1 Neapolis University, Pafos, Cyprus
This article deals with the role of the therapeutic relationship in psychotherapy of patients with Borderline Personality Disorder (BPD) (APA, 2013). Firstly, the paper refers to the therapeutic relationship in BPD in general as well as more specifically in the light of Cognitive Psychotherapy, through the major principles and new developments in clinical practice and survey. Cognitive treatment regards the therapeutic relationship as a necessary but insufficient component for the therapeutic change. However, in recent years, it has attached special importance to it, as indicated by clinical studies. Then it goes on to an overview of the major theoretical and clinical approaches for BPD, mainly through the work of Linehan, Kernberg, Gunderson and Young, which is followed by an elaborate analysis of the difficulties and instability of relationships in BPD as major characteristics, as well as of the peculiarities that the therapeutic relationship between the therapist and a BPD patient displays. Psychotherapy with BPD patients, the difficulties and suggestions for a positive therapeutic outcome are the major points of the third part of the paper, which is completed with the potential of the cognitive therapist and the contribution of cognitive therapy through a focus in the present, structured treatment, identification of thoughts, emotions and behaviors, cooperative work, concrete boundaries and honest and substantial communication.
Keywords: borderline personality disorder, therapeutic relationship, cognitive therapy
Published online: 2018/09/01
Published print: 2018/09/01
Agrawal, H.R., Gunderson, J.G., Holmes, B.M., Lyons-Ruth, K. (2004) Attachment studies with borderline patients: a review. Harvard Review Psychiatry, 12, 94-104.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing
Bachelor, A., & Horvath, A. (1999). The therapeutic relationship. In M. A. Hubble, B. L.
Duncan, & S. D. Miller (Ed.), The heart and soul of change: What works in
therapy (pp. 133-178). Washington, DC, US: American Psychological Association.
Bateman, A. & Fonagy, P. (2004). Psychotherapy for Borderline Personality Disorder. Mentalization based treatment. Oxford: Oxford University Press.
Bateman, A. W., & Fonagy, P. (2006). Mentalization-Based Treatment for Borderline Personality Disorder: A Practical Guide. Oxford: Oxford University Press.
Beck, A.T. (1970). Cognitive therapy: Nature and relation to behavior therapy. Behavior Therapy, 1, 184-200.
Beck, A. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press.
Beck, A.T., Emery, G., & Greenberg, R. L. (1985). Anxiety Disorders and Phobias: A Cognitive Perspective. New York: Basic Books.
Beck, A.T., & Freeman, A. (1990). Cognitive Therapy of Personality Disorders. New York: Guilford.
Beck A.T, Freeman A., Davis D.D. (2004). Cognitive Therapy of Personality Disorders. New York: Guilford.
Beck, A., Rush, A., Shaw, B., & Emery, G. (1979). The therapeutic relationship: Application to cognitive therapy. In A. Beck, A. Rush, B. Shaw, & G. Emery, Cognitive therapy of depression. New York: Guilford Press.
Beck, J.S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford.
Bedics J.D, Atkins D.C, Harned M.S, Linehan M.M (2015). The therapeutic alliance as a predictor of outcome in dialectical behavior therapy versus nonbehavioral psychotherapy by experts for borderline personality disorder. Psychotherapy (Chic). 52(1), 67-77.
Blackburn, I.M. & Twaddle, V. (1996). Cognitive Therapy in Action. London: Souvenir Press.
Butler, A.C., Brown, G.K., Beck, A.T., Grisham J.R. (2002). Assessment of dysfunctional beliefs in Borderline Personality Disorder. Behaviour Research and Therapy, 40, 1231-1240.
Choi-Kain, L.W., Zanarini, C.Z., Frankenburg, F.R., Fitzmaurice, G.M. &Reich, D.B. (2010). A Longitudinal study of the 10-year course of interpersonal features in Borderline Personality Disorder. Journal of Personality Disorders, 24(3), 365–376.
Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluating three treatments for Borderline Personality Disorder: A multiwave study. American Journal of Psychiatry, 164, 1-8.
Davidson, K. (2000) Cognitive Therapy for Personality Disorders. Oxford: Butterworth- Heinemann.
