Psychotherapy and Therapeutic Drugs

R. Skip Johnson

Group and individual talk-therapy are generally the primary treatments for Borderline Personality Disorder. Pharmacological agents are often prescribed based for specific symptoms shown by individual patients. There is no "BPD pill".


All of the psychotherapies proving successful for Borderline Personality Disorder (BPD) strive to address underlying deficits in the ability of patients to relate to others and manage emotions, longstanding problems that are typically rooted in childhood experience. Several forms of psychotherapy— including dialectical-behavioral therapy (DBT), cognitive-behavioral therapy (CBT), transference-focused therapy, and mentalization-based therapy - have been found in studies to be effective for Borderline Personality Disorder.

  1. Cognitive-behavioral therapy (CBT)
  2. Transference-focused therapy (TFP)
  3. Dialectical-behavioral therapy (DBT)
  4. Schema-focused Therapy (SFT) and
  5. Mentalization-based therapy (MBT)

Experts say this new crop of clinical trials has propelled the field into the era of evidence-based medicine. The effectiveness of DBT was demonstrated in a study in the July 2006 Archives of General Psychiatry. Transference-focused therapy was proven effective in a study published in the February 2006 Journal of Clinical Psychology. And a study of mentalization-focused therapy is currently ongoing. Schema therapy, the newest innovation integrating elements of several psychotherapies for BPD, has been found highly effective in its first randomized, controlled trial, reported in the August 2006 Archives of General Psychiatry.

"The field is coming into its own because we are doing randomized, controlled trials to determine what actually works," Joel Paris, M.D., told Psychiatric News. "In the past we were dependent on the charisma of therapeutic gurus." Paris is a professor and chair of the Department of Psychiatry at McGill University in Montreal and editor in chief of the Canadian Journal of Psychiatry. He is also a past president of the Association for Research in Personality Disorders.

Paris says there is no consensus about whether one therapy is any better than the others, though DBT has been around the longest and is widely taught.

Despite their proven effectiveness, all of the psychotherapies for BPD are time and labor intensive.

"All suffer from the need for highly trained therapists, specialized settings, human resources, and time," Paris told Psychiatric News. "There are many barriers to psychotherapy for BPD. Most involve money, since only a small number of these patients can pay, and few have adequate insurance. Another barrier is the failure of psychiatrists and other professionals to recognize and diagnose BPD. Still another is the current tendency to treat BPD with medication alone."

Paris said in an address at American Psychiatric Association's annual meeting last year in Toronto that drugs were vastly overused in treatment of all the personality disorders (Psychiatric News, July 7, 2006).

"The problem is that there is no science to support polypharmacy, and it's probably bad for patients," he said at the meeting. "When you give patients with classical depression an antidepressant, they may be cured in a few weeks. But you never see that in patients with borderline personality. It might take the edge off, but patients never go into remission."

Individuals with Borderline Personality Disorder, due to invalidating environments during upbringing and due to biological factors not well characterized at this point, react abnormally to emotional stimulation. Their level of arousal goes up much more quickly, peaks at a higher level, and takes more time to return to baseline. This explains why they often have crisis-strewn lives and extreme emotional lability (emotions that shift rapidly). Because of their past invalidation, they don't have any methods for coping with these sudden, intense surges of emotion.

Cognitive-behavioral therapy (CBT) Cognitive-behavioral therapy (CBT), founded by Albert Ellis, Ph.D. is a combination of two therapy techniques: cognitive and behavioral. Cognitive therapy refers to an approach that focuses on a person's cognitions: their thoughts, assumptions, and beliefs. With this therapy approach a person learns to recognize and change faulty or maladaptive thought patterns. The focus is on restructuring the dysfunctional cognitions through a process of identifying, challenging, and reshaping them. Behavioral therapy focuses on changing a person's unhealthy and problematic behaviors, actions, and responses. The focus is not on "why" something happens, but changing the process to prevent, alter, or replace it with a healthier more effective behavior. Dialectical-behavioral therapy (DBT), and Schema-focused Therapy (SFT) are specialized types of CBT.

Dialectical-behavioral therapy (DBT) Developed by Marcia Linehan, Ph.D., of the Department of Psychology at the University of Washington, DBT directly targets suicidal and other dangerous, severe, or destabilizing behaviors. Standard DBT strives to increase behavioral capabilities, improve motivation for skillful behavior through management of issues and problems as they come up in day-to-day life and reduction of interfering emotions and cognitions, and structure the treatment environment so that it reinforces functional rather than dysfunctional behaviors. Therapy consists of weekly individual psychotherapy, group skills training, telephone consultation, and weekly meetings between therapist and a consultation team to enhance therapist motivation and skills and to provide therapy for the therapists. DBT skills for emotion regulation include:

  1. Identifying and labeling emotions
  2. Identifying obstacles to changing emotions
  3. Reducing vulnerability to emotion mind
  4. Increasing positive emotional events
  5. Increasing mindfulness to current emotions
  6. Taking opposite action
  7. Applying distress tolerance techniques

A recent report compares patients that DBT vs those that received treatment by community experts. The latter were therapists who were experienced in the treatment of BPD but used methods other than DBT to treat randomly assigned patients.

