Contrasting Clients in Dialectical Behavior Therapy for Borderline Personality Disorder: "Marie" and "Dean," Two Cases with Different Alliance Trajectories & Outcomes

Dialectical Behavior Therapy (DBT; Linehan, 1993a) has garnered a strong evidence base to support its efficacy in treating borderline personality disorder (BPD). Despite this, some clients do not benefit from evidenced-based approaches. There is a recent emphasis on identifying the processes and mechanisms of DBT in order to improve treatment outcomes. This report describes the course of treatment for two individuals who were treated with one-year of standard, outpatient DBT in the context of a randomized control trial. The two clients were selected because (1) both reported poor initial alliances, and (2) they had different outcomes. The first case, "Marie," showed considerable change across a broad range of outcomes whereas the second case, "Dean," made only limited treatment gains. The two cases are contrasted in order to highlight potential factors that may have contributed to the different alliance trajectories and outcomes. We explore several hypotheses to help to explain the relationship between treatment outcome and client characteristics, the therapeutic alliance, the consultation team, and the research context.