This programme is a treatment manual for mental health professionals. It assumes clinical training, experience with personality disorders and with managing suicide risk, and a supervision or team framework. It replaces neither your clinical judgement nor your professional responsibility. Diagnostic criteria are reworded here in our own words, never reproduced. Two warnings specific to this indication. Suicide risk is real and must be assessed and organised from the start, section 9; a patient in immediate danger belongs in emergency services, not in this manual. And this manual describes structured individual care; it does not replace a full specialist programme — dialectical behaviour therapy, mentalisation-based treatment, transference-focused psychotherapy, schema therapy — to which patients who need one must be referred, section 37.
1. The programme at a glance
Indication. Borderline personality in adults, as outpatients, with suicide risk assessed and organised, and a care setting that allows crises to be managed.
Reference model. Structured care that brings together the common foundation of effective treatments: an explicit model of emotion dysregulation and interpersonal hypersensitivity, a hierarchy of targets, validation and the request for change held together, chain analysis of crises, training in distress tolerance, emotion regulation and interpersonal effectiveness skills, and work on the capacity to think about one's own mental states and those of others under stress.
Format. Treatment lasting about a year, that is, some forty to fifty sessions; this manual describes sixteen key sessions, organised in five phases, with extension points indicated. 50-minute sessions, weekly. A skills group running in parallel where one exists. An explicit policy on contact between sessions. Booster sessions.
Targeted mechanism. Reducing behaviours that threaten life and those that damage the treatment, replacing crisis behaviours with skills, stabilising emotions by acting on their vulnerability and their regulation, soothing hypersensitivity to rejection and fear of abandonment, restoring the capacity to think under stress, and building a life the patient considers worth living.
| Phase |
Session |
Topic |
Session output |
| I. Engaging |
1 |
Understanding and validating |
Story heard, first validation |
|
2 |
Diagnosis and prognosis |
Diagnosis disclosed, model explained |
|
3 |
Assessing and securing safety |
Written safety plan |
| II. Understanding |
4 |
The contract and the targets |
Hierarchy of targets, written contract |
|
5 |
Chain analysis |
One crisis reconstructed link by link |
|
6 |
Observing emotions |
Emotion log kept |
| III. Skills |
7 |
Getting through a crisis |
Three crisis skills tried |
|
8 |
Regulating emotions |
Vulnerability reduced, opposite action tried |
|
9 |
Asking, refusing, keeping the bond |
Two requests prepared and made |
|
10 |
Mid-point review |
Measures repeated, plan revised |
| IV. Relationships and self |
11 |
Fear of abandonment |
Rejection scenario examined |
|
12 |
Thinking under stress |
A situation reviewed from both sides |
|
13 |
Emptiness and identity |
Values written down, one action chosen |
| V. Consolidation |
14 |
Trauma, at the right time |
Shared decision on trauma treatment |
|
15 |
A life worth living |
A plan for work, study or activity |
|
16 |
Review, relapse, next steps |
Written plan, measures repeated |
What sets this programme apart from the other manuals on this site. Three things. A disorder whose prognosis is much better than its reputation. A suicide risk that organises the hierarchy of treatment. And research solid enough for us to say that structure matters more than brand.
2. Before you begin
Who this programme is for
Psychologists, psychiatrists and psychotherapists trained in cognitive behavioural therapy, with experience of personality disorders and of suicide risk, who work in a team or with regular supervision. This last point is essential: this work exhausts therapists who are isolated, and an exhausted therapist makes mistakes.
The four preliminary decisions
1. Does the suicide risk allow outpatient treatment? Section 9.
2. Does an associated disorder need to be treated first or at the same time? A severe addiction, a serious eating disorder, a severe major depressive episode, a bipolar disorder, post-traumatic stress. Section 8.
3. Does this patient need a specialist programme from the outset? Very frequent suicidal behaviour, repeated hospitalisations, failure of structured care. Section 37.
4. What framework for crises between sessions? Whom the patient calls, when, for what, and what you do. To be decided before the first crisis, not during it.
What this programme does not treat
Patients in immediate suicidal danger, who belong in emergency services.
Adolescents, for whom specific adaptations exist, even though the principles are similar.
Predominant psychotic and bipolar disorders.
Severe, unstabilised addictions, which call for joint work.
What this programme is not
It is not full dialectical behaviour therapy, which requires a skills group, telephone coaching and a consultation team. Nor is it mentalisation-based treatment, schema therapy or transference-focused psychotherapy. It borrows from all of them, describes their principles in its own words, and acknowledges that they go further.
How to use it
Read sections 3 to 14 first, then sections 31 and 32 before the first session: validation and crisis management are at stake from the start. The sessions described are key sessions; each may take several, and phase III in particular often extends over months. Section 39 says what must not be dropped.
3. The clinical picture
What defines the disorder
A lasting and pervasive instability of relationships, self-image and emotions, together with marked impulsivity, present since early adulthood and across a range of contexts.
The forms it takes
Intense efforts to avoid abandonment, real or imagined.
Intense and unstable relationships, alternating between idealisation and devaluation.
An unstable self-image: who I am, what I want and what I am worth change from moment to moment and from person to person.
