The Axis II group: treating severely characterologically disturbed patients

Treating the chronically mentally ill involves not only working with patients suffering from schizophrenia and other prolonged or recurrent psychotic illnesses, it also means providing treatment for patients with severe personality disorders. Many of these patients are also active substance abusers. This article examines the therapeutic and management issues raised for outpatient clinicians who work with these patients. Consideration is devoted to the special problems in treating the dual diagnosis patient, issues of patient and therapist safety, limit setting, splitting dynamics, and countertransference reactions. A set of recommendations is offered for conducting outpatient group therapy, specifying what is needed from both the clinicians and the facility in which this type of treatment is provided.