Conflict begets conflict: Executive control, mental state vacillations, and the therapeutic alliance in treatment of borderline personality disorder

Clinicians routinely note the challenges involved in psychotherapy with individuals with BPD, yet little research exists on the therapeutic alliance with this population. An important question is, what patient factors contribute to a disturbed alliance with individuals with BPD? Executive attention has been identified as a mechanism of BPD, and mental state vacillations (e.g., idealization/denigration, incoherence in self-concept) are a hallmark of the disorder. The goals of this study were to examine the link between executive attention and the alliance and assess mental state vacillations as a mediator. Thirty-nine participants diagnosed with BPD, participating in a randomized clinical trial, were administered the Attentional Network Task (ANT). Early psychotherapy sessions were coded using the Working Alliance Inventory (WAI). In addition, six items were generated and coded representing in-session vacillations in mental states. Performance on the ANT was related to the alliance (r=.34, p=.035), as were in-session mental state vacillations (r=.59, p <.001). A model was supported in which in-session mental state vacillations mediated the relationship between executive attention and alliance. Executive attention was related to therapeutic alliance, and this relationship was found to be mediated by in-session mental state vacillations. These findings emphasize the importance of executive attention in the disorder and uncover a link between poor executive attention and mental state vacillations. Mental state vacillations as a mediator suggests a path in which poor executive attention leads to greater vacillations, which leads to poorer working alliance.