This chapter focuses on services for people who have ‘severe’ personality disorder, in which personality-related problems are complex and associated with grossly impaired social functioning and/or risk of severe harm to self or others (Tyrer & Johnson, 1996; Crawford et al, 2010). Although people with less severe forms of personality disorder can and often do benefit from interventions and treatments, those with severe personality disorder are more difficult to engage with services, more likely to drop out of contact and less likely to benefit from standard treatments (Crawford et al, 2009a). The nature of personality disorder and the challenges associated with providing services for people with such disorder have meant that standard approaches to delivering psychosocial treatments have had to be modified. For those with more severe problems, specialist treatment services are increasingly being provided. These aim to structure treatment to better help people who often have very complex needs. However, even these services do not engage many of those referred to them, and further work is needed to establish optimal methods for helping people with severe personality disorder.

Challenges to the development of therapeutic Relationships

It is in the nature of personality disorder that those affected have difficulties in relationships with others and that these difficulties are generally manifested in relationships with healthcare professionals. Previous experiences of inconsistent or abusive care lead some people with severe personality disorder to experience the neutral actions of others as dismissive or threatening and to have concerns that professional carers may try to abandon or harm them. Such reactions can make it harder for professionals to form a therapeutic alliance with them. The tendency of individuals with severe personality disorder to separate out people and relationships into extreme forms of good or bad (Kernberg, 1984), and the ways that staff respond to this ‘splitting’, can make it difficult for teams to deliver a consistent and reliable service.