Introduction

Borderline personality disorder (BPD) is a cluster B

personality disorder, which throughout its history has gained a

reputation of one of the most complicated and hard to treat

psychiatric disorders. Recent studies report a 5.9% lifetime

prevalence of this disorder in the general population, with BPD

occurring more often in women than in men (Grant et al, 2008).

Characterized by impulsivity, difficulty in controlling emotions,

recurrent suicidal and self-mutilating behaviors, unstable

interpersonal relationships and distorted self-image, BPD is an

extremely devastating condition. Those afflicted by it experience

deep emotional distress, fluctuating self-esteem, as well as

trouble in maintaining a meaningful relationship with other

people. Its frequent comorbidity with substance abuse, mood and

anxiety disorders complicates the treatment of BPD even further.

As a consequence, borderline personality disorder has even been

considered untreatable for the major part of its history.

However, some psychotherapies, such as dialectical behavior

therapy (DBT), transference-focused therapy and a couple of

other, not discussed in this paper, therapies have been proved to

be effective in reducing symptoms of BPD clients and improving

their social adjustment (Dixon-Gordon et al., 2011). DBT has been

developed specifically for the treatment of BPD patients, and so

far reports the largest amount of clinical research on its

effectiveness with BPD. Since it was introduced in the late

1970s, DBT has become a treatment of choice for many clinicians.

Incorporating principles of cognitive-behavioral and humanistic

approaches, DBT also includes some of the Zen Buddhist concepts,

such as mindfulness and meditation. DBT emphasizes clients’ self-

acceptance as the main mechanism of change. This kind of therapy

has proved to be very successful in modulating problematic

behaviors, such as self-mutilation or drug abuse, and decreasing

depression and anxiety symptoms (Koons et al., 2001).

Transference-focused psychotherapy (TFP), on the other hand,

stems from the object relations psychodynamic theory. It holds

that BPD arises from object representations that were incorrectly

formed during the childhood. According to this theory, BPD

clients failed to develop stable identity and self-image because

of their parents’ inconsistent behavior. Therapeutic relationship

based on the transference can help to overcome the evolved

psychopathology and promote the development of the autonomous

self. As research shows, TFP can be very effective in dealing

with such borderline symptoms as impulsivity, inappropriate anger

and poor emotion control (Clarkin et al., 2007).

Contrasting these two approaches, one can come to a conclusion

that two therapies are equally effective in treating BPD.

However, when it comes to treating particular symptoms,

psychotherapies vary in effectiveness depending on symptoms in

question (Clarkin et al., 2007). This paper will attempt to

compare these psychotherapies’ effectiveness in treating

borderline personality disorder. It will also describe BPD in

greater detail, and thoroughly discuss dialectical behavior

therapy and transference-focused therapy, their theories of

personality and psychopathology, as well as their basic tenets

and approaches to the treatment of BPD.

Borderline Personality Disorder

As it was already mentioned, borderline personality disorder

(BPD) is notoriously difficult to treat. Individuals afflicted by

this psychopathology tend to be very impulsive and irritable,

often engage in risky behaviors (substance abuse, unprotected

sex, excessive spending, gambling, etc.), and experience frequent

mood swings. Their emotions are very deep, intense, and can shift

rapidly and abruptly, going from affectionate idealization to

extreme anger and disappointment. This rapid switch in affect may

seem really puzzling and unexpected, as other people do not see

any apparent reason for such a drastic change. A tendency towards

overreaction and dramatization is another characteristic of BPD

patients. Their emotional reaction to other people and events may

often be extreme, sometimes inappropriate and out of range: what

at most causes a slight irritation in a healthy person can

provoke a temper tantrum in a person with BPD.

Self-image and self-esteem of BPD sufferers are also unstable

and widely fluctuating. As their perception of self has not been

developed properly, they tend to be inconsistent in self-

judgments and attitudes. The absence of a steady identity leads

to inconsistency in values, beliefs, and life goals. It produces

chronic feelings of emptiness and inadequacy, which can be

overwhelming for BPD clients.

