The existing evidence base most strongly supports the use of dynamic psychotherapy, variants of cognitive-behaviour therapy (particularly dialectical behaviour therapy) and therapeutic communities in the treatment of personality disorders, with the usefulness of the latter being limited by its inaccessibility. Quite how much change occurs in the core features of personality disorders in response to psychotherapy remains a moot point since completed research has often failed to differentiate this from amelioration of comorbid conditions. However, we have enough evidence to support the conclusion that psychological therapies can effect sufficient change in individuals with a range of personality disorders, generally coexisting with other difficulties, to improve their quality of life.

Bateman & Tyrer (2002) identify the core features of psychological therapies that have demonstrated efficacy with personality disorders. They:

• are well structured;

• emphasise the facilitation of compliance;

• are theoretically coherent for both therapist and patient;

• are relatively long term;

• encourage strong attachment between therapist and patient; and

• are integrated with other services available to the patient.

We would expect all effective therapy to fulfil the first four criteria, but the remaining three are also essential if we are to assist people who, as Rutter suggests, struggle most fundamentally with the challenge of forming and maintaining healthy relationships.

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