Recent political initiatives in England and Wales have increased the focus on providing clinical services for personality disordered individuals. Increased attention on those identified as having dangerous and severe personality disorder (DSPD) has led to the piloting of specialist services to trial new assessments and interventions for the DSPD group in both health and prison settings. This article outlines the development and provision of clinical services for those within The Peaks, the DSPD pilot service within Rampton Hospital. The Peaks, the first new-build health-based unit, aims to provide a comprehensive service specifically focused on addressing the full range of clinical and criminogenic needs of those within the DSPD group. The philosophical underpinnings of the unit and the practical components of the service provided are described.

This paper has been written following an influential therapeutic encounter that we experienced while working with an emotionally distressed woman. The barriers that can get in the way of providing a structured therapeutic approach are discussed. The paper focuses on dialectical behaviour therapy as a treatment model, and discusses how the concept of ‘dialectics’ provide an over‐riding context for case conceptualisation (Linehan, 1993). The dialectical dilemmas and powerful dynamics that can be enacted between individuals, teams and patients in their endeavours to cope with distress will be illustrated. The dialectical philosophy is described and elaborated upon, providing a framework for the synthesis of clinical interpersonal encounters and metaphorical concepts of a therapy seesaw. The paper discusses how these ideas can guide us in our work with emotionally distressed individuals.

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