Borderline Personality Disorder

Anthony W. Bateman

In 1938, an American psychoanalyst, Adolph Stern, identified a group

of patients who did not respond to classical psychoanalytic treatment. He
described a constellation of symptoms found in this group closely related to
the current diagnostic criteria of borderline personality disorder (BPD) and
referred to the patients as the “border line group.” He later described mod-
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ifications of psychotherapy for his borderline group that remain relevant

today (Stern, 1945). In doing so, he started a search for more effective treat-
ments that continues to this day. Although there has been persistent pes-
simism over the years about the treatment of personality disorders, there is
increasing optimism about psychotherapeutic treatments for BPD, which
continues to be the only serious mental disorder for which the primary
treatment recommendation is psychotherapy (Oldham, Phillips, Gabbard,
& Soloff, 2001).
I discuss contemporary treatments later in the chapter, but first they
are placed in the context of earlier pioneering treatments that developed
within a different health care context but which continue to inform current
psychotherapies.

EARLY PIONEERS

The majority of early attempts to treat patients suffering from BPD fol-
lowed a psychoanalytic model primarily because this was the most influential
treatment paradigm for understanding personality disorder until the 1980s,
but second because the disorder was first described within a psychoanalytic
context. Given the common practice for psychoanalysts to publish case
material, it is not surprising that the early literature is full of individual case
reports commenting on the demanding nature of patients, their tendency to
break boundaries, and their propensity to regress. To address these problems,
more ambitious long-term treatments became the norm, aiming to effect per-
manent changes in personality structure.
Knight (1953) first described reasonable results for patients, many of
whom probably would today have a diagnosis of BPD, treated with psycho-
analysis in an inpatient context. Patients spent months or years in the hospi-
tal undertaking intensive psychotherapy, despite some senior clinicians noting
that long-term institutional care could be counterproductive, inducing regres-
sion and stimulating dependence rather than engendering independence. In
short, the predominance of long-term inpatient treatments led to the recogni-

588 ANTHONY W. BATEMAN

http://dx.doi.org/10.1037/12353-037
History of Psychotherapy: Continuity and Change (2nd Ed.), edited by J. C.
Norcross, G. R. VandenBos, and D. K. Freedheim
Copyright © 2011 American Psychological Association. All rights reserved.
 tion that intense emotional relationships could induce harm in patients with
BPD. However, regressive phenomena were not confined to inpatient settings
and similar observations were being made in outpatient settings with therapies
ending abruptly and without warning. Despite all these concerns it is clear that
some, but not all, patients benefited from long-term inpatient treatment,
although the evidence for this remains primarily descriptive and naturalistic
in nature (e.g., Tucker, Bauer, Wagner, Harlam, & Sher, 1987).
Gradually practitioners developed compelling theories, often based on
observed developmental origins of BPD, which were translated into treat-
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ments. Different theories led to contrasting emphases in approach, with

marked differences emerging between treatments for BPD. Kernberg (1967)
emphasized the low level of ego function in patients and the predominance
of primitive defense mechanisms deployed to manage excessive development
of early aggression and intolerable conflict. His treatment for BPD became
increasingly focused on these areas of psychological function, leading even-
tually to the development of transference-focused psychotherapy (TFP).
Kernberg suggested that the integration of split internal states, themselves
characteristic of BPD, was essential for improvement, and that interpretation
and insight were the primary techniques to effect this change. In contrast,
Kohut (1977) emphasized deficit, rather than conflict, as the core of narcis-
sistic and borderline patients and highlighted empathy and attunement in
treatment, rather than interpretation and insight, as the curative factors in
successful treatment.
Contemporaneously, other pioneers, such as Masterson (1981), Rinsley
(1980), and Gerald Adler (1985), developed psychotherapeutic treatments.
Whereas Masterson and Rinsley focused treatment on exploration of rela-
tional units, one being rewarding and the other being withdrawing and with-
holding, Adler was more concerned with the borderline patient’s inability to
develop and maintain a “holding-soothing” internal object. Exactly how these
differences in emphasis translated into variation in treatment itself is some-
what unclear. None of the treatments were carefully defined in terms of tech-
niques and principles until much later. But the major distinctions were related
first to the controversy between whether expressive or supportive techniques
should take primacy in treatment of BPD, and second to the concern about
the context in which treatment should take place.