Davidson, K., Norrie, J., Tyrer, P., Gumley, A., Tata, P., Murray, H., & Palmer, S. (2006). The effectiveness of cognitive behavior therapy for Borderline Personality Disorder: Results from the BPD study of cognitive therapy (BOSCOT) trial. Journal of Personality Disorders, 20, 450-465. Davidson, K., Tyrer, P., Gumley, A., Tata, P., Norrie, J., Palmer, S., Macaulay, F (2006). A randomized controlled trial of cognitive behavior therapy for Borderline Personality Disorder: Rationale for trial, method, and description of sample. Journal of Personality Disorders, 20, 431-449.
Dawson, D., & MacMillan, H.L. (1993). Relationship Management and the Borderline Patient. New York: Brunner/Mazel.
Farmer, R.F., & Chapman, A.L. (2002). Proceedings from Psychological Society Meetings New Zealand: Christchurch.
Gold, J. R. (1993). The therapeutic interaction in psychotherapy integration. In G. Stricker& J. R. Gold (Eds.), Comprehensive handbook of psychotherapy integration (pp. 525–531). New York: Plenum.
Hazlett-Stevens, H. (2008). Psychological approaches to generalized anxiety disorder. New York: Springer.
Frank, A. F. (1992). The therapeutic alliances of borderline patients. In J. F. Clarkin, E. Marziali, & H. Munroe-Blum (Ed.), Borderline Personality Disorder: Clinical and empirical perspectives (pp. 220–247). New York: Guilford Press.
Gabbard G.O. (1989) Splitting in hospital treatment. The American Journal of Psychiatry, 146, 444-451.
Gabbard, G.O. (1994). Treatment of borderline patients in a multiple-treater setting. Psychiatric Clinics of North America, 17, 839–850.
Grinker, R., Werble, B., & Drye, R. (1968). The borderline syndrome: A behavioural study of ego functions. New York: Basic Books.
Gunderson J.G (1984). Borderline Personality Disorder. Washington, DC: American Psychiatric Press.
Gunderson, J.G. (1996) The borderline patient’s intolerance of aloneness: insecure attachments and therapists’ availability. American Journal of Psychiatry, 153, 531–546.
Gunderson, J.G. (2001) BPD: A Clinical Guide. Washington, DC: American Psychiatric
Gunderson J.G., Frank A.F., Ronningstam E.F., Wachter S, Lynch, V.J., & Wolf, P.J. (1989). Early discontinuance of borderline patients from psychotherapy. The Journal of Nervous and Mental Disease, 177, 38-42.
Gunderson, J.G. & Links, P.S. (2008). Borderline Personality Disorder: A Clinical Guide (2nded) Arlington: American Psychiatric Publishing, Inc.
Gunderson, J.G., Lyons-Ruth, K. (2008). Borderline Personality Disorder’s Interpersonal Hypersensitivity Phenotype: A Gene-Environment-Developmental Model. Journal of Personality Disorders, 22 (1), 22-41.
Gutheil, T.G. (1985). Medicolegal pitfalls in the treatment of borderline patients, The American Journal Psychiatry 142, 9-14.
Gutheil, T.G. (1989) BPD, boundary violations, and patient-therapist sex: medicolegal pitfalls. The American Journal Psychiatry, 146, 597-602.
Hobbs, N. (1962). Sources of gain in psychotherapy. American Psychologist, 17, 741-747.
Grencavage, L.M., & Norcross, J.K. (1990). Where Are the Commonalities Among the Therapeutic Common Factors? Professional Psychology: Research and Practice, 21, (5), 372-378
Jørgensen, C.R. (2010). Invited essay: identity and Borderline Personality Disorder. Journal of Personality Disorders, 24(3), 344–364. Kazantzis, N., MacEwan, J., & Dattilio, F. M. (2005). A guiding model for practice. In N. Kazantzis, F. P. Deane., K. R. Ronan, & L. L’Abate (Ed), Using homework assignments in cognitive behavior therapy (pp. 359–407). New York: Routledge.
Kempler, W. (1980). Some views on effective principles of psychotherapy. In M. R. Gold fried (Ed., special section), Cognitive Therapy and Research, 4, 269-306.
