Transactional Analysis as a Cognitive Treatment
for Borderline Personality Disorder
Peter Sterrenberg and Moniek M Thunnissen
Abstract
This article describes the use ofTA as a
cognitive therapy in the treatment of border-
line personality disorder. The pathology of
the borderline patient is considered to be the
result of stagnation in the structural devel-
opment of the Child ego state. The authors
describe how pathology related to the
boundaries between and cathexis of ego
states is treated first. Later stages of therapy
emphasize game and script analysis.
Until recently, most of the professional litera-
ture concerning the treatment of borderline
patients has been psychoanalytically oriented.
Most therapies described were more or less
modified forms of traditional psychoanalysis.
The major representative of this treatment
approach is Kernberg (1984; Kernberg, Selzer,
Koenigsberg, Carr, & Appelbaum, 1989), who
suggested that with borderline personality
organization there is a core conflict concerning
aggression (as compared to a neurotic conflict).
Although reality testing is intact, there is (in
contrast to neurotic personality organization)
identity diffusion and the use of primitive de-
fense mechanisms. Masterson (1972), another
proponent of psychoanalytic treatment with
borderline personality disorder, viewed the
inability to cope with loss and independence as
central in the psychopathology of the borderline
adolescent. In childhood, these patients were
rewarded for dependency and rejected when
they tried to function independently.
According to Kernberg (1984), the aim of
treatment is the resolution of the borderline's
core conflicts as well as structural change of
personality. Such so-called expressive psycho-
therapy is an intensive (two or three times
weekly) outpatient form of analytically oriented
psychotherapy. Recently, however, there has
been growing awareness that in many cases
Vol. 25. No.3. July 1995
these insight-oriented methods of treatment,
using interpretation as a central technique, do
not give the best results (Beck & Freeman,
1990; Linehan, 1993; Stone, 1987; Westen,
1991). Long-term residential treatment, on the
other hand, often stimulates regression in a way
that is not beneficial to personality integration
with this population (Singer, 1987).
Other theoreticians (Beck & Freeman, 1990;
Robbins, 1989) have advocated a more struc-
tured approach based on cognitive principles.
Robbins (1989), for example, hypothesized a
fundamental impairment in the borderline pa-
tient (in contrast to a core conflict) that leads to
impaired cognitive and affective development.
According to Robbins, the structural aspects of
cognitive and affective impairment must be
handled in treatment before dealing with content
and meaning:Thatis, how the patient constructs
meaning from experience is of primary impor-
tance; what it means is secondary. When cogni-
tion and behavior are dealt with first, the patient
is more availablefor reflection about content. In
their book about the cognitive treatment of
personalitydisorders, Beck and Freeman (1990)
also offered a more structured cognitive ap-
proach. In addition, Linehan (1993) outlined a
cognitive framework for working with border-
line patients.
Although not usually considered to be a
cognitive theory per se, transactional analysis
(T A) contains many cognitive aspects (Clark-
son, 1992; Hellinga, 1994). Transactional anal-
ysis can thus contribute theoretically as well as
technically to the treatment of borderline pa-
tients. This article presents a model of border-
line personality disorder from a TA perspective
and then considers the usefulness of transac-
tional analysis as a cognitive theory and therapy
fur these patients. Specific techniques are illus-
trated with a clinical vignette and the possibil-
ities and limitations ofTA in treating borderline
patients are reviewed.
221
PETER STERRENBERG AND MONIEK M. THUNNISSEN

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Figure 1
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Developmental Roadmap of Formation of Ego States
a. Normal. b. Pathologic (Broken vectors indicate developmental arrests)
c. Characteristic object relations

Transactional Analysis Theories about
Borderline Personality Disorder
Among the models that view borderline
personality disorder from a TA viewpoint.
Haykin (1980) described the development of
ego states following the phases outlined by
Mahler(see Figure 1). In borderline personality
disorder, the first phases (autistic, symbiotic,
and the first part ofseparation-individuation) are
unimpaired. Stagnation occurs when the split
structure of the rapprochement crisis has to
develop into a second-order structure. The
rapprochement crisis is incompletely mastered
and borderline pathology develops with split

222 Transactional Analysis Journal

 TRANSACfIONAL ANALYSIS AS A COGNITIVE TREATMENT FOR BORDERLINE PERSONALITY DISORDER
objects or narcissistic pathology develops with
excessive idealizing and devaluation.