Persistent feelings of emptiness, inability to control one’s

emotions and extremely vulnerable self-esteem get rise to

depression and anxiety, which appear as comorbid conditions in

the majority of BPD clients (Grant et al., 2008). Other important

symptoms of BPD are suicidality and self-mutilating behaviors. It

has been estimated that lifetime suicide range is about 3 to 10 %

in BPD clients, with even greater percentage of uncompleted

suicide attempts (Paris & Zweig-Frank, 2001). Self-mutilation

(e.g. cutting) can occur with or without suicide attempt, but the

underlying reasons of non-suicidal self-injury are usually

dissimilar to the reasons for suicide attempts. Whereas suicide

attempts arise from an extreme distress, desperation and feeling

of being a burden, non-suicidal self-injury is often an immediate

response of borderline clients to their anger and negative

emotions. Self-injury can also be used as a method of self-

punishment, or a way to distract oneself from an intense

emotional pain and regain normal feelings (Brown et al., 2002).

In addition, dissociative episodes are frequently reported

in BPD clients. These episodes are supposed to serve as a way to

protect and distract oneself from traumatic experiences and

extreme negative emotions, which can be provoked by these

experiences.

The interpersonal relations of people suffering from BPD are

also complicated and troubled by their condition. They are very

sensitive to the way other people treat them and are

exceptionally vulnerable to criticism, rejection, and

abandonment. Although BPD clients have no difficulty establishing

close relationships with other people, they usually fail to

maintain them in the long run. In general, interpersonal

relations of BPD clients tend to be very intense and pretty short

in duration. Having established an emotionally close

relationship, they very soon become dissatisfied with the way

other person treats them. Scared of the possibility of

abandonment, they begin to put a tremendous effort into avoiding

the perceived desertion and receiving nurturance. They can go a

long way in their desire to get attention from their loved ones,

and sometimes they can even engage in outright manipulation.

Furthermore, borderline clients’ perceptions of other people

are as unstable as their views of themselves. They shift attitude

to their significant others from aggrandizing to devaluation, and

tend to view others as either “all good” or “all bad”. This can

produce a significant distress in all spheres of life and

undermine establishing successful and long-lasting friendships,

families, and romantic relationships.

To sum it up, BPD is a complex psychological condition and

its treatment may be complicated by many factors, such as

inability of a client to form a stable therapeutic relationship

with a therapist, high risk of suicide, and multiple comorbid

conditions. A successful therapy for this disorder should be able

to decrease the overall amount of personal distress, improve the

most devastating symptoms and strengthen clients’ social skills.

In the next two sections of this paper, two successful therapies

for BPD will be introduced.

Dialectical Behavior Therapy (DBT)

Marsha Linehan developed DBT in 1970s specifically for the

treatment of borderline personality disorder. As it was discussed

above, DBT encompasses the basic principles of behavior

therapies, humanistic approach, and Zen Buddhism concepts. The

basic tenets of DBT hold that individuals suffering from BPD have

genetic and biological predisposition to experience intense

uncontrolled emotions. They are very vulnerable and reactive to

the emotional stimuli, and once they are emotionally aroused,

they have a difficulty to calm down. When this biological

predisposition to high emotionality is combined with a social

environment, which is hostile and emotionally invalidating or

abusive, BPD can be quickly generated. As mentioned before, BPD

clients may become very sensitive to any expression of criticism

or rejection. This sensitivity can create a significant obstacle

to establishing successful therapeutic relationship. In such a

way, any attempt of the therapist to modify client’s behavior may

be perceived by a client as some form of criticism or

invalidation. To overcome this difficulty, Carl Rogers’

principles of unconditional positive regard, genuineness and

empathy were incorporated into DBT. Moreover, to help clients

accept their own disturbing thoughts and emotions some components

of Buddhist practices were introduced in DBT as well. DBT is

designed to fit the most important needs of BPD clients and its

main goal is to help these people learn to react in a balanced

way to other people and situations, and live a life, which allows

for a full range of healthy emotional experiences.

The therapeutical processes of DBT are based on the process

of dialectic. During the course of the therapy a thesis of

behavioral therapy (“Client needs to change some of his/her

behaviors”) is contrasted with an antithesis (“Therapist should

accept client, without trying to modify his/her behaviors”). At

some point of therapy the synthesis is created, enabling the

client to balance change and acceptance. However, this process

can be rather intricate and complicated. To fulfill all of its

goals therapeutic interventions are delivered in four main modes.

During the first mode, therapy is focused on building a solid

therapeutic relationship between the client and his/her

individual therapist and exterminating the most problematic

behaviors of the client. First, life-threatening and dangerous

behaviors are targeted. Among these behaviors are self-injury,

suicidal thoughts and attempts, drug abuse and reckless driving.

Next, the therapist seeks to eliminate behaviors that interfere

with therapy, such as non-attendance or not doing homework. And

finally, behaviors and conditions that decrease life quality

(e.g. homelessness, axis I disorders) are ameliorated.