Subjects receiving DBT were half as likely to make a suicide attempt, required fewer hospitalizations for suicide ideation, and had lower medical risk across all suicide attempts and self-injurious acts combined. They were also less likely to drop out of treatment and had fewer psychiatric hospitalizations and psychiatric emergency department visits, according to the report.

An abstract of the study, "Two-Year Randomized Controlled Trial and Follow-Up of Dialectical Behavior Therapy vs. Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder," is posted here.

Schema Therapy Builds on CBT Schema therapy, the newest of the psychotherapies for BPD, appears to synthesize elements of several successful therapies. Paris has described it as "CBT with a psychodynamic component."

Schema therapy founder Jeffrey Young, Ph.D., who is on the faculty of the Department of Psychiatry at Columbia University College of Physicians and Surgeons, was one of the first students of Aaron Beck, M.D., the founder of cognitive therapy.

"I found that cognitive therapy was extremely effective with many Axis I disorders, as research has since substantiated, but was much less effective by itself with Axis II personality disorders," he told Psychiatric News. "I began to look for ways to expand cognitive-behavior therapy to work with Axis II issues by integrating elements drawn from other approaches as well as CBT, including psychodynamic therapies such as object relations, emotion-focused/gestalt therapies, and attachment theory."

Young described schema therapy as an active, structured therapy for assessing and changing deep-rooted psychological problems by looking at repetitive life patterns and core life themes, called "schemas." Schema therapists use an inventory to assess the schemas that cause persistent problems in a patient's life.

"Once we have determined what schemas a patient has, we use a range of techniques for changing these schemas," Young said. "These include cognitive restructuring, limited re-parenting, changing schemas as they arise in the therapy relationship, intensive imagery work to access and change the source of schemas, and creating dialogues between the `schema,' or dysfunctional, side of patients and the healthy side."

He added that systematic behavioral techniques are also employed to change dysfunctional coping styles, especially maladaptive behaviors in intimate relationships. More information about schema therapy is posted here.

In a randomized trial of schema therapy versus transference-focused therapy published in the Archives in June 2006, statistically and clinically significant improvements were found for both treatments on all measures after one, two, and three-year treatment periods. Data on 44 schema therapy patients and 42 transference-focused therapy patients were available.

Main outcome measures included scores on the Borderline Personality Disorder Severity Index, quality of life, and general psychopat hologic dysf unction. Patient assessments were made before randomization and then every three months for three years.

Significantly more schema therapy patients fully recovered (46 percent versus 26 percent) or showed reliable clinical improvement (66 percent versus 33 percent) on the Borderline Personality Disorder Severity Index than patients receiving transference-focused therapy. They also improved more in general psychopathologic dysfunction and showed greater increases in quality of life.

Statistical analysis also revealed a higher dropout risk among transference-focused therapy (52 percent) patients than among patients receiving schema therapy (29 percent), according to the study report.

The report, "Outpatient Psychotherapy for Borderline Personality Disorder: Randomized Trial of Schema-Focused Therapy vs. Transference-Focused Psychotherapy," is posted here.

"This is the first controlled study demonstrating that a treatment is capable of reducing all of the BPD manifestations as defined by DSM-IV, reduces associated personality features and general psychopathology, and increases quality of life," study co-author Arnoud Arntz, Ph.D., told Psychiatric News.

He is with the Department of Medical, Clinical, and Experimental Psychology at the University of Maastricht, in the Netherlands.

The authors also stated that, in a separate analysis, schema therapy was found to be highly cost-effective for society, despite the length and intensity of the treatment.

Young, who was not involved in the study, said it is the first to demonstrate "deep personality change" in a high percentage of patients long considered untreatable.

"Up until now, existing therapies for BPD have proven to lead to only partial recovery or have only been able to reduce self-harming behaviors," he said. "This should be of great interest to psychiatrists because patients with BPD are usually considered the most difficult, frustrating, and risky patients within most therapists' practices.

"The second important implication for psychiatrists is that the use of a neutral stance toward the BPD patient, which is advocated in most psychody namic approaches to BPD, is clearly much less effective than the more engaged, warm, and nurturing stance of schema therapy," Young said. "This was demonstrated by the dramatic differences in dropout rates between the two treatments."

Mentalization Therapy It has been proposed that people with BPD have hyperactive attachment systems as a result of their history or biological predisposition, which may account for their reduced capacity to mentalize. They would be particularly vulnerable to side-effects of psychotherapeutic treatments that activate this attachment system. Because the approach is psychodynamic, therapy tends to be less directive than cognitive-behavioral approaches, such as dialectical behavior therapy (DBT), another common treatment approach for borderline personality disorder.

