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Approaches to the therapeutic relationship in patients with personality disorders

Andrew Skodol, MD
Donna Bender, PhD
Section Editor
Murray B Stein, MD, MPH
Deputy Editor
Richard Hermann, MD


The relationship between a clinician and a patient in psychotherapy plays a central role in alleviating symptoms and fostering character change [1]. The treatment relationship can be a potentially powerful vehicle for patient improvement, as it can provide a supportive environment for exploration and because issues that come up in this context can be processed in a very immediate and instructive way.

The importance of establishing and maintaining a productive therapeutic relationship requires the clinician to consider the personality style and personality psychopathology of each patient. Personality fundamentally affects interpersonal relations, and personality pathology is always associated with significant interpersonal impairment in areas such as empathy and intimacy [2]. The therapeutic alliance, a measurable conceptualization of the therapist-patient relationship, is one of the most robust predictors of outcome in psychotherapy [3-7]. Personality difficulties can significantly affect the alliance, contributing to ruptures that must be attended to carefully [8].

This topic describes common treatment issues, problems, and opportunities in the clinician-patient therapeutic relationship. Establishing and maintaining a therapeutic relationship in psychiatric practice are described separately. The epidemiology, clinical manifestations, diagnosis, and treatment of specific personality disorders are also discussed separately. (See "Establishing and maintaining a therapeutic relationship in psychiatric practice" and "Overview of personality disorders" and "Antisocial personality disorder: Epidemiology, clinical manifestations, course and diagnosis" and "Treatment of antisocial personality disorder" and "Borderline personality disorder: Epidemiology, clinical features, course, assessment, and diagnosis" and "Treatment of borderline personality disorder".)


Studies have shown that the quality of a patient’s interpersonal relationships in general significantly affects the building and nature of the therapeutic relationship [9-11]. The clinician should consider an individual’s characteristic way of relating, so that appropriate interventions (regardless of modality) can be made to effectively retain and involve the patient in the treatment. Forming a relationship with a patient is often difficult, however, particularly in work with patients with severely narcissistic, borderline, or paranoid personality characteristics, because troubled interpersonal attitudes and behaviors will affect the patient’s engagement with the therapist.

Diagnostic clusters of DSM-5 personality disorders are useful in considering issues related to the therapeutic relationship [12]. However, increasing evidence suggests that the DSM categories and clusters do not adequately capture the complexity of character pathology traits and symptoms. Patients often meet criteria for two or more personality disorders, perhaps spanning different clusters, such as the co-occurrence of schizotypal personality disorder with borderline personality disorder or borderline personality disorder with avoidant personality disorder [13], or a patient may not meet full criteria for any one disorder, but has prominent features associated with one or several personality disorders. Personality and personality pathology are often viewed dimensionally. Whether or not a patient meets full criteria for a specific DSM-5 personality disorder, knowledge of his or her personality traits and patterns of personality functioning are critical for building and maintaining a therapeutic relationship.

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Literature review current through: Nov 2017. | This topic last updated: Sep 02, 2016.
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