The Menninger Project

This distinction between support and expression of underlying conflicts

was highlighted in the Menninger Project, and the debate is still alive today.
But it was the Menninger Project (Wallerstein, 1986), which began in 1954
as a prospective study and spanned a 25-year period looking at assessment,

PSYCHOTHERAPY FOR SPECIFIC DISORDERS 589

 treatment, and outcome, that fuelled the debate and continues to be an out-
standing example of detailed naturalistic observation. Forty-two patients
were selected for detailed study, some of whom were in psychoanalysis and
some in less intensive psychodynamic psychotherapy. The patients, their
families, and their therapists were subjected to a battery of tests; process notes
and supervisory records were kept that charted the progress of therapy.
(Wallerstein’s [1992] chapter in the first edition of this volume provides
details of the study.)
The conclusions about this group of patients were that the best form of
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therapy is supportive-expressive for however long it is necessary, a lifetime if

need be; that periods of hospitalization will be required alongside long-term
therapy; and that a network of informal supports, often centered around the
subculture associated with mental health centers, is also an important ingre-
dient if these patients are to survive at all, let alone thrive. These conclusions
have, to some extent, stood the test of time. Current psychotherapeutic treat-
ments emphasize the need for intervention to be well-structured, to devote
considerable effort to enhancing compliance, and to have a clear focus. That
focus may be problem behavior such as self-harm or a disruption of interper-
sonal relationship patterns. Treatments tend to be relatively long term and
to be well integrated with other services available to the patient.

Expressive and Supportive Techniques

Support, directiveness, and expressiveness are found in all psychother-

apies in different proportions. Following on from the Menninger Project,
debate in the 1970s focused on the level of direct support that a patient
required in treatment, the techniques that were believed to effect change, and
the level of emphasis recommended on actively fostering a therapeutic
alliance.
Establishing and maintaining a therapeutic alliance with a patient with
BPD is problematic although universally acknowledged as an essential part of
the framework for treatment. Masterson (1981), Modell (1968), and others
advocated supportive techniques rather than focusing on expressive work in
order to establish an alliance. In supportive work, a passive, opaque stance
is avoided and the therapist tries to provide an honest, open relationship,
combining warmth, empathy, and firmness. The therapist serves as a secure
container for the patients’ anxieties, experiences, and feelings. Positive trans-
ference is actively nurtured and not interpreted by the therapist. When neg-
ative reactions occur, the therapist has to accept the patient’s frustration,
anger, distress, and disappointment. Mistakes and misunderstandings are han-
dled with honesty and tact, with therapists owning up to their own contribu-
tion and some of their own imperfections.

590 ANTHONY W. BATEMAN

 This stance contrasts with the approach of Kernberg, who promoted a
more confrontational approach, addressing anxieties and negative responses.
He advocated more interpreting the distortions within the relationship
between the patient and therapist, so that the patient could view the ther-
apist more accurately and recognize that his or her reactions were governed
by past experiences rather than the current reality. Although the debate
about the most appropriate balance between expressive and supportive
techniques continues within the dynamically orientated therapies, more
emphasis is now being placed on the importance of repairing alliance rup-
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tures to prevent dropout from therapy, which hitherto had been unaccept-
ably high.

Therapeutic Communities

A related development to inpatient psychoanalytic treatment for person-

ality disorder, emerging as a treatment initially in response to the psychologi-
cal trauma of war, was the therapeutic community (TC). This is commonly
defined as a consciously designed social environment (Main, 1957) in which
the community itself becomes the primary therapeutic instrument through
processes of democratization, permissiveness, reality confrontation, and com-
munalism. Programs within the community often included a range of therapies
including small analytic groups, psychodrama, art therapy, music therapy, and
gestalt. The TC movement quickly adapted to treating people with personal-
ity disorders, initially within full-time residential settings but currently more
often operating as partial hospital programs. Most TCs succumbed to the
developing changes in health care in the 1980s. Proponents of the TC move-
ment were unable to gather robust evidence for their effectiveness over many
years, and the challenge of evidence-based treatment led to the closure of facil-
ities around the world. Recent valiant attempts to summarize the research that
has been done over the years (Lees, Manning, & Rawlings, 1999) and to rein-
vent TCs have met with limited success (Kennard, 1998). Yet spirited defenses
of the TC movement (Haigh, 2002) continue, suggesting that the focus on
helping people humanely and with compassion through a permissive milieu,
hallmarks of the movement, may be revived.

THE RISE OF OTHER PSYCHOTHERAPIES

The dominance of the psychoanalytic treatments for people with BPD

continued unchallenged for nearly 2 decades with few other practitioners tak-
ing an interest in the condition, perhaps because the patients continued to
be considered “heart sink” patients who were impossible to treat.

