Harvard Mental Health Letter

Borderline personality disorder: Treatment

Personality, by definition, is pervasive and ingrained, not an isolated set of troubling symptoms. Borderline personalities usually do not seek mental health care to have their characters transformed; they want help for depression, anxiety, and problems in their work and family lives. But a psychiatrist, psychologist, or counselor can help make these patients more aware of how their patterns of behavior and thinking aggravate those symptoms and complicate those problems.

Borderline personalities are not easy to work with. They make therapists feel uncomfortable or guilty, demand special treatment, become uncooperative and ungrateful, and provoke crises with self-destructive actions. They are prepared to feel rejected and to read hostility into neutral comments and expressions. Therapists are hailed as saviors and then denounced as inept or even malevolent when they fail to live up to unrealistic expectations.

In these circumstances it's useful to have definite rules and priorities, set at the start of treatment, with clearly established roles and responsibilities. For the patient, that may include arriving at and leaving therapy sessions regularly and on time, paying fees, and taking medications as prescribed. It is often a good idea to start with an informal agreement stating the aims of therapy and specifying plans for responding to crises.

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