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Background: There is a wealth of evidence to suggest that the Borderline Personality Disorder (BPD, or similar Emotionally Unstable Personality Disorder, EUPD) construct is harmful. We provide a commentary on the ideas expressed in the May Debate issue, highlighting both concerns and alternatives. Method: We bring together lived experience, clinical, and research expertise. This commentary was written collaboratively drawing on all these sources of evidence. Results: We outline evidence that the BPD construct is invalid, harmful, not necessary for effective treatment and a potential block to the development and evaluation of alternatives. Conclusions: We ask readers to consider these concerns, perspectives, and ideas.

It is well-established that there is a fundamental need to develop a robust therapeutic alliance to achieve positive outcomes in psychotherapy. However, little is known as to how this applies to psychotherapies which reduce suicidal experiences. The current narrative review summarizes the literature which investigates the relationship between the therapeutic alliance in psychotherapy and a range of suicidal experiences prior to, during and following psychotherapy. Systematic searches of MEDLINE, PsycINFO, Web of Science, EMBASE and British Nursing Index were conducted. The search returned 6,472 studies of which 19 studies were eligible for the present review. Findings failed to demonstrate a clear link between suicidal experiences prior to or during psychotherapy and the subsequent development and maintenance of the therapeutic alliance during psychotherapy. However, a robust therapeutic alliance reported early on in psychotherapy was related to a subsequent reduction in suicidal ideation and attempts. Study heterogeneity, varied sample sizes and inconsistent reporting may limit the generalisability of review findings. Several recommendations are made for future psychotherapy research studies. Training and supervision of therapists should not only highlight the importance of developing and maintaining the therapeutic alliance in psychotherapy when working with people with suicidal experiences, but also attune to client perceptions of relationships and concerns about discussing suicidal experiences during therapy.