PSYCHOTHERAPY FOR SPECIFIC DISORDERS 591

 Cognitive Therapy

With the emergence of cognitive–behavioral therapy (CBT) for depres-

sion in the late 1970s, more as a result of dissatisfaction with the results of
psychoanalysis for neurotic patients than as a development of behavior ther-
apy, it was inevitable that attention would turn to cognitive understanding
of personality and personality disorders. Beck and Freeman (1990) published
Cognitive Therapy of Personality Disorders, and shortly after, Layden, Newman,
Freeman, and Morse (1993) laid out a more specific cognitive understanding
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of BPD. While maintaining the basic core of cognitive therapy as presented

by Beck (e.g., identifying automatic thoughts and beliefs typical of patients
with BPD), they identified an additional level of cognition and termed it the
schema. There was no consensus on definition: Some practitioners suggested
schemas were a mental filter or template that guided processing of informa-
tion, whereas others considered them as latent core beliefs. All agreed that
they were difficult to assess and to access in treatment to effect change.
These developments were predicated on the basis that unmodified CBT
was relatively ineffective with patients with personality disorder; just as
unmodified psychoanalysis had been found to be ineffective in BPD decades
earlier, so it was that unchanged CBT was also found to be wanting. How-
ever, traditional CBT continues to be developed and, to a certain extent,
there is an unhelpful schism between the modified CBT approaches and the
more traditional CBT practitioners, just as there is between some of the
dynamically orientated treatment developers (see later in this chapter).
Jeffrey Young (1990) challenged some of the traditional assumptions
associated with CBT—for example, that patients can change their problem-
atic cognitions and behaviors through empirical analysis, logical discourse, and
experimentation. In BPD he thought these techniques are undermined by per-
sistent self-defeating behaviors, and thus different techniques are required.
This led to the development of schema-focused psychotherapy (SFT) as a
more systematic approach to the maladaptive schemas associated with BPD.
There has thus been a profound change over time within the cognitive
tradition. Initially, personality disorders were at worst ignored or at best seen
as a collection of isolated symptoms such as cognitive distortions. This
changed to the view of personality as a disorder of interpersonal behaviors,
arising out of dysfunctional cognitive schemas and self-perpetuating cognitive-
interpersonal cycles.

Behavior Therapy

Behaviorists traditionally rejected the idea that personality traits could

determine behavior, preferring to think of actions as being determined by

592 ANTHONY W. BATEMAN

 situations. As a result, they paid little attention to personality disorders, con-
sidering personality variables as accounting for only a small component of the
variance in human behavior. But with the advent of the Diagnostic and Statis-
tical Manual of Mental Disorders (3rd. ed.; American Psychiatric Association,
1980) in which personality disorders were defined as “enduring patterns of per-
ceiving, relating to, and thinking about the environment and oneself” which
are “exhibited in a wide range of important social and personal contexts” and
“which are inflexible and maladaptive and cause significant functional impair-
ment or subjective distress,” behaviorists began to recognize that dysfunctional
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patterns and groups of symptoms might respond to behavioral methods.

As this recognition was gaining ground, principally in the treatment of
patients who attempted suicide or self-harmed, a further development was
taking place within the radical behavioral tradition. Behavioral practitioners
were dissatisfied with results of traditional behavioral methods for patients
with BPD who self-harmed. Marsha Linehan (1993) developed a complex
treatment program for patients who self-harmed known as dialectical behav-
ior therapy (DBT). DBT includes techniques at the level of behavior (func-
tional analysis), cognitions (e.g., skills training), and support (empathy,
teaching management of trauma) with the creative use of aspects of Bud-
dhism (e.g., mindfulness), which has become a treatment for depression in its
own right. DBT provided the biggest challenge to the dominance of psycho-
dynamic treatments for BPD simply because it was the first treatment for BPD
to be subjected to a randomized controlled trial at a time when empirically
supported treatments were in the ascendancy. This brings our historical nar-
rative to the current psychotherapeutic treatments for BPD.

Current Psychotherapies for BPD

Stimulated by the controlled studies conducted on DBT, most contem-

porary treatments for BPD have embraced an evidence-based approach. The
rigors of managed care in the United States and the increasing controls on
spending in health care elsewhere in the world have meant that only treat-
ments with research evidence of effectiveness will be increasingly paid by
insurance companies or form part of a national service provision. The com-
plexity of treatments for BPD makes this problematic. So, in keeping with
their long history of neglect, patients suffering from BPD continue to have
limited access to intensive psychotherapy due to patchy provision, inadequate
funding, and nonreimbursement from insurance companies. Self-help and
pressure groups have developed to counter these trends, and family support
groups for relatives of people with BPD thrive. But overall, not only are nat-
ural outcomes better overtime than previously believed (e.g., Zanarini,
Frankenburg, Hennen, & Silk, 2003), but a number of psychotherapies are

PSYCHOTHERAPY FOR SPECIFIC DISORDERS 593

 helpful at least for the more acute symptoms of the disorder, such as self-harm
and suicide attempts.