Borderline pathology is mainly situated in the
Child ego state. Woods and Woods (1981,
1982) described the incomplete separation
between AI (primitive cognitions) and C\ (af-
fect), while the primitive split between + and -
remains intact. The outer boundary of the ego
states is often fragile, leading to a strong ten-
dency toward symbiotic relationships. Bound-
aries between ego states are also weak, which
explains rapid shifts between ego states.
Since borderline pathology is considered to be
a stagnation in the structural development of the
Child ego state, there are consequences for the
functioningof other ego states as well. With the
Adult. ego state cathexis is insufficient; there are
crude discounts and contaminations, and mecha-
nisms such as redefining, generalizing, and
overdetailing are often used. With regard to the
Parent ego state, little has been written about it
in relation to borderline personality disorder.
However, considering that many adult border-
line patients come from emotionally and physi-
cally abusive families, one can assume that the
introjected Parent images must show some
degree of impairment,
Transactional Analysis as a
Cognitive Therapy
Few writers within TA, with the exception of
Woods and Woods (1982), have described how
transactional analysis can be used with border-
line patients. In writing about therapy in general,
Berne (1961) described different levels of anal-
ysis: ego state analysis, transactional analysis,
game analysis, and script analysis. This se-
quence implies a hierarchy in which script
analysiscan only be done after the other types of
analysis. Games and script do, of course, playa
role in the first phase of therapy, but they can
only be analyzed fully after ego states and trans-
actions are analyzed. Some authors (Hellinga,
1994) state that script analysis is impossible
with borderline patients because of the severity
ofthe pathology.
In our experience, however, transactional
analysis (including script analysis) provides a
useful framework for treating borderline person-
alitydisorders because it offers the possibility of
Vol. 25. No.3. July 1995
structuring and focusing the treatment. The
sequence we use in treating borderline patients
with TA is as follows:
I. The focus of treatment is articulated in a
contract, which offers a guideline for
treatment.
2. The boundaries of and between ego states
are strengthened by discussing contamina-
tions, redefinitions, exclusion of ego
states, division of energy between ego
states (e.g., an egogram), and weak bound-
aries. Special emphasis is placed on ex-
ploring the boundaries between and ca-
thexis of ego states rather than on game
and script analysis (e.g., analysis of fixated
traumatic experiences in Child).
3. Transactional analysis is used to analyze
transactions between the patient and the
group members and therapists as well as
to consider favorite ego states, a stroke
profile, and time structuring.
4. Game analysis is used to highlight the
patient's favorite position on the drama
triangle and repetitive patterns in and
outside of therapy; links are made to game
analysis and roles in the original family.
5. Finally, script analysis is used to consider
the content of ego states, structural re-
building of the Child ego state, and intro-
jections within the Parent.
We have found that redecision therapy
(Goulding & Goulding, 1979) is not as useful in
the treatment of borderline patients as it is with
neurotic patients. Rather, emotionally experi-
enced insight with regard to the content of ego
states, softening of the influence of sadistic
Parent introjects, and increased Adult function-
ing are the goals that can realistically be reached
with most borderline patients.
Transactional Analysis in the Treatment of
Borderline Patients
The following sections elaborate on the
treatment sequence just outlined and illustrate it
with a clinical vignette. Our setting is a center
fur clinical psychotherapy (de Viersprong, Hal-
stereo, The Netherlands) at which a three-month
inpatient psychotherapy program is offered to
personality-disordered patients. Most patients
admitted into the program have a long-standing
223
PETERSTERRENBERG AND MONIEKM. THUNNISSEN
history of problems with work, relationships,
fiunily, andpurposeful time structuring. Some of
them suffer from milder forms of DSM-III-R
borderline personality disorder (so-called
higher-level borderlines). Treatment utilizes
psychoanalytic and group dynamic principles in
addition to transactional analysis. An important
aspectof treatment is the integrationof psycho-
therapy, milieu therapy, and nonverbal therapy.
The Contract
In transactional analysis different types of
contracts are described (Loomis, 1982), includ-
ing:
I. the care contract, which is aimed at pro-
tection, care,and avoiding rackets, games,
and their payoffs
2. thesocialcontrol contract, which is aimed
at crisis intervention, structural analysis,
treating contaminations and exclusions,
strengthening the Adult, analyzing the
patient's stroke economy, and time struc-
turing
3. the relational contract involving short-
term, focused therapy with script analysis,
which is aimed at early traumatic experi-
ences, script decisions, and their effect on
current relationships
4. the structural change contract involving
multifocused, long-term, insight-promot-
ing therapy with an emphasis on re-
parenting, redecisions related to preverbal
injunctions, and kinesthetic patterns
In short-term treatment, the norm is a type 3
contract focused on and aimed at structural
change. In such clinical situations, describing
the central conflict is crucial. In neurotic pa-
tients this can usually be described as "restric-
tion versus autonomy"; in borderline patients it
is morelikely to be "surviving versus living." In
neurotic patients, conflicts center around needs
and (sometimes fantasized) demands and trau-
matic experiences; in borderline patients, the
central issue is rebuilding internalstructures and
delineating boundaries.
