Mark L. Ruffalo, MSW, DPsa
Editor in Chief, The Carlat Psychotherapy Report. Psychotherapist in private practice in Tampa, Florida. Instructor of Psychiatry at the University of Central Florida College of Medicine and Adjunct Instructor of Psychiatry at Tufts University School of Medicine.
Borderline personality disorder (BPD) is a severe mental illness affecting roughly 0.7 to 2.7% of the population (Leichsenring F et al, JAMA 2023;329(8):670-679). This can be even higher in psychiatric care settings, ranging from 10% in outpatient settings to 20% in the inpatient setting (Zimmerman M et al, Am J Psychiatry 2005;162(10):1911-1918; Zimmerman M et al, Psychiatr Clin North Am 2008;31(3):405-vi). Tragically, up to 10% of those with BPD will lose their lives to suicide (Paris J, Medicina (Kaunas) 2019;55(6):223).
The societal impact of BPD is substantial. In fact, it’s more than double the costs connected with depression (Soeteman DI et al, J Clin Psychiatry 2008;69(2):259-265). The treatment of choice is psychotherapy, although medications can also play a role in managing symptoms. Specifically, transference-focused psychotherapy, a psychodynamic treatment introduced by Kernberg and his team in the 1970s and 80s, has proven to be as effective as more well-known therapies in treating BPD, such as dialectical behavioral therapy (DBT) (Clarkin JF et al, Am J Psychiatry 2007;164(6):922-928; Clarkin JF et al, Am J Psychotherapy 2022;76(1):39-45; Leichsenring F et al, JAMA 2023;329(8):670-679). Psychodynamic therapies in general have a long history in the treatment of BPD.
The Psychodynamics of BPD
BPD is often recognized by a conflicted sense of self and others and intense emotional reactions. This “split psychological structure” leads to the “black-and-white thinking” often associated with the disorder. Instead of thinking in shades of grey, patients see things as all good or all bad (Stern B and Yeomans F, 2023). Patients with BPD alternate between these two extremes depending on time and circumstance; they cannot seem to integrate their feelings about themselves and others. These symptoms often develop in the context of abusive and traumatic childhood experiences and can be considered pathological defenses against anxiety (McWilliams N. Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process, 2nd ed. Guilford; 2011).
“Maya,” a 29-year-old woman, seeks therapy following a series of intense but short-lived relationships. Initially in relationships, she feels ecstatic, as if she's met her soulmate. But as partners seek normal personal space, Maya perceives it as rejection. Her thoughts oscillate: "He truly loves me" to "He's going to leave me."
Feeling too close, Maya panics and pushes her partner away. Yet, when given space, she feels profoundly abandoned, leading her to act out by being overly clingy or distant. This pattern also emerges in therapy: Maya alternates between praising her therapist for understanding her and feeling slighted over minor issues.
Maya's past reveals that her understanding of love is intertwined with pain due to inconsistent caregiving. She craves closeness but her actions, driven by her black-and-white thinking, often precipitate the very abandonment she dreads.
As mentioned earlier, this way of thinking drives a chaotic pattern in relationships. The person with BPD might idealize a partner, only to later feel trapped and act out destructively. This cycle often repeats with different partners, leading to significant relational chaos. A key to the treatment of borderline symptoms (discussed below) is examining this cycle as it plays out in the treatment relationship itself.
Nancy McWilliams describes it this way: “Borderline clients seem caught in a dilemma: When they feel close to another person, they fear engulfment and total control; when they are alone, they feel traumatically abandoned. The central conflict of their emotional experience results in their going back and forth in relationships, including the therapy relationship, in which neither closeness nor distance is comfortable.” (McWilliams N. Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process, 2nd ed. Guilford; 2011).
For these patients, love often equals pain. When relationships are stable, they may feel anxious and disrupt the calm—for them, love is associated with hurt. Indeed, one of the great paradoxes of BPD is that while fear of abandonment dominates, those with the disorder often act in ways that make abandonment more likely.
