Lois W. Choi-kain, MD

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Clinicians often see patients with personality disorders as treatment resistant-and, in some cases, untreatable. While it is true that patients with personality disorders may be challenging to treat, they are treatable.

Borderline Personality Disorder: Treatment Resistance Reconsidered

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Do personality disorders get a bad rap? Take the quiz and learn more.

Mini Quiz: Borderline Personality Disorder

The concept of treatment resistance deserves reconsideration. Originally formulated in psychoanalytic terms, resistance in treatment referred to the inevitable ways patients unconsciously express their psychology in terms of defense mechanisms and transference enactment. This form of resistance provides a window into the patient’s problems; therefore, it is a major focus of the inquiry and intervention. Modern psychiatry defines treatment resistance as a lack of response to adequate treatment. Both conceptualizations locate treatment resistance within the patient, rather than as a product of limited, underdeveloped, and ineffective treatments. As a result, the term “treatment resistant” can fuel views of patients as “oppositional” and recalcitrant, instead of expectably symptomatic.

Trait Stages of Diagnosis for Borderline Personality Disorder

Treatment resistance is highly prevalent across most psychiatric disorders-even in common diagnoses generally associated with positive outcomes, such as depression. There are many more obstacles to effective treatment (

) than the patient’s psychological resistance alone. Identification of specific factors that diminish treatment response may provide more useful points of intervention than the label of treatment resistance.

Comorbid disorders contribute to poor treatment response. Treatment guidelines are often based on a false assumption that patients present with single disorders that respond to specific evidence-based treatments. Regardless of increasing attention to problems of comorbidity, guidelines for combining and prioritizing the treatment of different diagnoses remain largely underdeveloped.

Comorbid personality disorders complicate treatment. Over 50% of patients in specialized psychiatric settings have personality disorders.

 These patients are more likely to face social adversity, suffer from complex comorbidities, and drop out of treatment or not adhere to medication regimens-all of which contribute to an increased risk of a lack of response to treatment. The presence of a personality disorder, particularly borderline, predicts persistence of anxiety and substance use disorders as well as poorer outcomes in depressive disorders. Moreover, 13% of those who complete suicide have personality disorders.

Clinicians often see patients with personality disorders as treatment resistant-and, in some cases, untreatable.

 While it is true that patients with personality disorders may be challenging to treat, they are treatable. The self-defeating coping skills and difficulty with relationships that are central to personality disorders make a productive treatment alliance difficult to sustain. Clinicians prototypically react with feelings of frustration, disengagement, incompetence, confusion, helplessness, and even rage.

 The identification of these countertransference reactions can facilitate the diagnosis of personality disorders but can overwhelm and disturb clinicians, leading them to avoid diagnosis and personalize problems as a product of either the patient’s immutable character or the clinician’s limitations.

Our progress in understanding and treating borderline personality disorder (BPD) illustrates the benefits of centralizing the personality disorder diagnosis in care management. For over half a century, patients with BPD were identified by their negative therapeutic reactions, that is, worsening with what was thought to be otherwise appropriate treatment. While pessimism and stigma about the disorder remain, our notion of BPD’s prognosis has radically improved with research.

A major longitudinal study of BPD and other personality disorders with 16 years of follow-up showed that virtually all subjects with BPD achieve sustained remission for at least 2 years, and 78% sustain remission for 8 years. Recovery, that is attending work or school and sustaining at least one meaningful relationship, occurred for 60% of patients for 2 years, and was maintained in 40% over 8 years.

 This evidence suggests that the majority of individuals with BPD (and other personality disorders) can achieve remission and most can recover some sustained functioning, which challenges the notion that patients themselves resist treatment.

Research findings also demonstrate that BPD responds to a variety of treatments. Several specialized psychotherapies formulated for BPD-dialectical behavior therapy (DBT), mentalization-based treatment (MBT), schema-focused psychotherapy, and transference-focused psychotherapy (TFP)-reduce self-injury, suicide attempts, and hospitalizations.

These gains remain 3 years after the beginning of treatment.

Although the results are positive for long-term treatment effectiveness for BPD, difficulty in learning and implementing these psychotherapies because of their specialization and intensity renders them largely unavailable to most patients and clinicians.

 The difficulty in providing or referring patients to effective care is therefore a major factor in treatment resistance and challenges to treating BPD.

A recent meta-analysis of evidence-based psychotherapies for BPD suggests that structure and focus on BPD-related problems such as self-harm and suicidality, rather than intensity, determine outcomes.