The power of the contract lies in the way it
highlights the relationship between behavior,
suppressed needs, and early decisions. The
contract also offers an alternative with more
freedom andopportunitiesto fulfill basic needs.
224
The contract mustbe clear and easy to check for
groupmembers and therapists. All ego states of
both patient and therapist must be involved: A
goodcontract is realistic and meaningful(A-A),
is notan order, does not go against the person's
ethics(P-P), and is creative and stimulating(C-
C).
Clinical example: Carla, a 29-year-old wom-
an, suffered from borderline personality disor-
der.This diagnosis was based on both behavior
and symptoms: impulsivity, affect lability,
suicidal threats and self-mutilation, problems
withidentity (identitydiffusion), and feelings of
emptiness. Her parents, both alcoholics, were
separated when Carla was young, and she was
sexually abused at an early age. She was admit-
ted into our program for three months of treat-
ment, and herdeeply felt distrust and aggressive
way of creating distance became clear during
contract setting. Therapists were not to be
trusted, and so setting the contract was difficult.
Finally a contract wasdetermined: "The fighting
is over. I show up and you are welcome."
Boundaries Between Ego States
Whentheytalkabouttheir problems, border-
line patients often get tangled up in a chaotic
mix of feelings, thoughts, and fantasies with
little structure. The Adult ego state is not ca-
thected well (or excluded), and there are crude
contaminations. Boundariesbetween ego states
are diffuse and too permeable;ego states them-
selves are not well-differentiated and do not
work together very well. Strengtheningbound-
aries between ego states is central in the first
phaseoftreatment, as is rebalancingthe energy
between egostates. In particular, Adult cathexis
must to be improved and emotions must be
contained. Work on Child and Parent ego states
is only possible with a sufficiently functioning
Adult. Useful techniques in this phase include
discussing contaminations and redefinitions and
constructingan egogram.
Clinical example: The boundaries between
Carla's ego states were weak, and there were
crude contaminations such as, "Other people
cannot be trusted" (Parent-Adult) and "When I
show negative feelings, I will damage others"
(Child-Adult). A first step in decontamination is
to speak out loud the mix of negative feelings
Transactional AnalysisJournal
 TRANSACTIONAL ANALYSIS ASA COGNITIVE TREATMENT FOR BORDERLINE PERSONALITY DISORDER
and thoughts. Carla noticed that the other person
survived as she experimented with voicing her
negative thoughts and feelings. As she investi-
gated her fantasies about others, she began to
differentiate.
Transactional Analysis
The language ofTA structures the analysis of
transactions. It helps the patient to stay in touch
with realityand to structure experience, which is
especially important for borderline patients.
T A's simple, clear language is easily mastered
and put into practice, although the danger of
oversimplifying the patient's complex pathology
with simple words must be prevented through
careful coaching by the therapist.
Strong transference reactions appear rela-
tively early in the treatment of borderline pa-
tients. These reactions are the result of strong
primitive defense. mechanisms such as pro-
jective identificationand splitting. Moiso (1985)
considered these projections as projected parts
ofP,. As the patient alternates between positive
and negative parts of P t, strongly fluctuating
transference reactions occur. The patient thereby
reenacts old relationship patterns, hoping for
improvement, but instead approaching his or her
payoff.
To analyze the patient's aggressive and de-
structive impulses, a partial symbiosis has to
occur. This enables the therapist to analyze the
transactions between patient and therapist,
investigate projections, confront lapses in reality
testing, and maintain a working relationship.
This process strengthens Adult functioning and
promotes decontamination.
Borderline patients are accustomed to receiv-
ing negative strokes and are trained to provoke
them. Thus, giving them positive strokes (condi-
tional and unconditional) is of major impor-
tance. However, prior to decontamination, such
positive strokes tend to be distorted by Parental
messages. Checking the effect of a stroke can be
helpful, as is continuing to give strokes until
they are accepted, although in early treatment
positive strokes can lead to increased anxiety
and distrust.