Dialectical Behavior Therapy

The aim of DBT is initially to control self-harm, but its main aim is to pro-
mote change in the emotional dysregulation judged to be at the core of the dis-
order. In the first trial undertaken by its founder, DBT reduced episodes of
self-harm initially, but was less effective in the long term. Control patients were
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significantly more likely to make suicide attempts, spent significantly longer

periods of time as inpatients over the year of treatment, and were significantly
more likely to drop out of the therapies to which they were assigned. At
6-month follow-up, DBT patients continued to show less parasuicidal behav-
ior than controls, though at 1 year there were no between-group differences.
The widespread adoption of DBT is both a tribute to the energy and
charisma of its founder, Marsha Linehan, and to the attractiveness of the
treatment, with its combination of acceptance and change, skills training,
excellent manualization, and a climate of opinion that is willing and able to
embrace this multifaceted approach (Swenson, 2000). Whereas some have
felt that the popularity of DBT is not justified by the strength of the evidence
(Tyrer, 2002) and some have felt that the conclusions are premature (Scheel,
2000), currently it is the best validated treatment for BPD. A recent replica-
tion of the original study that found, in most respects, results very similar to
the original study gives further support to its effectiveness (Linehan et al.,
2006). An additional randomized study by an independent group supports the
findings as well (Verheul et al., 2003).

Cognitive–Behavioral Therapy

The evidence for modified CBT as a potential treatment for BPD

began with a small (N = 34) randomized controlled trial using manual
assisted cognitive–behavioral therapy (MACT) in the treatment of recurrent
self-harm in those with Cluster B personality disorders (the rate of suicide acts
was lower with MACT and self-rated depressive symptoms also improved;
Evans et al., 1999). In a more recent large study (N = 480), following from
the first, brief MACT slightly increased the likelihood of self-harm rela-
tive to treatment as usual with personality-disorder patients and in BPD
increased the costs associated with ongoing treatment (Tyrer et al., 2003;
Tyrer et al., 2004). In a more recent randomized controlled trial of BPD
with longer treatment (up to 30 sessions), from therapists trained in
advance, there was significant benefit on suicidal behavior (N = 104) but a
nonsignificant increase in emergency presentations in those allocated to

594 ANTHONY W. BATEMAN

 cognitive–behaviorial therapy (Davidson et al., 2006). There is an inter-
esting contrast in terms of the duration of treatments focusing on a cogni-
tive approach, which might limit availability and certainly reduces utility.
SFT appears to be an efficacious long-term treatment when offered for a period
of 3 years, but the 30-session version of MACT, still a relatively long-term
therapy, is limited in its effectiveness. Both cognitive therapies are, however,
promising and may occupy different niches in the treatment of BPD.

Dynamic Psychotherapy
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Just as behavioral and cognitive treatments have been adapted to the

special needs of patients with BPD, so too have the classical techniques of
psychoanalytic psychotherapy. This has led to more detailed elaboration of
treatments with manualization of TFP (Clarkin, Kernberg, & Yeomans,
1999) and dynamic deconstructive psychotherapy (Gregory & Remen, 2008)
in the United States and mentalization-based treatment (MBT; Bateman &
Fonagy, 2004a, 2006) in the United Kingdom and psychodynamic inter-
personal psychotherapy in the United Kingdom and Australia.
Differences between the dynamic treatments are reminiscent of the ear-
lier debates about the relative treatment emphasis placed on either supportive
or expressive techniques. Some favor a supportive approach, whereas others
promote emotional understanding. It still remains unclear whether this is a
debate over small differences or over an important technical aspect.
The initial variant of dynamic therapy was TFP, which emphasizes
expressive and interpretive techniques; it has now been manualized and sub-
jected to clinical trials (Clarkin, Levy, Lenzenweger, & Kernberg, 2004,
2007). Ninety patients, 92% of whom were female, were randomized to TFP,
DBT, or supportive psychotherapy. At completion of treatment at 1 year,
there were no differences among groups on global assessment of functioning,
depression scores, social adjustment, anxiety, and measures of self-harm.
However, whereas TFP showed significant improvement in irritability and
verbal and direct assault, this was not observed in either DBT or supportive
psychotherapy. The lack of significant difference may be due to lack of power
in the study, but equally might be because all three treatments in this com-
parative trial met the general criteria for effective treatment.
A further randomized controlled trial (Gieson-Bloo et al., 2006) com-
pared TFP with SFT. Patients who received TFP showed significantly less
improvement than did those who received schema-focused CBT over 3 years,
and TFP was more expensive. Both groups showed improvement, but changes
in the combined measure of outcome in the group treated with SFT were
greater and more prolonged than in the TFP group. However, the results
should be interpreted with caution (Fonagy & Bateman, 2006), especially as

