Psychotherapy for BPD - what works for whom?

Simone Hoermann, Ph.D. Updated: May 21st 2009

image of a graph with three lines against blue background I sometimes receive emails asking me which type of therapy would be best for someone with Borderline Personality Disorder. This is a tough question, and, as it happens so often in my field, there is just not one easy answer.

During my postdoctoral training several years ago, I was involved in a research study that was recently written up and published by Clarkin, Levy, Lenzenweger and Kernberg in the American Journal of Psychiatry in 2007. Part of my job back then was to help evaluate 90 people who had been diagnosed with Borderline Personality Disorder (BPD) and follow them over the course of at least a year.

When people entered the study, they had to complete self-report questionnaires and interviews that carefully assessed their symptoms and difficulties, including measures of impulsivity, self-destructive behaviors, depression, anger, and functioning at work and in relationships. After collecting all this information, participants were randomly – like with the flip of a coin - assigned to one of three types of manualized psychotherapy: Transference Focused Psychotherapy (TFP) , Dialectical Behavior Therapy (DBT) , and supportive psychotherapy.

After carefully analyzing the follow up data that were collected over the course of one year, the authors concluded that all three types of treatment were associated with improvement of symptoms of Borderline Personality. Of note, there was some difference in what symptom domains were improved by which treatment, though overall, the authors summarize: “The general equivalence of outcome across the three treatments studied suggests that there may be different routes to symptom change in patients with borderline personality disorder. In contrast to dialectical behavior therapy, which focuses directly on skills to help the patient regulate emotion and reduce symptoms, transference-focused psychotherapy focuses on developing greater self-control through the integration of representations of self and other as they are activated in the relationship with the therapists.”

When I asked Dr. Peter Fonagy, who is Freud Memorial Professor of Psychoanalysis, Head of the Research Department of Clinical, Educational and Health Psychology at University College London, and a proponent of Mentalization Based Psychotherapy (MBT) , the question of what treatment works for whom, his response was similar, indicating that he could not pinpoint a general rule as to which treatment works better, or what type of therapy works for whom.

Dr. Fonagy’s conclusion was that some people respond better to a certain style or person, so that it is less important which exact type of therapy it is. The idea is that any treatment that works has to be robust, meaning that it has to not get derailed by some of the dramatic actions that happen when treating someone with BPD. The people who are practicing these therapies have to be committed, and it helps if they are supported by a team, since some of these problems are too difficult to handle in a simple outpatient setting.

“I would go with the skill of the therapist,” he recommended, “Go with the therapist who is more competent. For example, if it is between someone who is a really good DBT therapist and someone who is a lousy MBT therapist, I would go with the good DBT therapist and send my family there, too. “

Simone Hoermann, Ph.D., is a Psychologist in private practice in New York City. She specializes in providing psychotherapy for Personality Disorders, Anxiety, and Depression. She is a faculty member of Columbia University, and facilitates psychotherapy and skills training groups at the Columbia East 60th Street Day Treatment Program.

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