 The small-to-medium effect sizes related to the efficacy of evidence-based therapies disappear in studies where the control treatment is structured. Intensity (ie, duration and exposure) did not appear to influence outcomes. This meta-analysis did not show significant differences between DBT and psychodynamic approaches (which included MBT and TFP). It also reported that cognitive behavioral therapy performed no better than control conditions, which indicates that structured treatment alone is not sufficient; the treatment needs to focus on BPD. These findings suggest that evidenced-based treatments might be simplified and still retain effectiveness by maintaining structure and specificity for BPD patients.

The findings from 2 large outpatient trials of DBT and MBT support the idea that less intensive but structured, informed, and systematic care of BPD patients can be effective. General Psychiatric Management (GPM)10 and Structured Clinical Management

 were compared with outpatient DBT and MBT, respectively. Both specialized and generalist approaches yielded similar decreases in suicidality and non-suicidal self-injury and improvements in interpersonal functioning and quality of life.

 While further research is needed, these findings suggest that treatment resistance can be overcome with informed and structured care. We propose the following strategies.

Good care for BPD begins with a diagnosis. Many clinicians avoid telling patients, particularly adolescents, that they have a personality disorder. But the BPD diagnosis can be made reliably before the age of 18, and early intervention is needed for better outcomes.

 When the diagnosis is made objectively and optimistically, patients typically feel less alienated and alone, as well as more hopeful. Sitting down with a patient to review the diagnostic criteria for BPD is an opportunity for clinicians and patients to think together about how each criterion can be applied to challenges the patient faces.

It is important to inform patients that social and vocational recovery is more difficult to achieve than symptom remission alone. These challenges and their course of treatment can be delivered in a clinical management approach that is not primarily psychotherapeutic. An essential part of this is to explain that difficulties in the clinical relationship are to be expected. This allows both patient and clinician to manage these disruptions, rather than react in overly personalized or pejorative ways.

The clarification of treatment goals and expectations, as well as predictions about therapeutic challenges, functions primarily to educate the patient. Psychoeducation alone can reduce symptoms of interpersonal instability and impulsivity.

 With a shared understanding of how interpersonal and emotional sensitivities connect to self-destructive tendencies (ie, self-harm or suicide attempts), the patient and clinician can communicate and collaborate around symptom management in a consistent way.

Evidence-based treatments for BPD stabilize high-intensity interchanges between self-destructive patients and their clinicians by providing an established framework for managing self-destructive behaviors. Good clinical management of any psychiatric diagnosis guides mental health professionals to establish a plan that patients can use when they have urges to hurt themselves at the beginning of treatment. When self-destructive problems arise, patients then have resources mapped out so that independent management can increasingly replace reflexive reliance on hospitalization or paging. According to GPM, clinicians can actively evaluate suicide risk by weighing risk factors (eg, prior attempts, access to means, dangerousness of plans, assessment of intent, substance use, and depression) against protective factors (eg, social supports, capacity to use skills and entertain alternatives). After these episodes, clinicians and patients can analyze what is working in the safety plan and what needs modification.

Chain analyses, reviews of the various events and internal reactions leading to self-destructive urges, are used in many evidence-based treatments for BPD.

 The chain analysis helps clinicians and patients to better understand what has happened and revise safety plans accordingly. With a shared system of managing safety and a shared expectation that reducing suicidality and self-harm is a focus of treatment, more treatment collaboration rather than resistance occurs.

BPD rarely presents without major comorbidity. Most patients with BPD also suffer from depression and anxiety disorders, and many have problems with substance use, eating, and other personality disorders. However, useful and scientifically informed guidelines for prioritizing focus on BPD over other comorbidities are provided in GPM (

 These guidelines encourage clinicians to prioritize BPD over its most common comorbidities of depression, panic disorder, generalized anxiety, and other personality disorders, because these comorbidities are less likely to remit if BPD symptoms do not improve. Moreover, randomized controlled trials of existing evidence-based treatments for BPD report concomitant reductions in depression and anxiety during and after treatment.

Other comorbidities, such as substance dependence, anorexia, and mania, must be prioritized over BPD treatments, because these disorders interfere with the learning required in BPD treatment. New evidence indicates that BPD and PTSD can be treated effectively at the same time. PTSD symptoms may even improve with the treatment of BPD alone.

These empirically informed guidelines mitigate the chaos and reactivity that challenge clinicians in their management of multiple comorbidities by providing an organizational framework. Improving BPD by enhancing coping and inter­personal functioning is likely to increase self-regulation and the sustainability of supportive relationships, while decreasing stressors. Informed management of comorbidities with BPD can reduce treatment resistance, with a focus on a central and treatable source of vulnerability and dysfunction.

