criticized, not knowing In the two high-rated sessions, trust evolved through
enough (incompetent), not being liked, or strong feelings repeated experiences of the therapist being able to guide,
of sympathy, may result in a therapeutic style with too little reflect, explore, understand, challenge, and/or interpret (help
confrontation. In the low rated sessions, therapists seemed the patient connect specific situations to a larger dysfunc-
to be avoiding difficult contents or trying to accommodate or tional behavioural pattern) the mental content. It is conciev-
please the patient. Therapist interventions included concrete/ able that improvement in epistemic trust could evolve from
practical advice or offering extra sessions. The low rated the therapists’ willingness to address and confront maladap-
MBT therapists seemed for various reasons to be brought out tive patterns according to an overarching strategy. We pos-
of their comfort zone and their competence was outplayed. tulate that such a process may have the potential of increas-
These sessions displayed a lack of mentalizing on behalf of ing the patient’s epistemic trust, which is crucial because
the therapist in terms of few MBT interventions and aban- therapy then works through three levels. First, the patient’s
donment of the overall therapeutic strategy. trust in the therapist allows her to learn new content about
The high rated MBT therapists seemed to have kept their mental states of self and others. Secondly, the therapy foster
ability for mentalizing during the session, and were able mentalization through a process of reflecting mental states.
to focus more explicitly on the alliance, and explore possi- Thirdly, the new content and reflection relaxes a hypervigi-
ble transference reactions in a transparent manner with the lance in social situations, which in turn opens for new social
patient. The therapists remained steadfast and committed to learning (Fonagy et al. 2018).
the overall goals of trying to increase the patients’ mental- A different conception could be that such battling of the
izing abilities and seemed to tolerate the patient’s anger, comfort zones induces what Davanloo (1990) refers to as an

13
Journal of Contemporary Psychotherapy

“unconscious alliance”. This means that the patients’ uncon- be eliminated, but as a necessity for interpretation of the
scious trust (alliance) is built by the therapists’ willingness qualitative data. It may thus be regarded a strength that the
to directly confront the patients’ defences (battle the comfort researchers are experts in the field they investigate (Binder
zones) in order to be helpful. McCullough (1991) found that et al. 2012). However, in order to balance possible biases
patients seemed more able to digest the painful informa- towards MBT, the last author is a psychoanalyst, and had no
tion contained in a therapist’s confrontation or interpretation formal MBT education.
when it was paired with a statement that reflected considera- The study focused on aspects of alliance. Alliance may
tion or care—it was detected that confrontations made along be assessed in a variety of ways, often by quantitative meth-
with a supportive or empathic statement by the therapist ods such as self-reports, and is shown to predict positive
resulted in a greater probability of affective activation. outcome across several measurement methods (Martin et al.
As we assume that epistemic trust can be gained or 2000). This suggests that trained clinicians should be able
regained, the alliance need not be high in all sessions. A to evaluate qualities of therapeutic alliance by observation
treatment may be efficient as a whole, despite some low of in-session processes. Our phenomenological analysis was
rated sessions. Consequently, it is more important to nego- based on the assumption that alliance could be analysed as
tiate the alliance than to have a positive personal bond at all the phenomena of the relational process (Henry and Strupp
times (Safran and Muran 2000; Zilcha-Mano et al. 2015). 1994). Built on this fundament, the three aspects of alliance
In the low rated sessions, the patients seemed to com- were investigated phenomonologically on the basis of the
mand the battles of the comfort zone. In our selection of transcripts. The study is nevertheless limited by a lack of
four sessions, the high rated therapists built on the personal quantitative data which could support our interpretations of
bond and managed to pull the patient towards their common alliance.
goal. The personal bond appeared as an asset allowing the
therapist to challenge the patients’ sensitive subjects. The
high rated therapists were selective about what s/he wanted
to battle (strategic competence). Both Diane and Monica Conclusion
(low rated sessions) displayed low trust in receiving help
from their respective therapists. In the session with Monica, Based on MBT therapy sessions for poorly functioning
the atmosphere was difficult to interpret, her mental state patients with BPD, we suggest a model where alliance and
was described as “indifferent”, and an increase in mental- strategic competence work together, enabling focused, but
izing could not be observed. In the session with Diane, the challenging work with highly sensitive patients. We postu-
atmosphere was tense, and the therapist struggled to improve late that such a process may have the potential of increas-
it, but lost focus on the overall therapeutic project in the ses- ing the patient’s epistemic trust, which is crucial because
sion. In the high-rated sessions, the general atmosphere was therapy then works through the three levels described by
not uncomfortable, but had the distinct quality of the patient Fonagy et al. (2018).
both protesting, but gradually working with and accepting The tension within the therapist-patient dyad was clearly
challenges. The atmosphere was coloured by the patient’s illustrated in all the therapies, challenged therapeutic strate-
content. gies, and was termed “battles of the comfort zone”.
However, within a framework of a trusting alliance,
Strengths and Limitations therapists were able to keep a focused strategy and address
problems. We suggest that this fruitful interaction, nurtured
In line with recommendations for purposeful sampling, we epistemic trust, and a willingness to manage sensitive top-
selected the most extreme or deviant sessions in order to ics within the therapeutic dyad. Conversely, poorly dem-
illuminate possible themes or patterns (Patton 1990). The onstrated therapist strategies were coupled with low confi-
logic and power of purposeful sampling lies in selecting in dence and lack of alliance in patients, and possibly further
formation-rich sessions, those from which one can learn a enhanced by activation of therapist countertransference.
great deal about issues of central importance to the purpose Such interaction implied severely restricted possibility for
of the research, for in-depth analysis. Hence, our findings managing sensitive topics within the therapist-patient dyad.
depend on the assumption that the four most deviant sessions The study raises the question of how not only the bond, but
will inform us about alliance in MBT. One could argue for a also the task aspect of alliance, may be a crucial factor in
larger sample, or for selecting more average sessions. treatment of poorly functioning individuals.
Smith et al. (2009) underscore that the purpose of IPA
Acknowledgements Thanks to Björn Phillips and Roland Pålsson at
is to attempt to gain an insider perspective, while acknowl-
the Stockholm Centre for Dependency Disorders, Sweden, Samantha
edging that the researcher is the primary analytic instru- Karrebæk and Kirsten Aaskov Larsen at Psychiatric Clinic Roskilde,
ment. The researcher’s beliefs are not seen as biases to Denmark, and Turid Helene Bergvik at The Section for Personality

