From the Guidelines
The best approach to communicate with a patient with a personality disorder is to maintain a consistent, calm, and non-judgmental demeanor while establishing clear boundaries. Begin by actively listening to understand their perspective and validate their feelings without necessarily agreeing with their interpretation of events. Use direct, simple language and avoid ambiguity that could be misinterpreted. Structure interactions with predictable patterns and be transparent about treatment plans and expectations. When setting limits, do so firmly but respectfully, explaining the rationale behind decisions. It's essential to remain professional even when faced with challenging behaviors, avoiding defensive reactions or power struggles. Team-based approaches can be helpful, with consistent messaging across all healthcare providers. Different personality disorders may require specific adaptations - for example, patients with borderline personality disorder often benefit from dialectical behavior therapy techniques that balance acceptance with change, while those with narcissistic traits may respond better to empathic validation before addressing problematic behaviors. The scientific basis for this approach lies in understanding that personality disorders involve deeply ingrained patterns of perception and behavior, and effective communication creates a secure therapeutic relationship that can gradually help patients develop more adaptive interpersonal skills, as supported by studies such as 1 and 1.
Some key points to consider when communicating with patients with personality disorders include:
- Establishing a collaborative approach to set an agenda for conversations, as recommended by 1 and 1
- Providing information that is timely and oriented to the patient’s concerns and preferences for information, and checking for patient understanding, as suggested by 1
- Responding empathically when patients display emotion, as recommended by 1
- Using dialectical behavior therapy techniques for patients with borderline personality disorder, as supported by 1 and 1
By following these guidelines and adapting communication strategies to the specific needs of each patient, healthcare providers can create a supportive and non-judgmental environment that promotes positive outcomes and improves quality of life for patients with personality disorders.
From the Research
Approaches to Communicating with Patients with Personality Disorders
- The therapeutic alliance is crucial in the treatment of patients with personality disorders, as it can predict more successful treatment outcomes 2.
- Clinicians should consider the patient's characteristic way of relating to select appropriate interventions and effectively retain and involve the patient in treatment 2.
- Patients with different personality disorders require different approaches:
- Cluster A personality disorders (schizotypal, schizoid, and paranoid): focus on building an alliance despite profound impairment in interpersonal relationships 2.
- Cluster B "dramatic" personality disorders (antisocial, borderline, histrionic, and narcissistic): exercise great care to avoid crossing inappropriate lines and pushing the limits 2.
- Cluster C "anxious/fearful" personality disorders (avoidant, dependent, and obsessive-compulsive): capitalize on the patient's willingness to take responsibility for their dilemma and engage with the therapist 2.
Tips for Interacting with Patients with Personality Disorders
- Organize care in a safe and predictable manner to prevent upsetting the patient 3.
- Maintain an investigative and inviting attitude while setting clear boundaries 3.
- Monitor the quality of the therapeutic relationship and restore it if necessary 3.
- Be firm, authentic, non-judgmental, and genuinely involved in the therapeutic relationship 4.
- Provide clarity and structure while remaining perceptive to boundary violations 4.
Therapeutic Interventions and Alliance
- Transference interpretations can enhance or deteriorate the therapeutic alliance, depending on the strength of the alliance 5.
- Defense interpretations and supportive interventions can enhance therapeutic work without increasing defensiveness 5.
- Supportive interventions can prepare the way for exploration and repair ruptured alliances 5.
- Dialectical behavior therapy and psychodynamic therapy are effective treatments for borderline personality disorder, with medium effect sizes 6.