The second mode of DBT focuses on skills training, during

which client learns a set of four primary skills: mindfulness,

distress tolerance, emotional regulation, and interpersonal

effectiveness. Mindfulness usually means the awareness of

individual of his or her present experience. Its practice often

includes focusing on unification with a current experience and

finding a middle ground between extreme mental states. The skills

of observing, describing, fully participating and focusing on one

thing at the moment are commonly taught in this module (Lynch et

al., 2007). Distress tolerance training usually equips clients

with a set of skills, which enable them to efficiently cope with

unpleasant situations and radically accept what cannot be changed

(Lynch et al., 2007). Emotional regulation training helps clients

to gain control over their emotional experiences by teaching them

to identify what emotion is experienced at the moment, whether it

is appropriate for current circumstances and whether the client

wants to change this emotion (Lynch et al., 2007). Finally,

interpersonal effectiveness skills learned by clients help them

to improve the relationships with others at the same time

preserving their values and self-respect.

In the third mode of DBT, skills learned during the therapy

begin to be generalized to clients’ daily life and experiences.

Sometimes, telephone contact between client and therapist is

established to help clients apply their skills to real-life

situations. And finally, the fourth mode employed by DBT is a

consultation team designed to help a therapist, who is working

with a difficult client. Such teams enhance certain skills of the

therapist, as well as provide support and prevent the clinician

from an emotional burnout.

In conclusion, it is worth noting that DBT is a flexible

treatment designed to help BPD clients at all levels of

dysfunction to combat their emotional distress. It acknowledges

the role of the interplay of biological and social factors in the

onset of this disorder. The eventual goal of DBT treatment is to

help BPD clients to achieve the levels of optimal functioning by

promoting self-acceptance, balanced experience of emotions and

meaningful interpersonal interaction.

Transference-focused psychotherapy (TFP)

TFP is an approach to the treatment of BPD that stems from

the psychodynamic theory of object relations. This theory

considers relationship between self and objects (other people) as

the main principle that determines an organization of people’s

life. According to object relations theorists, the personality

development begins in early childhood and proceeds in phases.

During these phases, the developing person first learns to

differentiate self from other objects and then to integrate the

characteristics of other objects into the self. At the stage of

integration, the child begins to form the representations of self

and others. The formation of the unique self is an important

process, which is actualized when the child integrates good and

bad object images into a single ambivalent self. Next stage of

personality development is the introjection, during which a child

incorporates other objects in his or her mind. At this phase, the

process of identification, ability to distinct one’s own

representation from the representation of another person is

essential for a successful development of autonomy. During the

whole process of development of the child, a secure attachment to

parents plays a critical role. Parents’ behaviors and attitudes

significantly contribute to child’s self-image. Moreover, parents

are the first objects to become introjected into the child’s

mind, and therefore they play a major role in the development of

their child’s healthy identity.

Nevertheless, sometimes the personality development goes

wrong and BPD arises as the result of certain unhealthy patterns.

For instance, if the parents behave in extremely authoritarian or

outright abusive ways during the child’s integrative phase, it

can lead to splitting off of the bad self-images. Splitting the

self-image is a defense mechanism by which a person tries to

protect him or herself from being overwhelmed by punitive

parents. In addition to this, child can also split off the images

of other objects: for example, splitting the image of an angry

mother makes the mother less threatening. However, when splitting

is taken to extremes it prevents the formation of an integrated

personality and leads to the dichotomous object representations.

In such a case, the self-image is distorted, with some parts of

it not being perceived, and other parts being perceived in black

and white colors. The same is true for the object representations

of other people: they are mostly perceived as either “all good”

or “all bad”. The reason for it is that the BPD patient has

trouble integrating ambivalent features into a single object,

and, as a result, begins to split these features. The distorted

object images create a significant distress in BPD sufferers,

promoting such symptoms as suicidality, instability in

interpersonal relations, and frequent emotional shifts.

TFP suggests that successful treatment of BPD clients should

not only focus on the improvement of their symptoms, but also

involve the therapeutic mechanisms that will target and

restructure underlying personality dysfunction. The main goals of

the TFP are creation of more whole and integrated personality,

elimination of suicidal behaviors and establishment of the

emotional control in BPD patient. These aims are achieved by the

means of transference, which allows split and polarized object

relations to be transformed into more complex and integrated

representations.