Treating BPD: What to consider
The psychodynamic treatment of BPD requires careful patient selection. Keep in mind that your patient must be capable of expressing themselves and reflecting on their thoughts and feelings; be of at least average intelligence; and not so severely ill as to require a more intensive or directive method of treatment. If antisocial tendencies are present, it could make treatment more challenging (Kernberg OF et al. Psychodynamic Psychotherapy of Borderline Patients. Basic Books; 1989). As always, a thorough evaluation for the presence of other mental disorders should be conducted.
Adhering to the basic ground rules of therapy (the psychotherapy “frame”) is essential. Since patients with BPD may test the therapist, staying true to the structure of therapy is crucial (Kernberg OF et al, 1989). This includes dealing with any deviation from the set frame, such as contact outside of the scheduled therapy hour or failure to pay the fee. Some psychodynamic therapists utilize a written contract in work with patients with BPD.
The therapist's skill in handling and interpreting repeated relational patterns plays a significant role in therapeutic change. A basic premise of psychodynamic therapy is that the patient’s patterns will play out with the therapist. Transference-focused psychotherapy focuses largely on this phenomenon, the understanding and resolution of which reflects the main element of treatment.
Clinical Vignette: Maya in Therapy
At the onset of therapy, Maya’s therapist ensures that she understands and agrees to the basic ground rules. A written contract is drawn up, outlining the framework of their sessions, including boundaries on contact outside of scheduled appointments and the necessity of timely payments.
However, as sessions progress, Maya begins to test the boundaries of this agreement. She occasionally sends late-night texts to her therapist, expressing distress or seeking immediate validation. When confronted about these messages, Maya becomes defensive, suggesting that the therapist doesn’t genuinely care about her.
In one session, after missing a payment, Maya attempts to manipulate the situation by bringing up her tumultuous past, insinuating that the therapist's insistence on the fee indicates a lack of compassion. However, the therapist calmly but firmly adheres to the previously agreed upon framework.
Maya's interactions with her therapist soon begin to mirror her previous relationships. She oscillates between viewing her therapist as the only one who truly understands her to feeling betrayed over perceived slights.
The therapist consistently works to recognize and interpret these repeated relational patterns. During one session, Maya's reactions to the therapist’s brief vacation is explored in depth. Maya’s feelings of abandonment and subsequent resentment mirror her reactions in her romantic relationships. With the therapist's guidance, Maya starts recognizing these patterns, leading to insightful discussions on her intense emotional swings and fears.
Through transference-focused psychotherapy, the therapist helps Maya see the patterns playing out in their own relationship, enabling her to confront and understand her fears, insecurities, and behavior.
The role of transference and countertransference
Transference (when a patient projects feelings about others onto the therapist) and countertransference (when a therapist projects feelings onto the patient) are central to psychodynamic therapy. In BPD, the patient will project onto the therapist their conflicted feelings about themselves; specifically, these patients’ characteristic use of splitting as a defense will manifest in their day-to-day interactions in psychotherapy.
Therapists, too, must be wary of their own reactions, including anger and frustration, and avoid falling into the trap of dismissing patients with BPD as “difficult” or harboring unrealistic beliefs about their ability to cure the patient. The therapist who dismisses patients because they find them too challenging may be participating in an acting out of the patient’s psychodynamics.
Missteps in the management of countertransference, such as believing that the therapist alone can save the patient, can lead to serious problems (Kernberg OF et al, 1989). For instance, a therapist may not consider psychiatric hospitalization as an option following a serious suicide attempt but may instead immediately make herself available to the patient to protect him from his impulses. She believes that were he to be admitted to the hospital, the staff would underestimate the severity of his condition and be less attentive to him than she. The consequences of such unresolved rescue fantasies are often disastrous.
