Approaches to the therapeutic relationship in patients with personality disorders
- Andrew Skodol, MD
Andrew Skodol, MD
- Section Editor — Personality Disorders
- Research Professor of Psychiatry
- University of Arizona College of Medicine
- Donna Bender, PhD
Donna Bender, PhD
- Clinical Professor of Psychiatry and Behavioral Sciences
- Tulane University
The relationship between a clinician and a patient in psychotherapy plays a central role in alleviating symptoms and fostering character change . 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 . 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 .
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 "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".)
PERSONALITY DISORDERS AND TRAITS
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 . 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 , 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.
- Orlinsky DA, Grawe K, Parks BK. Process and outcome in psychotherapy: Noch einmal. In: Handbook of Psychotherapy and Behavior Change, 4th ed, Bergin AE, Garfield SL. (Eds), Wiley, New York 1994. p.270.
- Bender DS, Morey LC, Skodol AE. Toward a model for assessing level of personality functioning in DSM-5, part I: a review of theory and methods. J Pers Assess 2011; 93:332.
- The Working Alliance: Theory, Research, and Practice, Horvath AO, Greenberg LS. (Eds), Wiley, New York 1994.
- Horvath AO, Symonds BD. Relation between working alliance and outcome in psychotherapy: a meta-analysis. J Couns Psychol 1991; 38:139.
- Horvath AO, Del Re AC, Flückiger C, Symonds D. Alliance in individual psychotherapy. Psychotherapy (Chic) 2011; 48:9.
- Horvath AO, Greenberg LS. Development and validation of the Working Alliance Inventory. J Counsel Psychol 1989; 36:223.
- Tracey TJ, Kokotovic A. Factor structure of the Working Alliance Inventory. Psychol Assess 1989; 1:207.
- Tufekcioglu S, Muran JC. A relational approach to personality disorders and alliance rupture. In: Integrated Treatment for Personality Disorder: A Modular Approach, Livesley WJ, Dimaggio G, Clarkin J. (Eds), Guilford Press, New York 2016. p.123.
- Connolly Gibbons MB, Crits-Christoph P, de la Cruz C, et al. Pretreatment expectations, interpersonal functioning, and symptoms in the prediction of the therapeutic alliance across supportive-expressive psychotherapy and cognitive therapy. Psychother Res 2003; 13:59.
- Hersoug AG, Monsen JT, Havik OE, Høglend P. Quality of early working alliance in psychotherapy: diagnoses, relationship and intrapsychic variables as predictors. Psychother Psychosom 2002; 71:18.
- Piper WE, Azim HF, Joyce AS, et al. Quality of object relations versus interpersonal functioning as predictors of therapeutic alliance and psychotherapy outcome. J Nerv Ment Dis 1991; 179:432.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
- McGlashan TH, Grilo CM, Skodol AE, et al. The Collaborative Longitudinal Personality Disorders Study: baseline Axis I/II and II/II diagnostic co-occurrence. Acta Psychiatr Scand 2000; 102:256.
- Colli A, Ferri M. Patient personality and therapist countertransference. Curr Opin Psychiatry 2015; 28:46.
- Lingiardi V, Tanzilli A, Colli A. Does the severity of psychopathological symptoms mediate the relationship between patient personality and therapist response? Psychotherapy (Chic) 2015; 52:228.
- Fonagy P, Allison E. The role of mentalizing and epistemic trust in the therapeutic relationship. Psychotherapy (Chic) 2014; 51:372.
- Horvath AO, Luborsky L. The role of the therapeutic alliance in psychotherapy. J Consult Clin Psychol 1993; 61:561.
- Gunderson JG, Najavits LM, Leonhard C, et al. Ontogeny of the therapeutic alliance in borderline patients. Psychother Res 1997; 7:301.
- Wnuk S, McMain S, Links PS, et al. Factors related to dropout from treatment in two outpatient treatments for borderline personality disorder. J Pers Disord 2013; 27:716.
- Lingiardi V, Filippucci L, Baiocco R. Therapeutic alliance evaluation in personality disorders psychotherapy. Psychother Res 2005; 15:45.
- Bender DS, Farber BA, Sanislow CA, et al. Representations of therapists by patients with personality disorders. Am J Psychother 2003; 57:219.
