Maintaining the therapeutic alliance with personality-disordered patients

Abstract

Abstract The task of therapy in severely personality disordered patients is to transfer all the destructive feelings, which are usually channelled into deliberate self-harm, into the therapeutic relationship, so that they can be contained, understood and mastered. However, it can be very difficult to create a therapeutic relationship where the patient feels secure enough to access horrors from the past, when these very horrors carry so much negative affect that they threaten to destroy the relationship. This paper discusses the problems in maintaining a therapeutic alliance with such patients using anecdotes from the author's work in a therapeutic community. The relevance of psychoanalytical concepts such as envy, hostile dependency, the negative therapeutic reaction, psychopathic transference, idealization and splitting are explained. A case is made for detailed psychodynamic formulations, as an aid to risk management with a particular focus on the interpersonal triggers of suicidal behaviour. The author believes that clinical practice informed by knowledge of attachment theory may enable clinicians to pre-empt life-threatening crises during therapy.