PERSONALITY DISORDERS – PARTICULARITIES OF THE THERAPEUTIC ALLIANCE

The  human  being  represents  a  concept  of  a particular complexity which builds himself and determines himself in life’s roles also according to how it relates to those around him. On the way of self-becoming it is gradually structuring a subjective identity that communicates, next to which the rational, spiritual, value and moral components of the person are maturing (1).

For two centuries the concept of person is focused on the personality one. In the version belonging to normality, the latter integrates harmoniously the diversity of temperamental and characterial dimensions, it adapts and functions efficiently in existential roles, adheres to community values structuring itself gradually the conscious of its own value and it assimilates the moral norms and those of the common sense.

The versions belonging to abnormality – pathological personalities – are dominated by an adaptive impairment – due to structural disharmony – in all the existential roles and by resistant and persistent interpersonal relationship difficulties at the therapeutic approach attempts. This the more so as frequently there are different versions of association between types of personality disorders and a multitude of comorbidity conditions (2).

Consequently, deviant psycho-behavioral manifestations of pathological personalities determine important social costs and stress intensely healthcare and social care services (3, 4).

Thus,  in  spite  of  a  variably  motivated  and sometimes objective reluctance – psychiatrists and their collaborators resort to a diversity of therapeutic intervention methods aiming to improve the behavioral- adaptive impairment. There are used psycho- pharmacological, psycho-therapeutic and socio- therapeutic techniques which are associated or alternated within certain complex programs and strategies that engage a therapeutic team composed both of psychiatrists and psychotherapists and also ex-patients and first degree relatives of the subjects.
The approach of personality disorders patients shaped like this, supposes the establishment of certain relationships of mutual acceptance, communication and collaboration between the members of the therapeutic team and patients within the therapeutic alliance (5, 6). This represents a completely particular endeavor taking into account the egocentrism and impairment of interpersonal relationship so characteristic to subjects with personality disorders, independently of the categorial version. Narcissistic, borderline, antisocial or paranoid traits make always difficult the formation of the therapeutic alliance (7, 8).
The approach of personality disorders patients shaped like this, supposes the establishment of certain relationships of mutual acceptance, communication and collaboration between the members of the therapeutic team and patients within the therapeutic alliance (5, 6). This represents a completely particular endeavor taking into account the egocentrism and impairment of interpersonal relationship so characteristic to subjects with personality disorders, independently of the categorial version. Narcissistic, borderline, antisocial or paranoid traits make always difficult the formation of the therapeutic alliance (7, 8).
Any therapeutic alliance must take into account the adaptive remaining dimensions or dimensional facets of patients and to select the ones on which the therapeutic effort must be focuses (9). It depends on the quality of the therapist-patient interpersonal relations, it supposes a c o n s c i o u s c o m m i t m e n t o f t h e t a s k s a n d t h e responsibilities, and defining certain clear purposes that integrate both the subjective well-being and the reinsertion – highly qualitative – in life’s roles (10). Purposes elaboration always precedes the emphatic respectively cognitive-motivational components of the therapist-patient relations (11).
Before any attempt of the formation of a therapeutic alliance they must be aware of the fact that patients with personality disorders lack of confidence, both in themselves and in those around them, and are dominated by a persistent attitudinal and motivational instability. Also, in more than half of the cases, there are associated at least two types of personality disorders.
On the other hand, the commitment of patients with pathological disorders into the therapeutic alliance may be done only by taking into account the current particularities of the diagnostic endeavour in which is envisioned the differentiation of temperamental and characterial traits, of the adaptive ones towards the non- adaptive ones, as well as the staged confirmation of the presence of diagnostic criteria. The accuracy of the diagnosis in the context of reference is higher at young ages – predominantly in case of Cluster A and B personality disorders – but criteria become more stable with aging. They often are less obvious in cluster C pathological personalities.
Patients with personality disorders may be engaged into a therapeutic alliance progressively and may be stimulated to be aware of the importance of this endeavor, the sequence of its stages and its benefits as they pass through them. Their participation is favored by dimensional dominants as the solitude, the sensitivity or the need of personal achievement. Thus, subjects with Borderline personality disorder (BPD), Histrionic personality disorder (HPD), Dependent personality disorder DPD) and Avoidant personality disorder (APD) wait or invoke the empathy and support messages to compensate the feelings of incompleteness, indecision, affective lability, anxious experiences and relational vulnerability. Narcissistic personality disorder (NPD) answer to empathic messages only when these do not undermine the basic need to feel appreciated. Antisocial personality disorder (ASPD) permit the initiation of therapeutic relations when is outlined a chance of satisfying the personal interests or when there are associated some Axis I comorbid conditions. In the case Obsessive compulsive personality disorder (OCPD) consciousness, fairness and the exacerbating sense of responsibility often favor the integration in a therapeutic relation.