13
 Journal of Contemporary Psychotherapy

Psychiatry, Oslo University Hospital, Norway for providing us with Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2018). Recon-
material to this study. ciling psychoanalytic ideas with attachment theory. New York:
Guilford Press.
Henry, W. P., & Strupp, H. H. (1994). The therapeutic alliance as
Compliance with Ethical Standards interpersonal process. In A. O. Horvath & L. S. Greenberg (Eds.),
Wiley series on personality processes. The working alliance:
Conflict of interest None of the authors have any financial disclosure/ Theory, research, and practice (pp. 51–84). Oxford: John Wiley.
conflict of interest related to this manuscript. Henry, W. P., Strupp, H. H., Butler, S. F., Schacht, T. E., & Binder, J. L.
(1993). Effects of training in time-limited dynamic psychotherapy:
Ethical Approval All procedures performed in studies involving human Changes in therapist behavior. Journal of Consulting and Clinical
participants were in accordance with the ethical standards of the insti- Psychology, 61(3), 434–440.
tutional and/or national research committee and with the 1964 Helsinki Karterud, S. (2012). Manual for mentaliseringbasert gruppeterapi
declaration and its later amendments or comparable ethical standards. (MBT-G). Oslo: Gyldendal Akademisk.
Informed consent: Informed consent was obtained from all individual Karterud, S., & Bateman, A. (2010). Manual for mentaliseringbasert
participants included in the study. terapi (MBT) og MBT vurderingsskala. Versjon individualterapi.
Oslo: Gyldendal Akademisk.
Karterud, S., Pedersen, G., Engen, M., Johansen, M. S., Johansson, P.
N., Schlüter, C., … & Bateman, A. W. (2013). The MBT Adher-
ence and Competence Scale (MBT-ACS): development, structure
References and reliability. Psychotherapy Research, 23(6), 705–717.
Killingmo, B., Varvin, S., & Strømme, H. (2014). What can we expect
from trainee therapists? A study of acquisition of competence
Bales, D. L., Timman, R., Andrea, H., Busschbach, J. J., Verheul,
in dynamic psychotherapy. The Scandinavian Psychoanalytic
R., & Kamphuis, J. H. (2015). Effectiveness of day hospital
Review, 37(1), 24–35.
mentalization-based treatment for patients with severe border-
Kvarstein, E. H., Pedersen, G., Urnes, Ø, Hummelen, B., Wilberg,
line personality disorder: A matched control study. Clinical
T., & Karterud, S. (2015). Changing from a traditional psycho-
Psychology & Psychotherapy, 22(5), 409–417.
dynamic treatment programme to mentalization-based treatment
Bateman, A., & Fonagy, P. (2001). Treatment of borderline personal-
for patients with borderline personality disorder—Does it make
ity disorder with psychoanalytically oriented partial hospitaliza-
a difference? Psychology and Psychotherapy: Theory, Research
tion: An 18-month follow-up. American Journal of Psychiatry,
and Practice, 88(1), 71–86.
158(1), 36–42.
Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding
Bateman, A., & Fonagy, P. (2009). Randomized controlled trial
the lens of evidence-based practice in psychotherapy: A common
of outpatient mentalization-based treatment versus structured
factors perspective. Psychotherapy, 51(4), 467–481.
clinical management for borderline personality disorder. The
Lemma, A., Target, M., & Fonagy, P. (2011). Brief dynamic inter-
American Journal of Psychiatry, 166(12), 1355–1364.
personal therapy: A clinician’s guide. Oxford: Oxford University
Betan, E., Heim, A. K., Conklin, Z., C., & Westen, D. (2005). Coun-
Press.
tertransference phenomena and personality pathology in clini-
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the
cal practice: An empirical investigation. American Journal of
therapeutic alliance with outcome and other variables: A meta-
Psychiatry, 162(5), 890–898.
analytic review. Journal of Consulting and Clinical Psychology,
Binder, P. E., Holgersen, H., & Moltu, C. (2012). Staying close and
68(3), 438–450.
reflexive: An explorative and reflexive approach to qualitative
McCullough, L. (1991). Davanloo’s short-term dynamic psycho-
research on psychotherapy. Nordic Psychology, 64(2), 103–117.
therapy: A cross-theoretical analysis of change mechanisms. In