Conservative prescribing of pharmacological and somatic therapies

No medication is FDA-approved for the treatment of BPD. Few randomized controlled trials have tested pharmacological treatments for BPD, and their results are inconclusive. European guidelines from the National Institute for Clinical Excellence state that existing evidence is insufficient to support any prescribing of medications, except for the treatment of diagnosable comorbidities. American Psychiatric Association guidelines, informed by meta-analysis of the small number of existing pharmacology studies, advocate for judicious use of mood stabilizers and antipsychotics for BPD symptoms related to affective instability, impulsivity, and cognitive perceptual symptoms.

Antidepressants show minimal benefit in the treatment of core BPD features. Similarly, BPD patients respond to ECT inconsistently, with lower degrees of antidepressant response and higher rates of relapse compared with patients without personality pathology.

 These psychopharmacological and somatic therapies for BPD patients should be used judiciously to target the symptoms of true comorbidities, rather than features of BPD. Conservative prescribing can reduce the burden of polypharmacy and exposure to an increasing number of treatments that are unlikely to achieve the desired results.

The concept of treatment resistance deserves reconsideration, especially in the case of BPD. While the treatment of BPD is challenging and potentially complex, the notion that it is treatment resistant is contradicted by longitudinal and treatment research that indicates high rates of remission over time, moderate rates of recovery, and significant response to structured treatments tailored to symptoms. Furthermore, exposure to adequate care is not the norm, since intensive evidence-based treatments for BPD are not easily learned or implemented. Structured generalist approaches, such as GPM, offer tips such as psychoeducation, systematic and informed management of self-destructive tendencies and comorbidities, and conservative use of pharmacological and somatic treatments. BPD may render comorbid disorders less responsive to therapy, but this may be an argument that treating BPD helps stabilize the expectable challenges and thereby reduces treatment resistance overall.

Dr. Choi-Kain is Director, Adult Borderline Center and Training Institute and McLean Gunderson Residence at McLean Hospital in Belmont, MA, as well as Assistant Professor of Psychiatry at Harvard Medical School in Boston; Mr. Glasserman and Ms. Finch are research assistants, McLean Hospital, Harvard Medical School.

The authors report no conflicts of interest concerning the subject matter of this article.

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 World Health Organization. Figures and Facts about Suicide; 1999. 

http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/

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 Colli A, Tanzilli A, Dimaggio G, Lingiardi V. Patient personality and therapist response: an empirical investigation. 

 Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G. Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: a 16-year prospective follow-up study. 

 Stoffers-Winterling JM, VÃ¶llm BA, RÃ¼cker G, et al. Psychological therapies for people with borderline personality disorder. 

 McMain SF, Guimond T, Streiner DL, et al. Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up. 

 Choi-Kain LW, Albert EB, Gunderson JG. Evidence-based treatments for borderline personality disorder: implementation, integration, and stepped care. 

 Cristea IA, Gentili C, Cotet CD, et al. Efficacy of psychotherapies for borderline personality disorder: a systematic review and meta-analysis. 

Handbook of Good Psychiatric Management for Borderline Personality Disorder

. Washington, DC: American Psychiatric Publishing; 2014.

Borderline Personality Disorder: An Evidence-Based Guide for Generalist Mental Health Professionals

. Oxford University Press: New York; 2013.

 Chanen AM, McCutcheon L. Prevention and early intervention for borderline personality disorder: current status and recent evidence. 

 Zanarini MC, Frankenburg FR. A preliminary, randomized trial of psychoeducation for women with borderline personality disorder. 

 Harned MS, Chapman AL, Dexter-Mazza ET, et al. Treating co-occurring Axis I disorders in recurrently suicidal women with borderline personality disorder: a 2-year randomized trial of dialectical behavior therapy versus community treatment by experts. 

 Rasmussen KG. Do patients with personality disorders respond differentially to electroconvulsive therapy? A review of the literature and consideration of conceptual issues. 

While treatment of bipolar disorder challenging , the notion that it is treatment resistant is contradicted by longitudinal and treatment research that indicates high rates of remission over time, moderate rates of recovery, and significant response to structured treatments tailored to symptoms.

