The ABC's of Psychotherapies for Borderline Personality

Which psychotherapy for BPD?

Posted Apr 05, 2011

Borderline Personality Disorder is the only major psychiatric illness for which there are more evidence-based studies demonstrating efficacy for psychotherapy than for pharmacotherapy. Several specific psychotherapy approaches have emerged, which attempt to standardize a specific treatment, usually with detailed instructions in a formalized manual for therapists. Although these different strategies emphasize unique features, they possess many commonalities.

All of these strategies establish clear, objective goals for patients, which focus on behavioral change.  The first and most important objective is to mitigate the risk of suicide.  All formal, "manualized" therapies are intensive, requiring consistent contact, usually one or more times per week. The patient-therapist relationship is more vigorously interactive than in classical psychoanalytic models. 

Dialectical Behavioral Therapy (DBT), a derivation of Cognitive Behavioral Therapy (CBT), has produced the most comparative studies demonstrating efficacy in the treatment of BPD. This model involves weekly individual psychotherapy together with weekly group skills therapy, combined with homework assignments. Emphasis is on educating the patient and reinforcing new coping mechanisms to better modulate emotions and impulses. Telephone coaching is also available. Therapists involved in the treatment team meet together regularly to insure a consistent approach and for their own support.

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a modification of DBT, utilizing group therapy. Educational training sessions can include family members and significant others.

Schema-Focused Therapy (SFT) connects maladaptive adult behavior to distortions emerging from childhood experiences. Psychodynamic understanding is combined with behavioral applications in a process of "re-parenting."

Mentalization-Based Therapy (MBT) focuses on the individual's ability to experience and understand his own feelings and behaviors, and to empathize with others. Psychoanalytically oriented therapy attempts to identify distortions in the perception of self and others that is elaborated in childhood, and to generate more accurate and healthier understanding.

Transference-Focused Psychotherapy (TFP) examines the patient's primitive methods of interacting through the relationship with the therapist. Emotions developed in the therapy are identified and compared to responses in other situations. More adaptive coping mechanisms can then be experimented with.

Although these programs have yielded the most objective studies, other standardized approaches to treating BPD have been developed. Evaluations comparing different therapy strategies have not consistently demonstrated superiority of one over the other. And, of course, treatment outcome is very dependent on the therapists involved. No matter how closely the therapist follows a structured treatment manual, the ineffable relationship between patient and treater is unique, and is the most important factor in the eventual results of treatment.
(A more detailed exploration of psychotherapy approaches to the treatment of BPD can be found in the new edition of our book, I Hate You, Don't Leave Me.)

 Coming next month--Pharmacological treatment of BPD.

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