Transference constitutes one of the main mechanisms by

which change and improvement are achieved in BPD clients. At the

same time, the transference process in TFP is different from the

traditional transference in psychoanalytic therapies. In

difference to neurotic patients, borderline clients, due to their

split object relations, cannot form transference relationship,

which will promote meaningful interpretations of resistance and

defense mechanisms. Instead, they may perceive therapist in the

same incoherent way that they experience other objects, and view

the clinician as a split-off of the “bad self” or the “bad

parent”. As a result, intense fear of abandonment, rejection and

losing the control will arise, leading the client to experience

extreme emotional swings. This may harm the therapeutic

relationship and lead the patient to leave the therapy. For this

reason, instead of using traditional transference, which requires

the therapist to stay a ”blank screen”, TFP employs the

transference in which therapists let themselves be known. They

react with empathy and genuineness to clients’ emotions and

feelings, but at the same time they set clear limits on the

therapeutic relations. Limits are set on the amount of phone

calls, therapy meetings and acting out aggression toward a

therapist. Setting boundaries on aggression is critical with BPD

patients, as the existing limits will provoke anxiety during the

transference. This anxiety creates an opportunity for

interpretations and raising client’s consciousness about split-

off representations. Once the client becomes aware of split-off

parts of self, he or she will be ready to move on to the

integration of these parts into existing object relations

(Kernberg, 1975).

All in all, TFP is a therapy built on a psychodynamic

approach, which emphasizes the role of defense mechanisms and

resistance in the development of BPD. It achieves its goal of

reconstructing the troubled personality of BPD clients, by

integrating the split-off parts of their object relations into

coherent object representation.

Research trials comparing DBT and TFP efficiency

There are a fair number of studies on the efficiency of DBT

and TFP for the treatment of borderline disorder. Although these

therapeutic approaches have a different structure and target

different aspects of the disorder, the rough outcomes of these

therapies are quite similar. Both therapies were shown to be

effective in BPD treatment when compared to the treatment as

usual. However, there is significantly more evidence in favor of

the therapeutical efficacy of DBT-based treatment, and most of it

is in the form of randomized controlled trials. A long-time

resistance of psychodynamic therapists, who limited their

research activities to describing case studies, may explain this

disparity. Additionally, the study comparing these two therapies

with each other and supportive therapy (Clarkin et al., 2007)

demonstrated that both therapies were equally effective in

treating BPD, and neither treatment approach was superior to

another. Nonetheless, TFP and DBT showed significantly different

results when their outcomes were compared across specific

symptoms, suggesting that an effective BPD treatment may require

a closer consideration of the problem in each specific case.

As mentioned above, DBT treatment has the biggest amount of

research and greatest empirical support of its efficiency for

BPD. A study by Linehan et al. (2006) has compared DBT to the

community treatment by experts (CTBE). The results of the study

show that BPD patients in DBT group committed two times fewer

suicide attempts, and medical risk of these suicide attempts was

significantly lower as compared to CTBE. Moreover, patients in

DBT condition used crisis services significantly less than

patients in CTBE condition. In addition, dropout rates for DBT

were almost twice as low as for CTBE (25% for DBT vs. 59.2% for

CTEB). Taken together, these data demonstrate superiority of DBT

in reducing BPD symptoms. However, there is an aspect of this

study that can raise concerns about its internal validity.

Patients in DBT group on average received more hours of treatment

than patients in CTBE group. DBT group also received group

therapy, which was not available to CTBE group. These factors may

have contributed to the results, skewing them in favor of DBT.

Another study compared DBT to general psychiatric management

for BPD and has found no significant difference in outcomes of

both (McMain et al., 2012). However, this study has demonstrated

that DBT was effective (although not more so than general

psychiatric management) in reducing suicidal and self-injurious

behaviors, improving depression and anger components, as well as

facilitating better interpersonal functioning. Remarkably, the

improvements in the condition of the clients were shown to be

stable over 2-year follow-up period. These data suggest that DBT

is effective in reducing suicide ideations and self-injurious

behaviors, improving interpersonal skills and life quality of BPD

clients.

The study of the effectiveness of TFP as compared to the

treatment by community psychologists has determined the

superiority of TFP (Doering et al., 2010). For this research BPD

clients were randomly assigned to one of the treatments, and

tested on the several scales assessing the severity of BPD

symptoms. After one-year study period, participants in the TFP

group indicated reduced suicide attempts and ideations, but their

self-harm behaviors remained unchanged. The patients in the

community treatment group, however, demonstrated almost no change

in both of these symptoms. No substantial differences were found

between two groups on the measures of self-reported anxiety and

depression, and TFP showed low effect size in the improvement of

these BPD components. The dropout rates for TFP treatment were

significantly lower than for community treatment (38.5% vs.