A. Develop insight into the way their childhood influences their current relationship dynamics

B. Repeat their schematized ways of reacting to relationships for limited re-parenting

C. Understand their object relations and tendency towards aggression

D. Gain capacity to reflect on what happens between themselves and others in relationships

The ultimate goal of mentalization-based treatment (MBT) is to broaden patient perspectives on particular relational events and to expand their receptivity to interpersonal contexts outside of treatment.




MBT borrows from psychoanalysis and modern research. It is based on the unique human capacity to understand mental states that underlie one’s actions as well as those of others (mentalization).

MBT appears to be widely applicable to various types of patients, at different developmental stages and with psychiatric diagnoses.

It has been adapted and empirically validated in an adolescent format (MBT-A) and modified to treat eating disorders, depression, PTSD, and antisocial personality disorder.


1. Rossouw TI, Fonagy P. Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2012;51:1304-1313.

For more on this topic, see “

Mentalization-Based Treatment: A Common-Sense Approach to Borderline Personality Disorder

” by Lois W. Choi-Kain, MD and Brandon T. Unruh, MD, on which this quiz is based.
 

Poll

What are the benefits of traditional psychoanalytic concepts and new discoveries of mentalization-based treatment?

Mini Quiz: Mentalization-Based Treatment Goals

Mentalization-based treatment (MBT) is an evidence-based psychotherapeutic approach for borderline personality disorder. MBT is derived from both traditional psychoanalytic concepts and new discoveries from attachment and social cognition research. Mentalization simply describes the common psychological process that people use to understand mental states (ie, emotions, beliefs, desires-intentions that underlie interpersonal interactions). It covers a wide territory of psychological activity that determines the way people manage their emotions and thoughts coherently; effectively respond to their own experience and that of others; maintain satisfying relationships; and understand themselves, thereby stabilizing their sense of self (ie, identity). The stability, flexibility, benevolence, and honesty with which people mentalize underpins how their psychology works, or how their personality functions. Mentalization therefore lies at the root of psychological health and resilience as a common process relevant to all psychotherapies.

MBT’s simple, common-sense approach has practical advantages over dialectical behavioral therapy (DBT). Those who use MBT need little formal training to be effective.

 DBT requires skills coaching, a skills training curriculum with numerous handouts and worksheets, weekly individual therapy, and a consultation team to support therapists.

DBT formulates borderline personality disorder as a problem of emotional dysregulation and lack of skills to manage distress and relationships. MBT centralizes instability of attachment and its developmental byproduct, mentalization, as the core dysfunction. Fonagy and Allison

 extended the formulation of borderline personality disorder and personality disorders in general as a problem of epistemic trust, the capacity to “trust in the authenticity and personal relevance” of information presented in an interpersonal context. This revised notion explains the rigidity of thinking that individuals with borderline personality disorder (as well as those with other personality disorders) have with interpersonal relationships. Because of a tendency toward epistemic mistrust, individuals with borderline personality disorder have difficulty learning and changing despite repeated patterns of painful interpersonal problems and efforts by others to teach them how to manage less destructively.

According to attachment research and theory, infants activate attachment by communicating emotional distress to their caretakers. When all goes well, the caretaker responds in a way that re-regulates the infant. The first step of the optimal caretaking response is to recognize the infant’s distress and then reinstate confidence with soothing and optimistic encouragement to explore the environment (ie, via a secure base). Secure attachment facilitates self-regulation in terms of emotions, attentional control, and behavior. Early attachment also provides a template for expec­tations of oneself and others in relationships.

Secure attachment embodies a developmental process whereby the caretaker manages to reasonably imagine and interpret the mental states of the child, responding in a way that helps the child understand and manage his or her own distress. This is the process by which secure attachment facilitates the development of mentalization (

). For example, when a child falls and bursts into tears, a caretaker may respond in a marked contingent way with a sympathetic frown, underpinned by the idea “Poor baby, you fell and are hurt and scared.” An unmarked response might involve the caretaker actually mirroring the child and crying in distress. A noncontingent response would be completely nonresonant with the child’s experience: for example, an angry response with underlying cognitions such as “Why do you have to be so clumsy?”

If the caretaker is able to provide marked and contingent mirroring when the child is emotionally distressed, the child begins to develop a coherent sense of his own experience. This kindles the child’s ability to mentalize, allowing him to begin to understand the relationship between actions and mental states in an interpersonal interaction. This process ultimately becomes the basis of epistemic trust, which provides an openness to learn from others in a relational process. (See Bateman and Fonagy

 for a review of empirical data that support this model.)

