Establishing an optimal working relationship with patients with an antisocial personality disorder. Aspects and processes in the therapeutic alliance

Abstract

ObjectiveDeveloping good interpersonal relationships is one of the main impediments for people with an antisocial personality disorder (ASPD). However, in treatment of psychiatric disorders, establishing a strong therapeutic alliance (TA) is important for effective treatment. Nevertheless, there is little knowledge on how to establish this TA with this challenging patient group. This study investigates which factors are important in TA development.MethodFor this study, a qualitative research methodology is applied. In‐depth interviews with therapists experienced in treating ASPD were conducted and analysed through thematic analysis.ResultsThe analysis revealed six themes important in alliance formation: the patient's needs, regulating interpersonal dynamics, connective attitude, connective skills, treatment process and treatment goals. Each theme is defined including aspects of the recommended therapeutic attitude and required skills for therapists working with patients with ASPD.ConclusionsThis study determined that, for therapists working with patients with ASPD, several key factors are essential in establishing a strong TA. These factors include the ability to be firm, authentic, non‐judgmental and genuinely involved. An attentive presence is crucial, in which the therapist takes initiative in establishing contact and makes the patient feel that he is truly seen as an autonomous and equal person. In doing so, the therapist needs to provide clarity and structure while remaining perceptive to boundary violations. The therapist must be able to set limits using a clear yet kind tone of voice. Furthermore, it was notable that an intensive appeal is made to the therapist's reflective capacity in these treatments.

Antisocial personality disorder and therapeutic pessimism – how can mentalization-based treatment contribute to an increased therapeutic optimism among health professionals?

“…It appears to be particularly difficult to establish a good working alliance with individuals with ASPD, primarily because of treatment-rejecting behavior and characteristics that affect the therapeutic relationship negatively. However, recent studies have identified factors related to establishing a positive therapeutic alliance such as tailoring the treatment, being attentive, authentic and non-judgmental, together with maintaining a firm stance or uphold boundaries ( Morken et al, 2022 ; Aerts et al, 2023 ).…”

Transgressive incidents targeted on staff in forensic psychiatric healthcare: a latent class analysis

“…Long-term consequences may include increased burnout rates, as shown in forensic mental healthcare workers (3)(4)(5). Apart from adverse consequences for healthcare workers, transgressive behavior can hinder therapeutic progress of the patient, potentially prolonging treatment due to disruptions in the clinical atmosphere (e.g., revocation of privileges) and/or the induction of fear and stress among professionals (6,7). Hence, preventive measures are needed (1,8).…”