- Benjamin LS. Interpersonal Diagnosis and Treatment of Personality Disorders, 2nd ed, Guilford, New York 1996.
- Akhtar S. Broken Structures: Severe Personality Disorders and Their Treatment, Jason Aronson, Northvale, NJ 1992.
- Tufekcioglu S, Muran JC, Safran JD, Winston A. Personality disorder and early therapeutic alliance in two time-limited therapies. Psychother Res 2013; 23:646.
- Safran JD, Muran JC, Eubanks-Carter C. Repairing alliance ruptures. Psychotherapy (Chic) 2011; 48:80.
- Kernberg O. Borderline personality organization. J Am Psychoanal Assoc 1967; 15:641.
- Diamond D, Stovall-McClough C, Clarkin JF, Levy KN. Patient-therapist attachment in the treatment of borderline personality disorder. Bull Menninger Clin 2003; 67:227.
- Waldinger RJ, Gunderson JG. Completed psychotherapies with borderline patients. Am J Psychother 1984; 38:190.
- Horwitz L, Gabbard GO, Allen JG, et al. Borderline Personality Disorder: Tailoring the Psychotherapy to the Patient, American Psychiatric Press, Washington, DC 1996.
- McMain S, Boritz TZ, Leybman MJ. Common strategies for cultivating a positive therapy relationship in the treatment of borderline personality disorder. J Psychother Integr 2015; 25:20.
- Kohut H. The Restoration of the Self, International Universities Press, New York 1977.
- Kernberg OF. Severe Personality Disorders: Psychotherapeutic Strategies, Yale University Press, New Haven, CT 1984.
- Meissner WW. The Therapeutic Alliance, Yale University Press, New Haven, CT 1996.
- Stone MH. Abnormalities of Personality, WW Norton, New York 1993.
- Gerstley L, McLellan AT, Alterman AI, et al. Ability to form an alliance with the therapist: a possible marker of prognosis for patients with antisocial personality disorder. Am J Psychiatry 1989; 146:508.
- Gabbard GO. Psychodynamic Psychiatry in Clinical Practice, 4th ed, American Psychiatric Press, Washington, DC 2005.
- Bach S. The Language of Perversion and the Language of Love, Jason Aronson, Northvale, NJ 1994.
- BERLINER B. The role of object relations in moral masochism. Psychoanal Q 1958; 27:38.
- Smith SW, Levy SR, Hilsenroth MJ, et al. Relationship Between Patient SWAP-200 Personality Characteristics and Therapist-Rated Therapeutic Alliance Early in Treatment. J Nerv Ment Dis 2016; 204:437.
- Barber JP, Morse JQ, Krakauer ID, et al. Change in obsessive-compulsive and avoidant personality disorders following time-limited supportive-expressive therapy. Psychotherapy 1997; 34:133.
- Dickinson KA, Pincus AL. Interpersonal analysis of grandiose and vulnerable narcissism. J Pers Disord 2003; 17:188.
- Hummelen B, Wilberg T, Pedersen G, Karterud S. The relationship between avoidant personality disorder and social phobia. Compr Psychiatry 2007; 48:348.
- Pos A. Emotion focused therapy for avoidant personality disorder: Pragmatic considerations for working with experientially avoidant clients. J Contemp Psychother 2014; 44:127.
- Shapiro D. Neurotic Styles, Basic Books, New York 1965.
- Mancebo MC, Eisen JL, Grant JE, Rasmussen SA. Obsessive compulsive personality disorder and obsessive compulsive disorder: clinical characteristics, diagnostic difficulties, and treatment. Ann Clin Psychiatry 2005; 17:197.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised. Washington, DC, American Psychiatric Association, 1987.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, American Psychiatric Association, Washington, DC 1994.
- Wetzler S, Morey LC. Passive-aggressive personality disorder: the demise of a syndrome. Psychiatry 1999; 62:49.
- PERSONALITY DISORDERS AND TRAITS
- Cluster A
- - Schizotypal
- - Schizoid
- - Paranoid
- Cluster B
- - Borderline
- - Narcissistic
- - Histrionic
- - Antisocial
- - Sadomasochistic character
- Cluster C
- - Dependent
- - Avoidant
- - Obsessive-compulsive
- - Passive-aggressive
- THERAPEUTIC ALLIANCE
- SUMMARY AND RECOMMENDATIONS