The attachment styles most common in borderline personality disorder include preoccupied, fearful, and disorganized types that combine oscillatory, dependent, mistrustful, hostile, and incoherent features. The individual with borderline personality disorder has a tendency to engage (or make attachment bids to) others with disorganized, confusing, and controlling strategies, which in turn elicits disorganized, confusing, controlling tendencies in return.

This attachment transaction not only fails to regulate and re-establish a sense of safety, but also creates additional distress, increasing vulnerability and need in the child as well as the risk of dysregulation and burnout in the caretaker. As depicted in 

, this vicious cycle of distress and ineffective attachment functioning leads to a “hyperactivated” attachment, in which mentalizing in both child and caretaker is likely to be overwhelmed in favor of behavioral means of communication and problem solving.

While the clinical theories and neuroscientific evidence integrated in MBT’s formulation of borderline personality disorder are sophisticated, the techniques involved in MBT are simple and direct. At the base of the mentalizing stance is a position of curiosity, of being interested in exploring different perspectives of the patient’s experience both in relationships outside treatment and with the therapist. The job of the therpista is to encourage patients to mentalize, rather than do it for them by providing interpretations or by instructing them on how to manage behavior or distress. The only agenda is to sustain the mentalizing process to optimize the patient’s capacity to arrive at autonomous insight or behavioral change.

Mentalization is prone to go off­line in situations of stressful arousal (eg, intense emotion) and hyperactivated attachment. The MBT therapist intervenes when mentalizing becomes compromised. Detecting prementalistic states (

) prompts the clinician to recognize that the patient is unlikely to be able to understand her or others’ mental states realistically, benevolently, or flexibly. The clinician uses MBT techniques to broaden and thereby stabilize the patient’s capacity for empathy. According to this model, a common mistake in psychotherapeutic practice is to assume that the patient can mentalize when emotionally activated. Offering complex interpretations or behavioral plans when the patient is too vulnerable is useless because the patient is incapable of trusting the therapist or of making use of any interventions.

MBT begins with assessment and formulation of the patient’s problems and treatment goals within a mentalizing framework. The therapist and patient collaboratively explore presenting problems to establish joint attention to a shared understanding of the therapeutic work. This first step provides a secure base from which issues can be addressed as treatment unfolds.

Assessment of the patient’s overall mentalizing capacities starts with inviting a general account of problems that were the catalyst to seek treatment. Particular attention is paid to how breakdowns in mentalizing are linked to suicidal or self-destructive behaviors, and these vulnerability points are targeted as a central focus in the treatment. The therapist explores the patient’s capacity to maintain and recover mentalizing when challenged by emotionally laden interpersonal events, such as misunderstandings, disagreements, rejections (real or perceived), or intensification of intimacy. Important developmental events and attachment figures, past and present, are discussed to elucidate how robustly a person can mentalize within close relationships and where this capacity breaks down.

While probing these areas, the therapist scans for spontaneous descriptions of particular nonmentalizing modes that are overly disconnected from emotion (pretend mode), unreasonably certain (psychic equivalence: “I worry I can’t manage being alone; therefore, I can’t”), or concrete (teleological mode: “He doesn’t like me because he didn’t call me back right away”). Poor mentalizing is seen when extremes arise in the patient’s focus and the therapist intervenes with “contrary moves.” The patient is invited to incorporate the missing vantage point into a more balanced perspective, which allows assessment of the patient’s ability to broaden overly rigid, reactive, unrealistic, or emotionally vacant perspectives.

The initial assessment yields a general understanding of how presenting problems stem from fluctuations in mentalizing capacities related to the level of emotional arousal and attachment system activation. The therapist summarizes her findings in an openly shared, plainspoken manner. Patients are asked to think about and revise the formulation of emotional and relational patterns, to foster an ever-evolving and enhanced self-understanding. The initial phase of treatment also incorporates an explanation of the appropriate diagnosis and psychoeducation about concepts of mentalization, evolutionary functions of basic emotions, attachment styles, and the relevance of mentalizing for treatment.

Within structured MBT programs, an 8- to 12-week introductory MBT group is the primary vehicle for providing psychoeducation and pre-treatment engagement for patients who are considering or entering the program. This preliminary group segues into a longitudinal weekly MBT group that runs parallel to weekly individual therapy sessions. Patients are informed that individual and group therapists-in addition to psychiatrists who provide medication management and any other team members-meet regularly as a group to review case formulations, progress, and challenges arising in treatment as well as to expand clinicians’ individual perspectives on each patient through the collective mentalizing of the treatment team.

