Managing Mistrust, Paranoia, and Relationship Rupture

Abstract

Therapeutic alliance is an important mediator of treatment effectiveness across disorders. Yet patients with BPD have specific difficulties with forming stable, trusting bonds, and may experience significant suspiciousness or paranoia, particularly during times of stress. In this context, establishing a trusting relationship can feel like a fast-moving target for both clinicians and patients. Conceptualizing the symptom of paranoia within the framework of interpersonal hypersensitivity is helpful for delivering effective psychoeducation to patients, and for maintaining compassion and mitigating burnout for clinicians. Clinicians working with individuals who have difficulty with interpersonal trust should provide psychoeducation early, be clear about expectations for active collaboration, and be active but not reactive when alliance is ruptured. The expectation for change should not be lost in the struggle to form a trusting relationship, and clinicians must be reflective about whether treatment is helping and should continue (or begin again, in the case of termination). In addition, prescribers should be cautious and judicious about the use of antipsychotic medications.