Keller, S., Stelmaszczyk, K., Kolly, S., de Roten, Y., Despland, J. Caspar, F., Drapeau, M., Kramer, U. (2018). Change in Biased Thinking in a Treatment Based on the Motive- Oriented Therapeutic Relationship for Borderline Personality Disorder, Journal of Personality Disorders, 32, 75-92.
Kellogg, S. H. & Young, J. E. (2006), Schema therapy for Borderline Personality Disorder. Journal of Clinical Psychology, 62: 445–458.
Kernberg, O.F. (1975) Borderline Conditions and Pathological Narcissism. New York: Jason Aronson.
Kernberg, O.F. & Michel’s, R. (2009). Borderline Personality Disorder. The American Journal of Psychiatry, 166, 505-508.
Kernberg, O., Yeomans, F., Clarkin, J., Levy K. (2008) Transference focused psychotherapy: overview and update. International Journal of Psychoanalysis, 89(3):601-620
Kramer, U., Caspar, F. &Drapeau, M. (2013), Change in biased thinking in a 10-session treatment for BPD: Further evidence of the motive-oriented therapeutic relationship, Psychotherapy Research, 23 (6) 633-645, retrieved from http://dx.doi.org/10.1080/ 10503307.2013.791404
Kramer, U., Stulz, N., Berthoud, L., Caspar, F., Marquet, P., Kolly, S., De Roten Y & Despland, J. (2017). The shorter the better? A follow-up analysis of 10-session psychiatric treatment including the motive-oriented therapeutic relationship for borderline personality disorder, Psychotherapy Research, 27(3), 362-370.
Κrawitz, R.&Watson, C. (2003). BPD, a practical guide to treatment. Oxford: University Press.
Jimenez, X. (2013) Patients with Borderline Personality Disorder who are Chronically Suicidal: Therapeutic Alliance and Therapeutic Limits. American Journal of Psychotherapy, 67 (2), 185-201.
Linehan, M.M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford.
Louw, F. &Straker, G. (2002). Borderline Pathology: An Integration of Cognitive Therapy and Psychodynamic Therapy, Journal of Psychotherapy Integration, 12 (2), 190–217.
Luborsky, L. (1988). Who will benefit from psychotherapy? New York: Basic Books.
Manos, Ν. (1997). Basic Elements of Clinical Psychiatry (Vasika Stichia Klinikis Psichiatrikis (in Greek). Thessaloniki: University Studio Press.
Neenan, M. &Dryden, W. (2004). Cognitive Therapy: 100 key points and techniques. Sussex: Brunner-Routledge.
Newman, C. (1998). The therapeutic relationship and alliance in short term cognitive therapy. In J. Safran& C. Muran, The therapeutic alliance in brief psychotherapy. Washington, DC: American Psychological Association.
Van Oppen, P. (2004). Cognitive therapy for obsessive-compulsive disorder. Clinical Case Studies, 3, 333–349.
Orlinsky, D. E., Ronnestad, M. H., & Willutski, U. (2004). Fifty years of psychotherapy process-outcome research: Continuity and change. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (pp. 307–390). New York: Wiley.
Padesky, C.A. & Greenberger, D. (1995). Clinician’s Guide to Mind Over Mood. New York: Guilford.
Safran, J.D. and Muran, J. C. (2000) Negotiating the Therapeutic Alliance. New York: Guilford.
Safran, J. & Segal, Z. (1990). Interpersonal processes in cognitive therapy. New York: Basic Books.
Salsman, N.L., Linehan, M.M. (2006). Dialectical behavioral therapy for Borderline Personality Disorder. Primary Psychiatry, 113 (5), 51-58.
Sanislow, C.A, Morey L.C., Grilo, C.M., Gunderson, J.G., Shea, M., Skodol, A.E, et al. (2002). Confirmatory factor analysis of DSM-IV borderline, schizotypal, avoidant and obsessive-compulsive personality disorders: Findings from the Collaborative Longitudinal Personality Disorders Study. Acta Psychiatrica Scandinavica, 105, 28 –36.