PSYCHOTHERAPY FOR SPECIFIC DISORDERS 595

 longer term follow-up is needed and follow-on research has suggested that
over the same period approximately 40% of patients would have been
expected to have improved (Zanarini et al., 2003). MBT uses more support-
ive techniques and delays detailed exploration of transference until later in
treatment than does TFP. The focus of therapy is on the patient’s moment-
to-moment state of mind. Patient and therapist collaboratively generate alter-
native perspectives to the patient’s subjective experience of themselves and
others by moving from validating and supportive interventions to exploring
the therapy relationship itself as it suggests alternative understanding. The
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evidence for this approach comes primarily from the developers of the treat-
ment (Bateman & Fonagy, 1999, 2001), and replication is necessary, although
promising data has recently become available on the effectiveness of a simi-
lar program established in the Netherlands. The treatment has now been
manualized (Bateman & Fonagy, 2004b, 2006). Long-term follow-up sug-
gested that gains made during treatment are maintained over a further period
of 5 years after all treatment has ceased (Bateman & Fonagy, 2008).
Other dynamically orientated treatments have been developed, the best
known of which is psychodynamic interpersonal therapy (PI; Hobson, 1985).
This treatment has more supportive elements than does TFP and overlaps
considerably with MBT. There are a number of nonrandomized trials of PI in
the literature, which have suggested that treated patients show significant
reduction in symptom severity and increase in global assessment of function
scores relative to a waiting-list group (Meares, Stevenson, & Comerford,
1999; Stevenson & Meares, 1992).

Group Psychotherapy

Group psychotherapy in a partial hospital context is perhaps the remain-

ing representative of long-term inpatient treatment for BPD. Marziali and
Monroe-Blum concentrated on group therapy alone without the additional
milieu and social components of therapy, although their therapy was not for-
mally psychoanalytic but focused instead on relationship management. In a ran-
domized controlled trial, they found equivalent results between group and
individual therapy and concluded that on cost-effectiveness grounds, group ther-
apy is the treatment of choice (Monroe-Blum & Marziali, 1995). Further studies
are needed to confirm their findings, especially because the treatment offered
was less structured than most other treatments and dropout rates were high.

Other Psychotherapies

A number of other therapies have been modified for patients with BPD.
For one example, cognitive analytic therapy (CAT) has been manualized for

596 ANTHONY W. BATEMAN

 treatment of BPD, and many are enthusiastic about its effectiveness. A case
series of 27 patients with BPD treated with 24 sessions of CAT (Ryle &
Golynkina, 2000) found that at 6-month follow-up, 52% of the sample no
longer met diagnostic criteria for personality disorder and were classified as
improved. Benefits of CAT have also been found in the treatment of adoles-
cents with borderline traits (Chanen et al., 2008). For another example,
interpersonal psychotherapy has been applied to patients suffering from BPD
(Markowitz, Skodol, & Bleiberg, 2006).
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IN THE FUTURE

A wide variety of psychotherapies have shown some effectiveness for BPD,

with minimal differences in overall outcomes when they have been directly
compared by unbiased investigators. This pattern, along with the general find-
ing that structured clinical care is superior to rather chaotic treatment as usual,
suggests that effective treatments have certain features in common. The effec-
tive therapies tend to (a) be well structured; (b) devote considerable effort to
enhancing compliance; (c) have a clear focus whether that focus is a problem
behavior, such as self-harm or an aspect of relationship patterns; (d) be theoret-
ically highly coherent to both therapist and patient, sometimes deliberately
omitting information incompatible with the theory; (e) be relatively long term;
(f) encourage a powerful attachment between therapist and patient, enabling
the therapist to adopt a relatively active rather than a passive stance; and (g) be
well integrated with other services available to the patient.
Clearly, there is much research to be done in better understanding the
effect of various therapeutic approaches to this complex psychological prob-
lem. But more important, future research needs to address the question of how
treatments can be disseminated more widely. Evidence-based therapies for
BPD require extensive training and stringent monitoring of adherence and
standards, all of which are obstacles to comprehensive implementation across
mental health services. To have the potential for broad dissemination, treat-
ments have to have minimal training and supervision demands. Research
needs to address these issues if patients with BPD are going to have access to
the treatment they deserve and so sorely need.

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