In case of patients with Cluster A personality disorders there are few studies referring to the structuring and dynamics of the therapeutic alliance. Psycho and socio-therapeutic interventions are considered to be less efficient on a short term and practically with no results on a long term. They could be facilitated – in case of pathological personalities of schizoid and schizotypal type by the administration in small doses of neuroleptics about which it has been ascertained that it diminished the intensity of the reference ideas (12).
Patients with schizoid personality disorder (SPD) do not feel the need of interpersonal contacts and adopt a conventional behavior, organizing their live so as to avoid any kind of affective implication. Nevertheless it is considered that they have a characteristic subclinical sensitivity, unapparent with the need of establishing relations with attentively selected persons around them (13). The social involvement impairment and the condition of quasi-continuous solitude explain the low frequency and poor character in symptoms of anxious and affective depressive decompensations that could facilitate a therapeutic intervention. A similar contribution to this end has also the single status of the overwhelming majority of schizoid patients.
Schizotypal personalities may be integrated to the schizophrenias spectrum and are dominated by cognitive, affective and attitudinal oddness. Moreover, the poorness of the social support does not cultivate in them the need of communication. The richness of their imagination and the paranormal types of convictions may favor though a particular therapeutic relation in which the schizotypal involves himself also outside the programmed sessions. This happens because he interprets every word or gesture of the therapist and assigns them particular meaning which strengthens his conscious of an odd personal authority according to which he tries to control all the stages of the relation.
The pride, the hypersensitivity and the lack of empathy of paranoid personalities make very difficult the commitment in a therapeutic relation. On a short term basis communication may be established in the case of association of certain Axis I psychopathological symptoms or in existential situations which the subject cannot manage, when the therapist may intervene supportively and reconciliatory and may initiate an otherwise very fragile dialogue. The poor social support – attentively selected for that matter – and the frequent condition of divorced persons or in conflictive relations with the family members also affects any commitment in a therapeutic relation.
In case of Cluster B personality disorders commitment in a therapeutic alliance must take into account the subjects’ tendency to involve themselves or to give up spontaneously the interpersonal communication often with manifestations of an extreme intensity.
Patients with borderline type personalities have a poor structure of the Self that confers them a quasi- continuous feeling of incompleteness and uncertainty because of which they are always in search of interpersonal relations. They commit themselves to them and abandon them as easily. The extreme affective oscillations and the frequent self-destructive conducts put a t d i s a d v a n t a g e c o n s t a n t l y t h e i n t e r p e r s o n a l communication. The therapist is alternatively worshiped or rejected and denigrated and he must resist the pressure exercised by patients who put him in limit situations and disorganize his motivational system. He must be prepared to approach situations full of tension and hostility, and also to suggest patients that they can trust him and that the relationships between them will not change. The therapist’s capacity to restore the numerous moments in which the relationships with the patients are ready to crumble may represent the key of the therapeutic alliance consistency and persistence. But this fact supposes special empathic and moral dimensions that complete the specific professional training of the therapist.
Histrionic pathological personalities have a high need of being noticed and appeal to a great diversity of means of expression to this purpose. These traits favor at the beginning the therapeutic relation and the therapist’s opinions are rapidly assimilated also because of the low tolerance for frustration which maintains the need of immediate gratification. Therapeutic relations with histrionic personalities are similar to those of the borderline personalities so that the clinician must be prepared to answer to the diversity of the patients’ d e m a n d s a n d s i m u l t a n e o u s l y t o e x p e c t r a p i d abandonments on their part. Paroxysms full of drama and the superficiality of the emotions imprint constantly the therapeutic relation.
The high self-esteem, but fragile of the narcissistic pathological personalities compels them to compensatory self-investments with attributes of omnipotence and grandeur, and to search the admiration of the surrounding persons. In case of vulnerable or fragile narcissistic type, who is dominated by shame and guilt feelings and who invokes the discrete complimentary attention and approval of those around him, the therapeutic relation starts relatively easy. The therapist must comply with the subjects’ expectations and offer them the moral support of which their so fragile subjective well-being depends. The duration and the quality of the therapeutic relation depend hereinafter of the empathic involvement of the therapist who has to anticipate and to approach carefully the self-esteem oscillations. The incisive and grandiose type of narcissistic treats those around him as simple objects, pouring always on them his megalomaniac fantasies and manipulates them in an authoritative manner to maintain his self-image. The therapist does not infirm the rule to that effect, and he is deliberately ignored for variable periods of time or he must conform himself to become a source of personal gratifications for the subject. The therapeutic relation in this case is practically very difficult to establish except for some comorbid affective decompensations that may confer it a certain level of flexibility.