Shedler, J., Westen, D. (2004). Refining personality disorder diagnosis: integrating science and practice. The American Journal of Psychiatry, 161, 1350–1365.
Skodol, A.E, Buckley, P., Charles, E. (1983). Is there a characteristic pattern to the treatment history of clinic outpatients with borderline personality? Journal of Nervous and Mental Diseases, 171, 405–410.
Skodol, A.E, Gunderson, J., Pfohl, B., Widiger, T.A., Livesley, W.J., Siever, L. (2002). The borderline diagnosis I: Psychopathology, comorbidity and personality structures. Biological Psychiatry, 51, 936 –950.
Spinhoven, P., Giesen-Bloo, J., van Dyck, R., Kooiman, K., Arntz, A. (2007) The Therapeutic Alliance in Schema-Focused Therapy and Transference- Focused Psychotherapy for Borderline Personality Disorder. Journal of Consulting & Clinical Psychology, 75 (1), 104-115.
Steffen, E. (2013). Both ‘being with’ and ‘doing to’: Borderline Personality Disorder and the integration of humanistic values in contemporary therapy practice, Counselling Psychology Review, 28 (1), 64-71.
Stern, A. (1938). Psychoanalytic investigation and therapy in the borderline group of neuroses. Psychoanalytic Quarterly, 7, 467–489.
Tee, J., & Kazantzis, N. (2011). Collaborative Empiricism in Cognitive Therapy: A Definition and Theory for the Relationship Construct Clinical Psychology: Science and Practice,18, (1), 47–61.
Trull, T.J., Stepp, S. D., & Durrett, C. A. (2003). Research on Borderline Personality Disorder: An update. Current Opinion in Psychiatry, 16, 77-82
Waddington, L. (2002). The therapy relationship in cognitive therapy: A review. Behavioural and Cognitive Psychotherapy, 30, 179–191.
Walen, S.R., DiGiuseppe, R., & Dryden, W. (1992) A Practitioner’s Guide to Rational– Emotive Therapy, 2nd end. New York: Oxford University Press.
Waldinger, R.J., Gunderson, J.G. (1984). Completed psychotherapies with borderline patients. Americal Journal of Psychotherapy, 38,190–202.
Weinberg, I., Gunderson, J.G., Henning, J. &Cutter, C.J. (2006). Manual assisted cognitive treatment for deliberate self-harm in Borderline Personality Disorder patients. Journal of Personality Disorders, 20, 482–492. Wenzel, A., Chapman, J.E. Newman, C.F; Beck, A.T., Brown, G.K., Beck, A. T. (2006). Hypothesized mechanisms of change in cognitive therapy for Borderline Personality Disorder. Journal of Clinical Psychology, 62(4),503-516.
Westefeld, J.S., Range, L.M., Rogers, J.R., Maples, M.R., Bromley, J.L & Alcorn,
J. (2000). Suicide: An overview. The Counselling Psychologist, 28, 445-510.
Westen, D. (1991). Cognitive-behavioral interventions in the psychoanalytic psychotherapy of BPDs. Clinical Psychology Review, 11, 211-230.
Wills, F. & Sanders, D. (1997) Cognitive Therapy: Transforming the Image. London: Sage Publications.
Wright, J. & Davies, D. (1994). The therapeutic relationship in cognitive-behavioural therapy: Patient perceptions and therapist responses. Cognitive and Behavioural Practice, 1, 25-45.
Wright, K. & Jones, F. (2012). Therapeutic alliances in people with Borderline Personality Disorder, Mental Health Practice, 16(2), 31-35.
Yeomans, F.E., Clarkin, J.F., &Kernberg, O.F. (2002). A primer of transference focused psychotherapy for the borderline patient. New York: Aronson.
Young, J.E. (1990). Cognitive therapy for personality disorders: A schema-focused approach. Sarasota, F.L: Professional Research Exchange.
Young, J.E. (1994). Cognitive therapy for personality disorders: a schema focused approach. Sarasota: Professional Resource Exchange.
Young, J.E., Klosko, J.S., &Weishaar, M. (2003). Schema Therapy: A Practitioner’s Guide. New York: Guilford Publications.