Bo, S., Sharp, C., Fonagy, P., & Kongerslev, M. (2017). Hypermen-
R. Curtis & G. Stricker (Eds.), How people change: Inside and
talizing, attachment, and epistemic trust in adolescent BPD:
outside of psychotherapy (pp. 59–79). New York: Plenum Press.
Clinical illustrations. Personality Disorders: Theory, Research,
Möller, C., Karlgren, L., Sandell, A., Falkenström, F., & Philips, B.
and Treatment, 8(2), 172–182.
(2017). Mentalization-based therapy adherence and competence
Bordin, E. S. (1979). The generalizability of the psychoanalytic con-
stimulates in-session mentalization in psychotherapy for border-
cept of the working alliance. Psychotherapy: Theory, Research
line personality disorder with co-morbid substance dependence.
& Practice, 16(3), 252–260.
Psychotherapy Research, 27(6), 749–765.
Boswell, J. F., Gallagher, M. W., Sauer-Zavala, S. E., Bullis, J., Gor-
Morken, K., Karterud, S., & Arefjord, N. (2014). Transforming disor-
man, J. M., Shear, M. K., … Barlow, D. H. (2013). Patient
ganized attachment through mentalization-based treatment. Jour-
characteristics and variability in adherence and competence in
nal of Contemporary Psychotherapy, 44(2), 117–126.
cognitive-behavioral therapy for panic disorder. Journal of Con-
Nissen-Lie, H. A., Havik, O. E., Høglend, P. A., Rønnestad, M. H., &
sulting and Clinical Psychology, 81(3), 443–454.
Monsen, J. T. (2015). Patient and therapist perspectives on alli-
Colli, A., Tanzilli, A., Dimaggio, G., & Lingiardi, V. (2014). Patient
ance development: Therapists’ practice experiences as predictors.
personality and therapist response: An empirical investigation.
Clinical Psychology & Psychotherapy, 22(4), 317–327.
American Journal of Psychiatry, 171(1), 102–108.
Østlie, K., Stänicke, E., & Haavind, H. (2016). A listening perspective
Davanloo, H. (1990). Unlocking the unconscious. Chichester: Wiley.
in psychotherapy with suicidal patients: Establishing convergence
Folmo, E. J., Karterud, S. W., Bremer, K., Walther, K. L., Kvarstein,
in therapists and patients private theories on suicidality and cure.
E. H., & Pedersen, G. A. (2017). The design of the MBT-G
Psychotherapy Research, 1–14.
adherence and quality scale. Scandinavian Journal of Psychol-
Patton, M. Q. (1990). Qualitative evaluation and research methods.
ogy, 58(4), 341–349.
Thousand Oaks: SAGE.
Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect reg-
Rønnestad, M. H. (2016). Is expertise in psychotherapy a useful con-
ulation, mentalization, and the development of the self. New
struct? Psychotherapy Bulletin, 51, 11–13.
York: Other Press.
Rossouw, T. I., & Fonagy, P. (2012). Mentalization-based treatment for
self-harm in adolescents: A randomized controlledtrial. Journal of

13
Journal of Contemporary Psychotherapy

the American Academy of Child & Adolescent Psychiatry, 51(12), Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate:
1304–1313. The evidence for what makes psychotherapy work. New York:
Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alli- Routledge.
ance: A relational treatment guide. New York: Guilford Press. Zilcha-Mano, S., Solomonov, N., Chui, H., McCarthy, K. S., Barrett,
Sandler, J. (1960). The background of safety. The International Journal M. S., & Barber, J. P. (2015). Therapist-reported alliance: Is it
of Psychoanalysis, 41, 352–356. really a predictor of outcome? Journal of Counseling Psychology,
Smith, J., Flowers, P., & Larkin, M. (2009). Interpretative phoneomo- 62(4), 568–578.
logical analysis: Theory, method and research. London: SAGE
Publications. Publisher’s Note Springer Nature remains neutral with regard to
Smith, J. A. (2011). Evaluating the contribution of interpretative phe- jurisdictional claims in published maps and institutional affiliations.
nomenological analysis. Health Psychology Review, 5(1), 9–27.
Stoffers, J. M., Voellm, B. A., Rücker, G., Timmer, A., Huband, N., &
Lieb, K. (2012). Psychological therapies for people with border-
line personality disorder. The Cochrane Library.
Strupp, H. H. (1998). Negative process: Its impact on research, train-
ing, and practice. Empirical Studies of Psychoanalytic Theories,
8, 1–26.

13

View publication stats