When the term “borderline” was first used in 1938 by the psychoanalyst Adolf Stern, he was defining a group of patients who were “extremely difficult to handle effectively by any psychotherapeutic method.”¹ In the early 1950s, Robert Knight emphasized their regressive responses to unstructured treatments.² In hospitals, borderline patients were referred to as “help-rejecting complainers.”

During that time, the term “negative therapeutic reaction” evolved as a way to describe how individuals with borderline personality disorder (BPD) destroyed their well-meaning therapists’ ability to be effective because of unconscious motivations of masochism, envy, and sadism. In light of the reports of resistance to treatment and the formulations of the mechanisms behind this resistance that blamed the patient, borderline became associated with treatment resistance and poor prognosis. At best, a diagnosis of BPD was a statement of therapeutic pessimism. At its worst, the diagnosis brought expectations of aggressive or hostile acting out against therapeutic efforts.

Findings from longitudinal research and the development of empirically validated BPD-specific treatments have since helped transform its reputation as an untreatable disorder into one that can be quite responsive to treatment. Two prospective longitudinal studies have shown that BPD psychopathology progressively improves, with impressive remission rates of 40% to 50% in 2 years and 70% to 80% by 10 years.^3,4

Empirically validated treatments have demonstrated how therapies need to be specifically tailored for successful treatment of BPD. The first of these, dialectical behavioral therapy (DBT) was developed only after it was realized that patients with BPD resisted a traditional behavioral approach. DBT incorporated techniques of validation and the concept of acceptance to a cognitive-behavioral framework.⁵ Similarly, schema-focused therapy was developed for personality-disordered patients who were “nonresponders” to—or “relapsers” from—standard cognitive-behavioral therapy.⁶ Several of these approaches explicitly address the borderline patient’s typical treatment-interfering behaviors so that his or her responses are not personalized or overreactive.

Originally, the concept of treatment resistance was defined in psychoanalytical terms. Freud described the phenomenon of resistance broadly as “whatever interrupts the progress of analytic work.” The term “resistance” often referred to defenses or aspects of character structure that were obstacles to therapists. Currently, treatment resistance often refers to psychiatric symptoms that do not respond to otherwise effective treatments. The most widely recognizable use of this modern meaning of resistance is treatment-resistant depression, which describes a form of depression that does not remit despite reasonable and extensive (usually psychopharmacological) treatment. Both psychological resistance to treatment and the resistance of symptoms to respond as expected refer to a variety of phenomena that can render generally effective treatments ineffective.

BPD is associated with both forms of resistance, and these underlying sources may overlap. Particular forms of defenses exhibited by patients with BPD can constitute therapeutic resistance. However, when BPD coexists with mood disorders, those disorders often fail to respond to treatments as well as expected.⁷

Here we present case vignettes to illustrate treatment of therapeutic resistance that clinicians commonly encounter. We first discuss treatment resistance related to an Axis I diagnosis that is comorbid with BPD. This is followed by a discussion of 2 other forms of therapeutic resistance—entitlement and dynamics between the patient with BPD and his family. We offer recommendations about how to manage these different forms of resistance.

Comorbidity as a source of treatment resistance for Axis I disorders

Patients with BPD often present with a history of diagnosis and treatment of multiple Axis I disorders, mainly in the realms of mood, anxiety, substance use, and eating.⁸ In such patients, it is important to determine whether BPD is present because it, like other personality disorders, is a commonly cited factor of treatment resistance for comorbid disorders.^9,10 Failure to recognize the effect of comorbid BPD or mood disorders often leads both the patient and the clinician to put undue hope on the expected response to medications.

CASE VIGNETTE

Sara, a 25-year-old woman with a history of repeated cutting and depression, was hospitalized when she took an overdose of an antidepressant after an angry breakup with a boyfriend. Her inpatient psychiatrist diagnosed depression and attempted unsuccessfully to treat her with medications. Electroconvulsive therapy was tried, without any improvement in either her mood or cutting behavior.

Every time Sara threatened to cut herself, the staff responded with increased monitoring. Eventually, she was constantly observed, her clothes were confiscated, and she was required to wear a gown at all times. The treatment team was afraid that without these constraints, Sara would kill herself. When Sara was finally discharged, the psychiatrist’s diagnosis had been changed to BPD, but the patient nonetheless clung to her primary diagnosis of major depressive disorder (MDD). Because the emphasis had been on MDD for so long, her stance toward treatment—passive and expecting a lot from medications—was predetermined. Her outpatient therapist struggled to get Sara to collaborate with her to discuss the events and feelings that preceded her impulses to cut herself. Sara believed that treatment should focus on making her “feel better” and that this depended on getting the right medication. She continually demanded medication changes and perceived the therapist’s questions as “not caring” or a “waste of time.”