Borderline personality: a therapist's manual

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 (Linehan, 2015), 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; section 2 and session 10 say where treatment is extended. Sessions last 50 minutes and are weekly. Where one exists, the patient attends a skills training group in parallel (section 33). A policy on contact between sessions is set out in writing (section 14), and three booster sessions, one, three and six months after the last session, follow the end of regular treatment.

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	One vulnerability point worked on, opposite action tried
	9	Asking, refusing, keeping the bond	Two requests prepared, at least one made
	10	Mid-point review	Measures repeated, plan revised
IV. Relationships and self	11	Fear of abandonment	Abandonment scenario examined
	12	Thinking under stress	A situation reviewed from both sides
	13	Emptiness and identity	Values written down, one action carried out
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

The concepts in this table and in the reference model are explained where they belong: the model in section 4, the hierarchy of targets in section 13, validation in section 31, skills in section 33, the safety plan in session 3, chain analysis in session 5, opposite action in session 8.

What sets this programme apart from the other manuals on this site. Three things. The disorder's prognosis is much better than its reputation. Suicide risk organises the hierarchy of treatment. And the research is solid enough for us to say that the structure of treatment matters at least as much as the name of the method (section 11).

2. Before you begin

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? The question arises with a severe addiction, a serious eating disorder, a severe major depressive episode, a bipolar disorder or post-traumatic stress. Section 8.

3. Does this patient need a specialist programme from the outset? This should be considered when there is very frequent suicidal behaviour, repeated hospitalisations or a failure of structured care. Section 37.

4. What framework for crises between sessions? You need to know whom the patient calls, when, for what, and what you then do. This is decided before the first crisis, not during it, and written into the contract in session 4 (section 14).

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 this programme does not treat on its own: the patient is followed in parallel by addiction services (sections 8 and 36).

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. You move on from one key session to the next when its criterion for moving on is met. Section 39 says what must not be dropped. The patient's folder contains eight worksheets: 1, "My safety plan" (session 3); 2, "Our agreement" (session 4); 3, "My chain" (session 5, then after each risk behaviour); 4, "My emotions" (sessions 6 and 8); 5, "Getting through the peak" (session 7); 6, "With other people" (sessions 9, 11 and 12); 7, "For those close to you" (section 35); 8, "My plan for what comes next" (sessions 13, 15 and 16).

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 (section 4).

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 (Gunderson et al., 2011; Zanarini et al., 2012) 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. The biosocial reading, which underpins dialectical behaviour therapy (Linehan, 1993), sees emotion dysregulation as arising from the meeting of a vulnerability and an environment: these are the first two subsections. The interpersonal reading places sensitivity to relationships at the heart of the disorder: third subsection. The mentalisation-focused reading, that is, focused on the capacity to represent one's own mental states and those of others — thoughts, emotions, intentions —, describes what collapses under stress: fourth subsection.

Emotional vulnerability

The patient shows greater emotional sensitivity, meaning that they react faster to events, as well as stronger intensity and a slower return to baseline. This vulnerability is partly temperamental.

An environment that did not teach regulation

The second factor is an environment that invalidated the child's emotions, that is, treated them as wrong, excessive or unimportant: denying them, punishing them, ignoring them, or responding only to extreme emotions. This environment often goes hand in hand 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, that is, their mutual influence over time, 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 (section 11) 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. Discussing complex post-traumatic stress disorder must not become a way of avoiding the word "personality": it is discussed because it changes the treatments offered. Sections 7 and 28.

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