The antisocial personality disorder is a personologic model of pathological pride and impulsive behaviour, intimidating and violent in the relations with the persons around them. He is maintained and may be aggravated up to acts of sadism by the hypotrophy of the Super-ego and by not assimilating the norms of common sense. The antisocial – totally non-empathic – lacks of sense of measure and has an extreme intolerance for frustration because of which a priori the persons around him become potential victims. The authority in the interpersonal relations often tyrannical, next to its own interests, very hard to be satisfied, are reflected also upon the attempts of engaging the subjects into a therapeutic alliance. Nevertheless, this has been proved to be possible under the conditions of confinement – when antisocial personalities manipulate the therapist in view of obtaining undeserved privileges – that do not trigger however any trace of gratitude. Another version of the pseudo- therapeutic alliance may be described in case of the associations of some depressive episodes when the antisocial may display a certain disclosure and compliance within the relations with the therapist.
Cluster C pathological personalities are dominated on the whole by anxious experiences and by social phobias that determine them to avoid any conflictive situation in the interpersonal relations. This fact favors the engagement into a therapeutic alliance to a greater extent compared to the rest of the personality disorders.
T h e a v o i d a n t p e r s o n a l i t y d i s o r d e r i s characterized by an extreme social hypersensitivity because of which – in spite of an unconfessed desire of entering into contact with those around him – keeps away of any kind of interpersonal closeness and allows to the others to have initiative to that effect only when they are sure of the fact that they are accepted or liked by these. The defensive style is maintained also by the capacity of living intensely the feelings of shame and humility that make very difficult the engagement into a therapeutic relation. These patients may be seen as very similar to the vulnerable or hypervigilant subtype of narcissistic personalities who pretend admiration to maintain their f r a g i l e s e l f – e s t e e m . T h e r e c o g n i t i o n o f t h e s e particularities has a special importance in any version of therapeutic approach.
In the case of dependant type of personalities, their passive and submissive style in which avoid any attitude which might disturb those around them, even when they totally disagree with them, mark any therapeutic relation. The patients engage themselves easily in the communication with the therapist, but their fragile self-esteem imposes a constant supportive attitude on his behalf in order to always reconfirm the presence of the attachment. Avoidance of the interruption of the therapeutic relation imposes prompt and more complete information of the subjects and a constant empathic availability of the therapist.
It is characteristic to obsessive compulsive personalities the stable social relations supported by the attitudinal pride and rigors, as well as by the moral attitude. However these patients control permanently the relationships between their inner world and the outside world, and they are very demanding in initiating interpersonal contacts. Stubbornness and reticence before affective and empathic messages make them hard to engage into a therapeutic relation, but they may respect and cultivate it to a greater extent than other types of pathological personalities.
Altogether patients with personality disorders must be engaged into a therapeutic alliance as earlier as possible after the confirmation of the personological diagnosis. The members of the therapeutic team must take into account the fact that the subjects are often susceptible and guard themselves not be humiliated or offended. They frequently appeal to intellectualization and speak excessively about other persons, changing the subject of the discussion, in order to communicate less of half of the content of their personal thoughts and experiences.
When applying psycho and socio-therapeutic programs on reference patients, it must be taken into account the necessity to avoid transfer and interpretation phenomena on the part of the therapist, of different means of expression of the subjects, as well as the interventions of high-risk and high-gain type. During the stabilizing phases of the therapeutic relation, the supportive techniques must be associated with interpretative- expressive ones that may be useful at most of the patients engaged into the program.
F r o m t h e p e r s p e c t i v e o f t h e psychopharmacological component of the therapeutic alliance that supposes also the administration – associated with or independent of the psycho and socio-therapeutic techniques – of some psychotrope preparations, it is required the adoption of a reconciling style in order to gradually gain the patients’ collaboration, who may consider the drugs dangerous and who always overdimension both the proper effects and the side effects.
The great majority of the patients with personality disorders prefer or accept the commitment – under the said conditions – in the version within the hospital of a therapeutic relation and avoids it or underestimates in an obvious manner, the out of the hospital one.
Any therapeutic endeavor in the context of reference must take into account the importance of detecting the socio-demographic and cultural reference points that may favor it on a long term. It remains in the first and last resort a moral act by mutual engagement of virtues and vices of human nature, respectively by accepting, understanding and attempting to restore the individual destiny.

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