Basic mentalizing stance and hierarchy of interventions

For patients in a position of epistemic mistrust, therapeutic attempts aimed at probing, sympathetic support, and self-reflection can inadvertently destabilize mentalization by escalating emotional arousal and hyperactivating insecure or disorganized attachment processes. These iatrogenic disruptions are minimized by deploying a basic mentalizing stance that serves as a “secure base” from which the therapist promotes good mentalizing and facilitates its recovery when it is lost (

Therapists monitor the levels of mentalizing, emotional arousal, and attachment activation as they fluctuate over the course of the session. The aim is to stimulate just enough emotional responsiveness so that the exploration of new perspectives becomes meaningful, but not so much that mentalizing collapses due to unmanageable arousal.

As the treatment progresses, MBT carefully balances support strategies to develop the appropriate levels of trust and emotional arousal needed for good mentalizing. Initially, supportive strategies with empathic validation maneuvers are used to clarify and elaborate the patient’s perspectives. More challenging interventions help patients make sense of emotional undercurrents and relational dynamics implicit within the therapeutic relationship, which generally reflect similar dysfunction in relationships outside of treatment.

Adherence to the MBT model is enhanced by the therapist’s affect focus, frequent use of challenge, and integration of patients’ experiences across individual and group sessions. For example, imagine a patient who describes a situation in which she yelled at her child and felt guilty about it. In the session, the patient seems anxious and hypervigilant to the therapist’s response. The therapist would focus on the affect the patient experiences about how the therapist is mentalizing about her. This helps the patient understand not only her own affect but also her experience of talking about what is on her mind in the presence of another person. The therapist develops an inquiry and exploration in vivo, so the patient can conceptualize and express her affect within the interpersonal context. The ultimate goal of MBT is not merely to broaden patients’ perspectives on particular relational events, but to expand their reflective receptivity to new learning in interpersonal contexts outside of treatment.

MBT is an integrative treatment approach for borderline and other severe personality disorders. It combines ideas from both psychoanalysis and modern research and is based on the unique human capacity to mentalize, or understand mental states underlying one’s own actions as well as those of others. MBT appears to be widely applicable to various types of patients, at different developmental stages and with psychiatric diagnoses. It has been adapted and empirically validated in an adolescent format (MBT-A) and modified to treat eating disorders, depression, PTSD, and antisocial personality disorder.

Public health interests to augment access to care inform our view that MBT should be taught to trainees of various clinical disciplines, especially psychiatry residents, as a psychotherapy approach to treating “difficult to reach” patients with personality disorders. As the empirical basis for psychoanalytic treatment of most major psychiatric disorders remains slim and the demands for psychoanalytic training remain lengthy and time consuming, MBT presents a compromise to bridge the valuable history of psychoanalytic ideas to both modern psychiatric research as well as present public health needs and practice.

Dr Choi-Kain is Director of the Adult Borderline Center and Training Institute at the McLean Hospital in Belmont, MA; she is also Medical and Program Director and Dr Unruh is Assistant Medical Director at McLean Gunderson. Dr Choi-Kain reports that she is Course Director and receives royalties from HMS Continuing Education, and she receives royalties from Springer as author and editor of Borderline Personality and Mood Disorders. Dr Unruh reports no conflicts of interest concerning the subject matter of this article.

 Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. 

 Bateman A, Fonagy P. Health service utilization costs for borderline personality disorder patients treated with psychoanalytically oriented partial hospitalization versus general psychiatric care. 

 Fonagy P, Allison E. The role of mentalizing and epistemic trust in the therapeutic relationship. 

Handbook of Mentalizing in Mental Health Practice

. Arlington, VA: American Psychiatric Publishing; 2012.

 Rossouw TI, Fonagy P. Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial. 

MBT presents a compromise to bridge the valuable history of psychoanalytic ideas to both modern psychiatric research as well as present public health needs and practice.

 (or both) can feel entitled to special treatment and often seek only approving forms of attention from those who treat them. Such appeals for special treatment may prompt clinicians to worry that gratifying them can reinforce unrealistic interpersonal expectations, but that withholding may elicit reactive worsening of symptoms or dropping out.

Questions to consider when reading the case:

1. In what ways might the therapist help the patient address her problems?

2. If therapeutic efforts fail, how much time should transpire before the therapist advises the patient s/he is unable to help?


Kathy is a 52-year-old divorced woman who is referred for treatment following a suicide attempt related to losing her job. Kathy began therapy with the goal of developing more close relationships. Her children don’t speak to her and her family reports walking on eggshells around her because of her volatility.

