This chapter considers how to care for patients who meet the criteria for a diagnosis of personality disorder. We reflect on the role of the psychiatrist in creating a resilient, honest and caring clinical environment, delivering interventions in a considered and coherent manner. Central to this is the relationship between doctor and patient, which includes not only direct clinical care but also the orchestration of work across the multi-disciplinary team and other agencies through clinical leadership.

We approach personality disorders as a relational problem in which the patient experiences their difficulties through their relationships with themselves and the world around them. These difficulties often, though not exclusively, are a developmental consequence of adverse childhood experiences, brought to life within the therapeutic relationship itself. This inevitably means the work is challenging, but it also means that the way we comport ourselves and lead becomes central to the therapeutic culture.

Much has been written on the challenges of working with people who are diagnosable with personality disorder, but perhaps less acknowledged is how these challenges represent not only the very material fundamental to our primary task but also the reason it is such rewarding work given the right circumstances.