Antisocial personality traits and outcome in psychotherapy: Does the therapeutic alliance mediate negative effects?

Process and outcome studies focusing on antisocial traits (ANT) are limited (Van den Bosch et al., 2018), especially in nonforensic/nonoffender outpatient settings (Thylstrup & Hesse, 2016). ANT can impact outcomes through several mechanisms, such as treatment rejection, premature dropout, or poor alliance formation (Van den Bosch et al., 2018; Messina et al., 2002). In a prior study (Cersosimo, Hilsenroth, Bornstein, & Gold, 2022), we found that patient-rated alliance early in outpatient psychotherapy was negatively related to pretreatment ratings on Personality Assessment Inventory scales assessing ANT. The present study extends this work by examining ANT, alliance, and treatment readiness with outcome. We found that ANT, treatment rejection, and patient-rated alliance were significantly related to patient-rated outcome (n = 65). Regression analysis indicated that both ANT (β = -.29, p = .014; f² = 0.09) and treatment rejection (β = -.28, p = .019; f² = 0.09) were unique, negative, predictors of outcome, explaining 18% of the variance. Adding the significant, positive, patient-rated alliance to the model (β = .34, p = .003; f² = 0.13) increased explained variance to 25%. Subsequent analyses revealed that the negative impacts of treatment rejection on outcome occur separate from both ANT and alliance, while the negative impact of ANT on outcome is partially mediated by the positive effects of alliance (indirect effect = -.10, lower level confidence interval = -.208; upper level confidence interval = -.003). We discuss how early assessment of ANT and treatment readiness informs treatment planning. Limitations of the study and next steps for research are noted. (PsycInfo Database Record (c) 2025 APA, all rights reserved).