The effect of working alliance on patient adherence and treatment outcome in patients suffering from severe personality disorders
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Patients suffering from severe personality disorders (SPD) pose a heightened risk for ruptures in the working alliance and adherence-related problems during treatment. This study aimed to investigate in patients with SPD the effect of the quality of the working alliance on treatment outcomes (i.e., level of psychosocial functioning and frequency of hospital admissions), and whether this effect is mediated by patient adherence indicated by the frequency of no shows and the extent of problems with patient motivation. In a longitudinal study design, 76 patients who met the criteria for SPD were assessed by their clinician as part of routine outcome monitoring on the quality of the working alliance (STAR-C), problems with patient motivation (HoNOS), and level of psychosocial functioning (HoNOS). Frequency of no shows and hospital admissions were derived from clinical records. Data were analysed by using multiple mediation analyses with the quality of the working alliance as predictor, the patient adherence variables as mediators, and psychosocial functioning and frequency of hospital admissions as outcomes. The results revealed that the quality of the working alliance had no direct, but rather an indirect effect on the improvement of psychosocial functioning through patient motivation. No direct or indirect effects were found between the quality of the working alliance and hospital admission days. The quality of the working alliance and patient motivation play a role in the change of the level of psychosocial functioning in the treatment of SPD. The interplay of these variables should be considered in psychological interventions for SPD, and focus more on repairing ruptures in the working alliance.