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Therapists’ Metacognitive Monitoring of the Psychotherapeutic Process With Patients With Borderline Personality Disorder


Journal of Psychiatric Practice®: July 2017 - Volume 23 - Issue 4 - p 246–253
doi: 10.1097/PRA.0000000000000247

Background: Therapy for borderline personality disorder (BPD) is challenging, in part, because of the impact of BPD on the therapeutic relationship. The therapist’s metacognitive capacity within therapy may be perturbed due to the complexity of verbal and nonverbal affect and cognition in the therapeutic interchange; however, research on this issue is lacking.

Methods: Therapists (N=20 clinical psychologists) were asked to discuss the treatment process when working with their patients with BPD (N=40) and their patients with major depressive disorder (N=40). Verbatim transcripts of the therapists’ verbalizations were then scored using computerized linguistic content analysis.

Results: When discussing their patients with BPD, clinicians used significantly fewer words associated with cognitive processes (think, understand, realize) or words indicating causation (cause, because, effect), and more first-person singular pronouns, and adverbs. When describing their depressed patients, the therapists used more words associated with negative emotions, anxiety, anger, and sadness than positive words. The results did not seem to be influenced by the therapists’ age, sex, or years of experience.

Conclusions: Reflection on the psychotherapeutic process with patients with BPD induced in therapists a self-focused, emotionally intense linguistic style dominated by references to themselves and their experience of intense emotional states. These results suggest that, when describing their work with patients with BPD, therapists experience metacognitive challenges and mentalization processes that may parallel the challenges therapists face when thinking and working during the psychotherapy sessions themselves. The results underscore the important role of supervision in assisting therapists to organize their reflective processes when working with patients with BPD.

BOURKE AND GRENYER: School of Psychology and Illawarra Health & Medical Research Institute, University of Wollongong, Wollongong, NSW, Australia

The authors declare no conflicts of interest.

Please send correspondence to: Brin Grenyer, PhD, School of Psychology and Illawarra Health & Medical Research Institute, University of Wollongong, Wollongong, NSW 2522, Australia. (e-mail:

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