Clinical Vignette: Maya in Therapy—Transference and Countertransference
Maya enters therapy with clear rules laid out in a written contract. As sessions unfold, her pattern of idealizing and devaluing others begins to manifest with her therapist. One day, she praises the therapist for being the only one who truly understands her. A week later, after a small perceived slight, she accuses the therapist of being just like everyone else, uncaring and dismissive.
This intense transference makes therapy sessions charged. Maya projects her conflicted feelings about significant figures from her past onto the therapist. For instance, when the therapist brings up the missed payments, Maya sees it as a replication of past neglect or rejection she felt from her parents.
The therapist, in turn, sometimes struggles with countertransference. Maya's intense emotions occasionally provoke feelings of frustration and, at other times, a deep urge to rescue. After one particular session, where Maya expresses despair and hints at suicidal ideation, the therapist feels an overwhelming need to save Maya from her pain. Instead of considering psychiatric hospitalization, the therapist offers additional sessions and constant availability.
This decision, driven by the therapist's unresolved rescue fantasy, reflects countertransference. It sidesteps the genuine need for a more comprehensive intervention. The therapist's belief that only they can truly help Maya, and that hospital staff might be negligent, mirrors Maya's own black-and-white thinking. Such decisions risk entangling the therapy process in Maya's psychodynamics, potentially leading to problematic outcomes.
It becomes crucial for the therapist to recognize these dynamics, manage their own reactions, and remain committed to the therapeutic framework, avoiding the pitfalls of their countertransference.
Psychodynamic psychotherapy provides a comprehensive method of understanding and treating borderline personality disorder, shedding light on the intricate emotional world of those who suffer from this challenging condition. It represents an important treatment option alongside pharmacotherapy, DBT, and some other psychotherapies. Transference-focused psychotherapy, a psychodynamically derived treatment, has a particularly strong evidence base.
It is important to remember that most patients with BPD improve or recover. Psychiatrist Michael Stone’s remarkable longitudinal research on BPD, following some patients in his private practice for more than 50 years, shows that two-thirds of patients eventually achieve either clinical remission or clinical recovery (Stone MH, Psychodyn Psychiatry 2016;44(3):449-474.).
Carlat Verdict: Psychodynamic therapy has a long and rich history in the treatment of borderline personality disorder. It represents an effective and evidence-based treatment for this condition, and it may be the treatment of choice for certain patients with BPD.
References in order of appearance in this article
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Zimmerman M et al, Rothschild L, Chelminski I. The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry. 2005;162(10):1911-1918. doi:10.1176/appi.ajp.162.10.1911
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Paris J. (2019). Suicidality in Borderline Personality Disorder. Medicina (Kaunas, Lithuania), 55(6), 223. https://doi.org/10.3390/medicina5506022
Soeteman, D. I., Hakkaart-van Roijen, L., Verheul, R., & Busschbach, J. J. (2008). The economic burden of personality disorders in mental health care. The Journal of clinical psychiatry, 69(2), 259–265. https://doi.org/10.4088/jcp.v69n0212
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Clarkin JF, Meehan KB, De Panfilis C, Doering S. Empirical Developments in Transference-Focused Psychotherapy. Am J Psychother. 2023;76(1):39-45. doi:10.1176/appi.psychotherapy.20220017
Stern B, Yeomans, F. The concept of personality disorders in general and borderline personality disorder. Accessed July 23, 2023. https://borderlinedisorders.com/borderline-personality-disorder-overview.php
McWilliams N. Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process. 2nd ed. Guilford; 2011.
Kernberg OF, Selzer, MA, Koenigsberg, HW, Carr AC, Applebaum AH. Psychodynamic Psychotherapy of Borderline Patients. Basic Books; 1989.
Stone M. H. (2016). Long-Term Course of Borderline Personality Disorder. Psychodynamic psychiatry, 44(3), 449–474. https://doi.org/10.1521/pdps.2016.44.3.449
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