67.3%). Besides, TFP group has demonstrated significantly lower

time of inpatient treatment, improved psychosocial functioning,

and better personality organization. Nevertheless, this study had

several limitations. First, this study accommodated only female

patients with less severe BPD, less comorbid Axis I and II

disorders, and fewer self-mutilating and suicidal behaviors than

other studies discussed here. This fact raises some concerns

about its external validity and limits the generalizability of

study outcomes. Yet, this study demonstrates strong evidence for

the TFP’s effect on the reduction in suicide behavior, hours of

in-patient treatment, and improvement in personality organization

of BPD clients.

When TFP and DBT were directly compared to each other and

supportive treatment (Clarkin et al., 2007), both therapies were

proven to be effective in improving multiple BPD symptoms. It was

also found that all of these three structured approaches were

equally effective in treating BPD. However, when the treatment

outcomes were compared across different BPD symptoms (e.g.

depression, anxiety, suicidality, anger, impulsivity,

irritability, verbal and direct assault), it was demonstrated

that the efficiency of various treatments varied for specific

symptoms. Both TFP and DBT produced a significant improvement in

suicidality, when only TFP and supportive treatment demonstrated

an improvement in anger. Besides, only TFP was associated with

improvement on irritability, impulsivity and assault measures. In

regard to depression and anxiety, all three therapies indicated a

successful improvement. Likewise, all the therapies were

equivalent in facilitating social adjustment and global

functioning. These outcomes imply that there may be variable

routes to symptom improvement in BPD. When DBT mostly focuses on

skill training and emotion regulation, TFP is more concerned with

promoting greater self-control in BPD clients by integrating

self-representation and other-representation through the

transference process in the therapeutic relationship. TFP was

shown to be effective across broader range of outcome domains

than DBT. However, the follow-up studies should be conducted in

order to find the stability of these improvements.

To sum up, several studies demonstrate that both DBT and TFP

were efficient for improving BPD symptoms. DBT study (Linehan et

al., 2006) has demonstrated that DBT performed significantly

better than CTBE on such BPD symptoms as suicidality, use of

crisis services and therapy dropout. However, another study

(McMain et al., 2012), which included a 2-year follow-up, did not

find a significant difference between DBT and general psychiatric

management. TFP was as well demonstrated to be on average more

effective than community treatment (Doering et al., 2010). When

directly compared to each other and supportive therapy, TFP and

DBT were found to be equivalent, but TFP performed better on

measures of impulsivity, anger, and direct and verbal assault

(Clarkin et al., 2007).

Conclusion

Summarizing the results discussed in this paper, it is worth

noting that BPD is a complex psychological disorder, which

requires a structured treatment. Two of these treatments were

discussed in this paper.

DBT is based on the synthesis of self-acceptance and need for

change. It incorporates in itself basic tenets of cognitive

behavior therapy, humanistic therapy, and Zen Buddhism. In the

course of DBT, clients are taught a set of skills, helping them

to improve their emotion regulation and social interaction. This

approach has the greatest number of randomized controlled trials,

supporting its efficiency, and there is evidence that DBT is

associated with reductions in suicidality, use of emergency

services, and dropout rates, as compared to community treatment

(Linehan et al., 2006). However, other studies found no

significant difference between outcomes of DBT and general

psychiatric management (McMain et al., 2012).

TFP relies on the process of transference for BPD symptoms

improvement and holds that to successfully treat BPD one needs to

target underlying personality structure and integrate person’s

representations of self and others. There is some evidence that

TFP is more effective than community treatment for such aspects

of BPD as suicidality, treatment compliance, and duration of

inpatient stay (Doering et al., 2010). A study comparing these

two therapies (Clarkin et al., 2007) has demonstrated that both

treatments were equally effective in improving anxiety,

depression, suicidality, and social adjustment, but TFP was

better in reducing anger, impulsivity and assault levels.

Taken together, these data suggest that both discussed

therapies are on average equivalent; however, they may vary in

efficiency, when they are compared across different symptoms. It

leads us to the conclusion that although the discussed structured

treatments for BPD are effective in improving this disorder’s

most distressing symptoms, such as self-injury and suicidality,

more controlled research should be conducted on therapies for BPD

and their underlying mechanisms of change.

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