Psychodynamic Approaches to Borderline Personality Disorder

Borderline personality disorder (BPD) is a severe mental illness that afflicts roughly 2 percent of the general population (Paris, 2010), 10 percent of psychiatric outpatients (Zimmerman, Rothschild, & Chelminski, 2005), and 20 percent of psychiatric inpatients (Zimmerman, Chelminski, & Young, 2008). Up to 10 percent of patients with BPD will die by suicide (Paris, 2019).

In addition to the disorder's significant psychological and interpersonal toll, its costs to society are high—more than double the costs associated with depression (Soeteman, Hakkaart-van Roijen, Verheul, & Busschbach, 2008). Despite the severity of the disorder, its prevalence, and its associated burden, borderline personality disorder remains poorly understood by many mental health professionals and the general public; it is also marked by significant stigma.

While psychiatric medications are sometimes prescribed to help manage the severity of symptoms, the treatment of choice for BPD is psychotherapy, and there is a long and rich history of the use of psychotherapeutic approaches with these patients. One such approach is psychodynamic psychotherapy, which traces its roots to Freud but has since been adapted by a number of theorists of the object relations school for the treatment of borderline disorders. The most notable of these theorists is Kernberg, whose work on BPD has spanned seven decades.

Transference-focused psychotherapy, which was developed by Kernberg and colleagues at Cornell University in the 1970s and 80s, represents an evidence-based psychodynamic treatment for BPD which has been shown to be at least as effective as Linehan's dialectical behavioral therapy (DBT) for this problem (Clarkin, Levy, Lenzenweger, Kernberg, 2007), despite DBT's wider-ranging popularity.

The Psychodynamics

At the heart of the psychodynamic approach to borderline personality disorder is the observation that problems in the patient's identity, that interact with a propensity toward extreme emotional responses and lead to the associated difficulties in the patient's social and interpersonal life, are best explained by a "divided" or "split" sense of self and others. This is often referred to as the "split psychological structure" in which different, contradictory ways of thinking about the self and others manifest themselves at different times, or in different ways, but rarely, if ever, at the same time (Stern & Yeomans, n.d.). This results in the "black-and-white thinking" that is characteristic of the disorder; the patient cannot seem to think in shades of grey.

These dynamics lead to a chaotic push-pull cycle in the borderline patient's interpersonal relationships that reflects, in part, the patient's deep-rooted fear of dependency. The patient idealizes (the pull), the enamored partner commits, and then the patient feels suffocated and responds by wreaking relational havoc (the push). Left unexamined, the pattern continues with the partner for months or years, and repeats again with the next partner and the series of partners to follow. A key to the treatment of these patients, discussed below, is examining this cycle as it plays out in the treatment relationship itself.

McWilliams (2011) 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."

A key to understanding the borderline syndrome is recognizing that for these patients, love is associated with painful rejection. In essence, to feel love is to feel pain. (This not infrequently extends to the sexual realm.) As a result, the patient exhibits a chaotic patterning in relationships; when things are going well, when things are calm and stable, they paradoxically feel anxious and "stir things up"—for to be loved is to be hurt.

It can be said that the great paradox of borderline personality disorder is that while the patient's greatest fear is abandonment, they will act in ways that virtually ensure they will be abandoned.

Treatment Considerations

Appropriate selection of patients for psychodynamic treatment in general is paramount, but it is perhaps especially important in the treatment of BPD. A good rule of thumb is that the patient must be adequately self-expressive, capable of introspection (i.e., psychologically-minded), of at least average intelligence, and not so severely regressed as to require a more intensive or directive method of treatment (Kernberg, Selzer, Koenigsberg, Carr, & Applebaum, 1989).

Personality Disorders Essential Reads

5 Common Misconceptions About Schizoid Personality Disorder

Borderline, Narcissist, and Schizoid Relationship Challenges

The presence of antisocial features worsens the overall outlook and is generally contraindicated (Kernberg et al., 1989). Some patients enter psychodynamic treatment for BPD after more directive therapies, such as DBT, have failed or offered only partial benefit. As always, a thorough evaluation for the presence of other mental disorders should be conducted.

The psychodynamic treatment of BPD was pioneered by Kernberg and colleagues at Weill Cornell Medical Center.

Source: Kenneth C. Zirkel, used with permission

Adherence to the treatment frame—that is, the basic ground rules for psychotherapy and the other contractual elements of the treatment relationship—is vital. Given that borderline patients have an unconscious tendency to "test" the therapist (Kernberg et al., 1989), much careful attention should be given to the patient's attempts or requests to deviate from the frame, such as contacting the therapist outside of the scheduled therapy hour or failing to pay the fee.

In fact, the therapist's ability to navigate these issues not only facilitates psychotherapy; adherence to the frame itself represents a fundamental therapeutic intervention, as Langs (1974) described decades ago. Some psychodynamic therapists utilize a written contract in working with patients with BPD.

Kernberg and colleagues (1989) note that "the therapist who fails to make it clear to the patient that therapy is a collaborative process colludes with the patient's grandiosity ('I can do anything I want to with no bad consequences'), devaluation ('I need to do nothing because the treatment is worthless anyways'), or demand for an omnipotent therapist ('All I have to do is show up and you will cure me')."

Transference and countertransference issues lie at the core of treatment. The patient with BPD will unconsciously repeat relational patterns with the therapist, and it is the therapist's skilled handling and interpretation of these patterns that, in part, facilitates therapeutic change. Common countertransference reactions include anger, fear, and frustration. Therapists who dismiss borderline patients, who are often described as "difficult," may be participating in the acting out of the patient's primitive dynamics.

Omnipotent countertransference—the therapist's belief that he or she alone can "save" or "cure" the patient—can be particularly harmful. This may manifest in the therapist who does not consider psychiatric hospitalization as an option following a serious suicide attempt, but immediately makes herself continuously 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 omnipotent fantasies are often disastrous.

Conclusion

Psychodynamic psychotherapy provides perhaps the most comprehensive method of understanding and treating borderline personality disorder, and 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. 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, 2016).