Clinical example: In the first few weeks of
treatment, Carla's fear of positive strokes was
evident. She was afraid to care about the group
Vol. 25. No.3. July /995
members and therapists because in her experi-
ence she was always abandoned. She repeatedly
behaved self-destructively and threatened to
drop out or to commit suicide. Carla tried to
activate the therapist's Parent: After quarreling
with a group member, she threatened suicide.
She was invited to take a risk by lying in the
middle of the group and waiting to see who
would come and touch her. After much hesita-
tion she agreed, and within seconds all group
members were gathered around to hold her. She
cried like a baby and gradually relaxed.
Game Analysis
Borderline patients often masterfully seduce
patients and therapists alike into playing games.
Teams get split into discussions in which team
members are often diametrically opposed to
each other. This is the result of the borderline
patient's use of primitive defense mechanisms
such as devaluing, idealizing, splitting, projec-
tion, and projective identification. The games
that result include: "Let's You and Him Fight,"
"NIGYSOB," "Rapo," "I'm Only Trying to
Help You," and "Uproar." Delineating the mech-
anisms behind such games-for example, by
describing the roles on the drama triangle--
offers the patient the opportunity to reflect on
repeated patterns and meanings.
Clinical example: Carla gradually became
attached to her psychotherapist. After the thera-
pist's holiday, Carla began the next session by
talking about horrid stories from her past (Vic-
tim role). When the therapist refused to play this
game and instead started giving Carla uncondi-
tional positive strokes, Carla's fear of abandon-
ment became clear. She defended against it with
anger, threatening to destroy herself and the
relationship.
Script Analysis
After establishing adequate boundaries be-
tween ego states, script analysis becomes possi-
ble. This, of course, requires a sufficiently
functioning Adult as well. The first part of script
analysis consists of writing down internal mech-
anisms derived from behavior. Use can be made
ofthe script matrix (Berne 1961; Steiner, 1966)
and racket analysis (Erskine & Zalcman, 1979).
One useful technique is to draw a second-order
225
PETERSTERRENBERG AND MONIEKM. THUNNISSEN
Child ego state diagram with its thoughts, feel-
ings, and messages. This can be helpful in
structuring the chaotic inner world of the pa-
tient, and it also addresses the Adult ego state,
promotes decontamination, and strengthensego
state boundaries.
Clinical example: Carla tells about a night-
mare in which her mother begs Carla to rescue
her. The nightmare "proves"that her mother has
cursedCarla: "You are doomed like me to lead
an unhappy life, addicted to alcohol and destined
to dieyoung." Carla is terrifiedafter this dream.
She does not want to die, and she realizes that
she has to separate fromher mother,which feels
likekilling her mother. (The second-orderstruc-
tureof her Childego state is shown in Figure 2.)
You are doomed
Live like mother or
kill mother
I am scared
Figure 2
Second-Order Structure of
Carla's Child Ego State
A third option is proposed: liftingthe curse.
FirstCarlamust loosenthe symbioticbond with
her mother in order to make an Adult decision.
She lifts the curseby symbolically pushingaside
a load of pillows and deciding to live. All the
group members gather around her and speak a
wish: to be happy and to have a family and a
good life.
226
Conclusion
One ofthe major advantagesoftransactional
analysis as compared to other cognitive treat-
ment approaches is its ability to explicitly ana-
lyze transactions. Because of the interpersonal
as opposed to the intrapsychic character of
borderline pathology, this offers great advan-
tages. Forexample. transactional analysiscan be
extremely helpful in creating a therapeutic
alliance. whichis generallyconsideredto be the
keyfilctor in successfultreatment(e.g.•Beck &
Freeman. 1990). Since transactional analysis
theory is still relatively underdeveloped. it
continues to be necessary to use additional
psychoanalytic concepts in the clinicaltreatment
ofborderline patients. To increasethe effective-
nessoftransaetional analysis with these patients,
further theoretical elaboration will be needed.
furexample. of the Parent ego state. Delineating
specific techniques forditrerent levels of border-
line pathology may prove to be anotherfruitful
area of inquiry.
Peter Sterrenberg is a psychiatrist at the
General Psychiatric Hospital Woljheze in The
Netherlands on a wardfor clinical psychother-
apy and in a day hospital. He trained in and
has worked with TA.
Moniek M Thunnissen is a Provisional
Teaching and Supervising Transactional
Analyst (clinical) and a psychiatrist in the
short-term therapy department in the Psycho-
therapeutic Centre "De Viersprong" in Hal-
steren, The Netherlands. Please send reprint
requests to M M Thunnissen, A. Cuypstraat
32, 4625 AM Bergen op Zoom, The Nether-
landst fax: 31 164042807.
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