Factors predicting the outcome of psychotherapy for borderline personality disorder: A systematic review

BackgroundThere is substantial variation between individuals with borderline personality disorder (BPD) in the degree of benefit gained from psychotherapy. Information on factors predicting the outcome of therapy for this group could facilitate identification of those at risk for poor outcome, and could enable helpful therapy processes to be identified.MethodA systematic search of PsycInfo, EMBASE, CINHAL and Medline identified research on factors predicting symptom change during therapy for patients with a BPD diagnosis. Non-English language papers and dissertations were included.ResultsTwo consistent positive predictors of symptom change were identified: pre-treatment symptom severity and patient-rated therapeutic alliance. Contrary to theories predicting increasing immutability with age, there was no evidence that age predicted poorer outcome.ConclusionMore severely ill patients may have greater potential to achieve change during therapy, and should remain a focus for psychotherapy services. The therapeutic alliance is an important common factor predicting outcome in patients with BPD, even in highly disorder-specific treatments. Outcomes may be improved by further clinical and research focus on forming strong therapeutic alliances. The advancement of the field requires identification and testing of new predictors of outcome, especially those related to specific theories of therapeutic change in BPD.

►Patients with higher pre-treatment symptoms may achieve greater symptom reduction. ►Older patients do not improve less. ►A stronger therapeutic alliance consistently predicts greater improvement in BPD. ►Research on predictors in BPD has lacked coherence — it shows breadth, not depth. ►Greater research focus on the alliance and specific therapeutic factors is needed.