Date of Award


Document Type


Degree Name



Social Work

First Advisor

Walter LaMendola, Ph.D.


Borderline personality disorder, Social presence, Technology mediated therapy, Therapeutic alliance


This research explores whether access to technology mediated resources that expand social presence opportunities during mental health treatment play a role in what therapists report as difficult therapeutic alliance demands. Borderline Personality Disorder (BPD) is a serious mental health problem, characterized by unstable relationships, anger outbursts and impulsive behaviors. People with BPD tend to be high service users and have difficulty remaining in the treatment setting long enough to benefit from treatment services. Treatment studies have found that the therapeutic alliance is a significant contributing factor to successful outcomes; however, the relational and behavioral difficulties inherent among those diagnosed with BPD can make the development and maintenance of a strong therapeutic relationship difficult. As a result, those with BPD are often stigmatized and denied care. To help ensure appropriate access to care and treatment success for this population, those providing treatment for people with BPD need specific tools and techniques for building and managing the therapeutic relationship. One possibility that is gaining popularity in mental health treatments is the use of information and communication technologies as a part of treatment services. However, little is currently known about how the therapeutic alliance is built and maintained through technology mediated communications. To understand the role technology plays in the therapeutic alliance, specifically when there are high demands on the relationship, this research explored how therapists treating persons diagnosed with a borderline personality disorder might use web-based Internet resources specifically targeted for adjunctive use in therapy. In this study, supportive, Internet based treatment resources for a specific form of evidence based BPD treatment, Dialectic Behavioral Therapy (DBT), were incorporated into a DBT Website and presented in various technology based formats, e.g. video, text, or animations, to intentionally vary and expand the opportunities for social presence between the client and therapist.

A concurrent, mixed methods design was used to deepen understanding of what role social presence and web-based resources play in the therapeutic relationship. The study used a parallel process in which therapeutic alliance, therapist burnout and client outcomes were measured before and after the implementation of the DBT website, using validated measurement tools. At the same time, therapist and client reports were gathered through qualitative techniques during and after the experimental period.

Results indicate that when different opportunities for social presence were available, therapists increased their communication with clients and did not rely solely on face to face encounters as the basis for maintaining the therapeutic alliance. Opportunities for social presence were reported as positive influences on the therapeutic alliance in the areas of client learning and provision of therapeutic support. In addition, therapists reported a reduction in burnout by having additional therapeutic support options available. The study also found that variations in social presence had a positive impact on client outcomes, as indicated by decrease in symptoms. In addition, there was also a statistically significant difference in the impulse control scale during the intervention period that was not present in the non-intervention group.

Implications from this study indicate that variations in social presence and the range of therapeutic tools available for managing therapeutic relationships may result in an improved therapeutic alliance, improved client outcomes and reduced therapist burnout. The exploratory design of this study had several limitations, primarily related to limited ability to link website use directly to client and therapist outcomes. Despite these limitations, this study begins to create a foundation for use of increased opportunities for social presence as a potential support for the treatment alliance.


Received from ProQuest

Rights holder

Amy Lopez

File size

260 p.

File format





Social work

Included in

Social Work Commons