background The working alliance between therapist and patient has been investigated frequently, but much less is known about the working alliance in specific patient groups in specific settings.
aim To obtain insight into the characteristics of the working alliance in intensive inpatient psychotherapy involving patients with severe personality disorders, and to pay special attention to patient characteristics such as diagnosis and attachment.
method At the end of the first phase of treatment we collected, on the basis of questionnaires, information about the working alliance and attachment of 60 patients with a severe personality disorders who had received inpatient psychotherapy.
results Working alliances with therapist and team were found to be weaker than in outpatient populations; working alliances with the therapist proved to be stronger than working alliances with the treatment team. Cluster C patients developed a better working alliance with the treatment team than did cluster B patients, particularly in the domain of treatment goals. Patients in this study turned out to be attached more anxiously and ‘avoidantly’ than patients in general outpatient populations; no correlation was found between patients’ attachment and the strength of the working alliance. However, when a distinction was made between patients with extreme scores and patients with average scores, results showed that the more anxiously patients felt attached, the higher were their scores for their working alliance with the treatment team.
conclusion It is more difficult to establish a working alliance with patients who have a severe personality disorder than with patients suffering from a less severe personality disorder. Patients with a severe personality disorder seemed to show a higher degree of anxious attachment and to have a more critical attitude to the working alliance.