Mentalization is the capacity to understand both behavior and feelings and how they’re associated with specific mental states, not just in the client, but in others as well. It is theorized that people with Borderline Personality Disorder (BPD) have a decreased capacity for mentalization. Mentalization-based therapy, pioneered by Andrew Bateman, M.A., and Peter Fonagy, Ph.D., seeks to facilitate the capacity for "mentalization"—the ability to perceive the mind of others as distinct from one's own and hence to reconsider and reassess one's own perceptions of reality. Mentalization is a component in most traditional types of psychotherapy, but it is not usually the primary focus of such therapy approaches.

Transference-focused Psychotherapy
Transference-focused Psychotherapy (TFP), founded by Otto Kernberg, M.D., is a psychodynamic treatment designed especially for patients with borderline personality disorder (BPD). Transference-focused psychotherapy among others, is an adaptation of psychoanalysis that aims to correct distortions in the patient's perception of significant others and of the therapist.

TFP, which dates back many years, places special emphasis on the assessment and on the treatment contract between the client and the therapist. The setting up of the contract and frame has a behavioral quality in that parameters are established to deal with the likely threats both to the treatment and to the patient's well-being that may occur in the course of the treatment. The patient is engaged as a collaborator in setting up these conditions.

After the behavioral symptoms of borderline pathology are contained through structure and limit setting, the psychological structure that is believed to be the core of borderline personality is analyzed as it unfolds in the relation with the therapist as perceived by the patient [transference].

For more information: Member discussion

Multiple Family Group Program at McLean Hospital (Harvard University) by John G. Gunderson, M.D. and Cynthia Berkowitz, M.D. Published by The New England Personality Disorder Association (617) 855-2680

Acknowledgement: The Guidelines are adapted from a chapter by the authors, “Family Pschoeducation and Multi-Family Groups in the Treatment of Schizophrenia,” McFarlane W. and Dunne B., eds, Directions in Psychiatry 11: 20, 1991.

Threapuetic Treatment of Borderline Personality Disorder: Drugs

Group and individual psychotherapy is generally the primary therapy. Pharmacological treatments are often prescribed based on specific target symptoms shown by the individual patient ~ National Institute of Mental Health

Treatments for BPD have improved in recent years. Group and individual psychotherapy are at least partially effective for many patients. According to the National Institute of Mental Health, pharmacological treatments are often prescribed based on specific target symptoms shown by the individual patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and/or labile mood. Antipsychotic drugs may also be used when there are distortions in thinking.

Robert O. Friedel, MD, author of "Borderline Personality Disorder - Demystified" says that three classes of medications have been found to be useful in reducing the core symptoms of borderline disorder:

  1. Neuroleptics/ atypical antipsychotics
  2. Certain antidepressants
  3. Mood-stabilizing agents


Neuroleptics Symptoms Improved by One or More Medications in the Class - anxiety, obsessive-compulsivity, depression, suicide attempts, hostility, impulsivity, self-injury/assaultiveness, illusions, paranoid thinking, psychoticism, poor general functioning

  1. thiothixene (Navane)*
  2. haloperidol (Haldol)*
  3. trifluoperazine (Stelazine)*
  4. flupenthixol*

Atypical Symptoms Improved by One or More Medications in the Class - anxiety, anger/hostility, paranoid thinking, self-injury, impulsive aggression, interpersonal sensitivity, low mood and aggression.

  1. olanzapine (Zyprexa)*
  2. aripiprazole (Abilify)*
  3. risperidone (Risperdal)°
  4. clozapine (Clozaril)°
  5. quetiapine (Seroquel)°

SSRIs and related antidepressants Symptoms Improved by One or More Medications in the Class - anxiety, depression, mood swings, impulsivity, anger/hostility, self-injury, impulsive-aggression, poor general functioning

  1. fluoxetine (Prozac)*
  2. fluvoxamine (Luvox)*
  3. sertraline (Zoloft)°
  4. venlafaxine (Effexor)°

MAOIs Symptoms Improved by One or More Medications in the Class - depression, anger/hostility, mood swings, rejection sensitivity, impulsivity

  1. phenelzine (Nardil)*

Mood Stabilizers

Symptoms Improved by One or More Medications in the Class - unstable mood, anxiety, depression, anger, irritability, impulsivity, aggression, suicidality, poor general functioning

  1. divalproex (Depakote)*
  2. lamotrigine (Lamictal)*
  3. topiramate (Topamax)*
  4. carbamazepine (Tegretol)°
  5. lithium°

This information is provided as a general informational guide to help readers understand the relationship of the category names, common brand names and generic names. This article was not written by a licensed health care professional. This web site is intended to support, not replace the relationship between the patient and the physician.


Staff report adapted from articles by the American Psychiatric Association, Steven Gans, MD, and John M. Grohol, Psy.D.

Last modified: 
January 04, 2021