At the start of treatment, Kathy made multiple requests to have her appointment times adjusted to accommodate her schedule and frequently needed to move the furniture in the office to suit her better. The therapist managed this by saying that she understood why such changes were preferred but that she was unfortunately not able to meet Kathy’s requests. The therapist also reminded Kathy that she was very much interested in helping her meet her treatment goals.

The greater difficulty was that Kathy used up quite a bit of time in therapy dwelling on how she was doing better than other people she knew. She reported only her successes in hopes of being praised. Her therapist had a hard time getting Kathy to focus on the problems that brought her into treatment.


In working with patients with BPD, feelings of entitlement and efforts to avoid criticism are common forms of resistance. Clinicians who respond to a patient’s sense of entitlement with efforts to withhold what is demanded or to interpret the unrealistic nature of the patient’s needs are likely to make such a patient feel 

. Providing validation for the patient’s needs without gratifying them offers a compromise that acknowledges the patient’s wishes without reinforcing his or her demands.

The problem of getting a patient focused on talking about difficulties is complicated. One approach involves making attention contingent on it. As a clinician, you can lean back in your chair and look perplexed when the patient dwells on how good he is at things. When the patient shifts to talking about difficulties, you can lean forward and give your undivided attention.

Along with these nonverbal reinforcements of behaviors, it can help to note that you already know that the patient is very good, if not exceptional, at the things he is describing. Then add, “I feel our limited time is valuable and want to make sure you have time to discuss the things you are having difficulty with.” This approach avoids confronting the patient’s efforts to support his own self-esteem while also helping him move onto more relevant material.

[Editor's note: For further reading, please see “

Borderline Personality Disorder and Resistance to Treatment

,” by Lois W. Choi-Kain, MD and John G. Gunderson, MD, from which this case was adapted.]

Patients with borderline personality disorder or narcissistic personality disorder (or both) can feel entitled to special treatment and often seek only approving forms of attention from those who treat them.

Treatment Resistance in a Woman With Borderline Personality Disorder

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.”

 In the early 1950s, Robert Knight emphasized their regressive responses to unstructured treatments.

 In hospitals, borderline patients were referred to as “help-rejecting complainers.”

” 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 

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.

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.

was developed for personality-disordered patients who were “nonresponders” to-or “relapsers” from-standard cognitive-behavioral therapy.

 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 

. 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.

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.

 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.

 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.

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.”

For clinicians who lack experience in treating patients with BPD, scenarios like this one are common. Some believe that treatment of a comorbid Axis II pathology can be deferred until after a patient has been discharged, despite the clear relationship between acute symptoms and interpersonal conflicts or other social stressors. In this vignette, Sara’s treatment team diligently attended to her depressive symptoms, but the approach they used encouraged an undue hope that somatic treatments would resolve her depression. It also encouraged a passive role on Sara’s part; she was not held responsible for any part of getting better. Her failure to stop cutting herself could be interpreted as her resistance against treatment, but it was almost certainly related to the misinformed strategies taken by the treatment team. Sara’s treatments reinforced her belief that her problems were outside herself and that she could rely on someone else to fix them.

Clinicians should actively treat both mood/anxiety symptoms and BPD symptoms, but comorbid BPD decreases the likely response to medications. Psychotherapeutic interventions that require activity and responsibility on the patient’s part are most effective. When there are ongoing borderline issues (such as recurrent self-harm and extreme reactivity to interpersonal issues), these issues need to be a central focus in the ongoing treatment from the start.

 By giving such patients tools to manage their anxiety, their affects, and their impulses in lieu of self-harm, we give them the opportunity to manage their own safety. This helps them begin to focus inwardly rather than depend on rescue by others.

Patients with BPD or narcissistic personality disorder (or both) can feel 

 and often seek only approving forms of attention from those who treat them. Such appeals for special treatment may prompt clinicians to worry that gratifying them can reinforce unrealistic interpersonal expectations, but that withholding may elicit reactive worsening of symptoms or dropping out.

Kathy is a 52-year-old divorced woman who is referred for treatment following a suicide attempt related to losing her job. Kathy began therapy with the goal of developing more close relationships. Her children don’t speak to her and her family reports walking on eggshells around her because of her volatility. At the start of treatment, Kathy made multiple requests to have her appointment times adjusted to accommodate her schedule and frequently needed to move the furniture in the office to suit her better. The therapist managed this by saying that she understood why such changes were preferred but that she was unfortunately not able to meet Kathy’s requests. The therapist also reminded Kathy that she was very interested in helping her meet her treatment goals. 

