The clinician–patient relationship in personality disorder management

The therapeutic relationship between the clinician and patient plays an important role in personality disorder management, and provides an environment that can facilitate change. It is often helpful for clinicians to remember that, when treating a person with personality disorder, they are usually seeing them at their lowest ebb, when problems are likely to be at their most severe.

Since personality disorder involves difficulties with empathy, intimacy, understanding others’ perspectives, managing conflict and self-reflection, the therapeutic relationship can become strained at times. The clinician should seek to understand how the person prefers to interact. In expressing their needs, the person may ask the clinician to say or do things that the clinician experiences as unrealistic or demanding. When the clinician is unable to meet these needs the patient may respond with, for example, aggression or extreme emotionality. Clinicians can often feel provoked by such encounters and reciprocate in ways that are often uncharacteristic. A flexible and self-reflective response style, acknowledging the patient’s needs while also letting the patient know the limits of what the clinician can provide, can help to maintain engagement. Clinicians should not be afraid to respectfully discuss their own limits with the patient or to seek advice from their peers.

Strategies to foster an effective therapeutic relationship include collaborative goal setting, being clear about mutual expectations and acceptable behaviour, encouraging the patient to develop self-control, and helping the patient to associate feelings with events and actions. Use a structured approach to personality disorder problems following the key principles in Key principles for working with a person with personality disorder. Discuss the case with other clinicians.