Impulsivity in at least two potentially harmful areas: spending, sex, substance use, driving, eating.
Repeated suicidal behaviour, threats, acts, or self-harm.
Marked emotional instability: intense states, often brief, triggered by relational events.
A chronic feeling of emptiness.
Intense and inappropriate anger, difficult to control.
Transient stress-related paranoid ideas or dissociative symptoms.
What patients describe
Emotions that rise faster, go higher and come down more slowly than in other people. A fear of being left that makes them accept everything or destroy everything. Relationships in which the other person is perfect, then unforgivable. An emptiness that no activity fills. Deep shame. Acts that bring relief in the moment — cutting, drinking, walking out, breaking up — and are regretted afterwards. And, often, a history of violence, neglect or invalidation.
What you see in the consultation
Intensity, marked sensitivity to the therapist's attitude, rapid changes of state within a single session. An alliance that can become very strong very quickly, then break over a detail. Great emotional intelligence in some areas and collapses in others. A great deal of suffering, often underestimated behind the anger.
Epidemiology and course
Borderline personality affects around one to two per cent of the general population, and far more in outpatient and inpatient psychiatry. It is diagnosed more often in women in clinical settings, with no clear difference in the general population.
The course is much better than people think. Large follow-up studies over ten and sixteen years show that the majority of patients achieve lasting symptomatic remission, and that relapses after lasting remission are uncommon. Social and occupational functioning improves more slowly and less completely, which is why it deserves early attention. Impulsive symptoms — self-harm, suicidal behaviour — decrease fastest; emptiness, fear of abandonment and dysphoria are slower.
4. The model
The model that guides this programme brings together three compatible readings, presented to the patient in plain language.
Emotional vulnerability
Greater emotional sensitivity — faster reactions to events —, stronger intensity, and a slower return to baseline. This vulnerability is partly temperamental.
An environment that did not teach regulation
An environment that invalidated the child's emotions — denying them, punishing them, ignoring them, or responding only to extreme emotions —, often associated with violence, neglect or instability. The child learns neither to name their emotions, nor to trust them, nor to regulate them, and learns that only extreme expressions are heard.
The transaction between vulnerability and environment produces dysregulation. This model blames no one: a highly sensitive child in an ordinary family can experience the same invalidation as an ordinary child in a harsh family.
Interpersonal hypersensitivity
The disorder shows itself above all in relationships. When the bond feels secure, the patient often functions well. When it feels threatened — an absence, lateness, a tone of voice, a criticism —, the dread of abandonment rises, and with it anger, devaluation of the other person or of oneself, and impulsive behaviour. When the patient is alone, emptiness, dissociation and self-harming behaviour dominate.
A capacity to think that collapses under stress
Under the effect of an intense emotion, especially in an attachment relationship, the capacity to represent one's own mental states and those of others collapses: the other person becomes entirely malevolent, oneself entirely bad, and what one feels becomes reality. Restoring this capacity under stress is a target of treatment.
The crisis cycle
1. A vulnerability of the day — lack of sleep, alcohol, fatigue, loneliness. 2. A trigger, often relational. 3. A rapid interpretation: he's going to leave me; I'm worthless. 4. An emotion that rises very high. 5. A capacity to think that collapses. 6. A behaviour that brings quick relief: self-harm, substance use, breaking up, anger. 7. Immediate relief, then shame, consequences, and increased vulnerability.
The immediate relief reinforces the behaviour; the shame and the consequences increase the next vulnerability.
What the treatment does
It reduces vulnerability, identifies triggers, slows down interpretations, teaches how to get through the peak without making things worse, restores thinking under stress, replaces crisis behaviours with skills, and builds relationships and a life that reduce the triggers.
What the model explains to the patient
That they are neither mad, nor bad, nor manipulative. That they have a strong emotional sensitivity and did not learn to regulate it. That their crisis behaviours have a function, which can be understood. And that regulation can be learned.
5. A diagnosis with a bad reputation
Why this section exists
Because borderline personality is one of the most stigmatised diagnoses in psychiatry, including among clinicians. Patients are described as manipulative, difficult, incurable. These representations are false, and they do harm: they produce poorer-quality care, refusals to treat, and despair in patients.
What is false
"It's incurable." The majority of patients achieve lasting remission.
"They manipulate." Crisis behaviours serve to regulate or to call for help, often learned in an environment where only extreme expressions were heard. Calling them manipulation shuts down understanding.
"It's not a real disorder." The suffering, disability and mortality are considerable.
"Nothing can be done." Several structured psychotherapies have proved their worth.
Should the diagnosis be disclosed?
Yes, in most cases, together with the prognosis and the model. The reference generalist approaches recommend disclosure. Many patients feel understood for the first time, and the diagnosis opens access to information, treatment and peer support groups.
How: by saying what the diagnosis describes — an emotional and relational sensitivity, and learned ways of reacting —, what it does not say — neither malice, nor manipulation, nor inevitability —, and what is known about the prognosis.
The case of complex post-traumatic stress
Many patients with borderline personality have experienced trauma, and the ICD-11 recognises complex post-traumatic stress disorder, which shares some features. The two diagnoses are not mutually exclusive. The discussion is not a way of avoiding the word "personality": it changes the treatments offered. Section 7.