The greater difficulty was that in therapy, Kathy dwelled on how she was doing better than other people she knew. She reported only her successes in hopes of being praised. Her therapist had a hard time getting Kathy to focus on the problems that brought her into treatment.

In working with patients with BPD, feelings of entitlement and efforts to avoid criticism are common forms of resistance. Clinicians who respond to a patient’s sense of entitlement with efforts to withhold what is demanded or to interpret the unrealistic nature of the patient’s needs are likely to make such a patient feel misunderstood, criticized, and angry. Providing validation for the patient’s needs without gratifying them offers a compromise that acknowledges the patient’s wishes without reinforcing his demands.

The problem of getting a patient focused on talking about difficulties is complicated. One approach involves making attention contingent on it. As a clinician, you can lean back in your chair and look perplexed when the patient dwells on how good he is at things. When the patient shifts to talking about difficulties, you can lean forward and give your undivided attention. Along with these nonverbal reinforcements of behaviors, it can help to note that you already know that the patient is very good, if not exceptional, at the things he is describing. Then add, “I feel our limited time is valuable and want to make sure you have time to discuss the things you are having difficulty with.” This approach avoids confronting the patient’s efforts to support his own self-esteem while also helping him move onto more relevant material.

Another important source of resistance in treating patients with BPD is their notion that change may entail betraying their family in particular ways as well as giving up habits they may feel work well for them in avoiding feelings.

Melody is the oldest child in a close-knit family. She has always been athletic, but she also has a long history of recurrent sports-related injuries. Melody is preoccupied with performance and sensitive to criticism. At home, negative feelings were not talked about: her parents thought they were shameful. Recurrent injuries were the only manner in which she could elicit sympathetic reactions from her parents. 

When Melody went to college and encountered academic difficulties, she started to fall down stairs and trip over things repeatedly. After each accident, her family came rushing to take care of her. When it was found out that Melody’s accidents were deliberate, she began psychotherapy.

At first, Melody was highly anxious and sat in silence, unable to verbalize her feelings. Over time, however, she began to talk about her accidents as ways to not think about missing home and to explain her failure to excel at school. Whenever she spoke about her fears of parental disapproval, she would have the impulse to hurt herself. Her parents became fearful and encouraged psychiatric hospitalizations every time she spoke about her difficulties. Melody became more anxious and angry as a result. She noted that her old way of hurting herself (accidents) was more effective in diverting her attention away from unwanted feelings and gaining her parents support than talking about feelings.

When her family was asked to be involved in her treatment, both Melody and her parents decided that therapy was not helpful and terminated the treatment.

This vignette illustrates a common situation in which self-harm functions to divert attention away from emotional difficulties and to enlist noncritical caregiving support. The behavioral “acting out” is itself a common form of resistance. Both Melody and her parents resisted the process of replacing self-harm with self-reflection and verbalization of feelings in therapy. When patients like Melody start the difficult tasks of change and confronting negative affects, they will feel worse before they feel better. It is helpful to teach borderline patients and their families that this is expected and is how therapy can work.

The vignettes presented here illustrate several forms of resistance that clinicians can expect to encounter in working with patients with BPD. We have not attempted to be comprehensive about all the forms of resistance encountered. A few of the other common resistances include deceit, projection, and “splitting.” Clinicians should appreciate that what may seem like willful deceit can often better be understood as the patient’s defensive ability to dissociate or deny, or to lose his mentalizing abilities, when stressed.

Projection can also become a formidable means of resistance. The clinician needs to seek out that sometimes-modest fraction of the patient’s complaints and attributions that are true and begin to validate them.

This principle is also central in responding to splitting. Clinicians who are idealized by their patients should accept the partial truth of this, while clinicians who are vilified should acknowledge that they did or said something that makes the patient’s 

Our review is intended to illustrate that the patient’s resistance to treatment can be aggravated by a therapist’s misunderstandings of BPD. It is easy to blame the patient for responding poorly to treatments (being “resistant”) without recognizing that when treatments don’t reflect an understanding of BPD, the treatments can aggravate these resistances.

These comments are not meant to minimize the diverse array of resistances that patients with BPD present. These patients will 

, but when their particular forms of resistance to treatment are understood as learned behaviors that have served adaptive function, we can move toward a more empathic and sympathetic therapeutic posture. Resistance can then be replaced by more truly adaptive responses.

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Historically, borderline patients were considered “help-rejecting complainers.” Clinicians should actively treat both mood/anxiety symptoms and BPD symptoms.