MAINTAINING THE THERAPEUTIC ALLIANCE WITH PERSONALITY-DISORDERED PATIENTS

The task of therapy in severely personality disordered patients is to transfer all the destructive feelings, which are usually channelled in to deliberate self-harm, into the therapeutic relationship, so that th ey 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 horror s carry so much negative affect that they threaten to destroy the rela tionship. This paper discusses the problems in maintaining a therapeut ic 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 ri sk management with a particular focus on the interpersonal triggers of suicidal behaviour. The author believes that clinical practice inform ed by knowledge of attachment theory may enable clinicians to pre-empt life-threatening crises during therapy.