Borderline Personality Disorder and Resistance to Treatment

When the term “borderline” was first used in 1938 by the psychoanalyst Adolf Stern, he was defining a group of patients who were “extremely difficult to handle effectively by any psychotherapeutic method.”¹ In the early 1950s, Robert Knight emphasized their regressive responses to unstructured treatments.² In hospitals, borderline patients were referred to as “help-rejecting complainers.”

During that time, the term “negative therapeutic reaction” evolved as a way to describe how individuals with borderline personality disorder (BPD) destroyed their well-meaning therapists’ ability to be effective because of unconscious motivations of masochism, envy, and sadism. In light of the reports of resistance to treatment and the formulations of the mechanisms behind this resistance that blamed the patient, borderline became associated with treatment resistance and poor prognosis. At best, a diagnosis of BPD was a statement of therapeutic pessimism. At its worst, the diagnosis brought expectations of aggressive or hostile acting out against therapeutic efforts.

Findings from longitudinal research and the development of empirically validated BPD-specific treatments have since helped transform its reputation as an untreatable disorder into one that can be quite responsive to treatment. Two prospective longitudinal studies have shown that BPD psychopathology progressively improves, with impressive remission rates of 40% to 50% in 2 years and 70% to 80% by 10 years.^3,4

Empirically validated treatments have demonstrated how therapies need to be specifically tailored for successful treatment of BPD. The first of these, dialectical behavioral therapy (DBT) was developed only after it was realized that patients with BPD resisted a traditional behavioral approach. DBT incorporated techniques of validation and the concept of acceptance to a cognitive-behavioral framework.⁵ Similarly, schema-focused therapy was developed for personality-disordered patients who were “nonresponders” to-or “relapsers” from-standard cognitive-behavioral therapy.⁶ Several of these approaches explicitly address the borderline patient’s typical treatment-interfering behaviors so that his or her responses are not personalized or overreactive.

Originally, the concept of treatment resistance was defined in psychoanalytical terms. Freud described the phenomenon of resistance broadly as “whatever interrupts the progress of analytic work.” The term “resistance” often referred to defenses or aspects of character structure that were obstacles to therapists. Currently, treatment resistance often refers to psychiatric symptoms that do not respond to otherwise effective treatments. The most widely recognizable use of this modern meaning of resistance is treatment-resistant depression, which describes a form of depression that does not remit despite reasonable and extensive (usually psychopharmacological) treatment. Both psychological resistance to treatment and the resistance of symptoms to respond as expected refer to a variety of phenomena that can render generally effective treatments ineffective.

BPD is associated with both forms of resistance, and these underlying sources may overlap. Particular forms of defenses exhibited by patients with BPD can constitute therapeutic resistance. However, when BPD coexists with mood disorders, those disorders often fail to respond to treatments as well as expected.⁷

Here we present case vignettes to illustrate treatment of therapeutic resistance that clinicians commonly encounter. We first discuss treatment resistance related to an Axis I diagnosis that is comorbid with BPD. This is followed by a discussion of 2 other forms of therapeutic resistance-entitlement and dynamics between the patient with BPD and his family. We offer recommendations about how to manage these different forms of resistance.

Comorbidity as a source of treatment resistance for Axis I disorders

Patients with BPD often present with a history of diagnosis and treatment of multiple Axis I disorders, mainly in the realms of mood, anxiety, substance use, and eating.⁸ In such patients, it is important to determine whether BPD is present because it, like other personality disorders, is a commonly cited factor of treatment resistance for comorbid disorders.^9,10 Failure to recognize the effect of comorbid BPD or mood disorders often leads both the patient and the clinician to put undue hope on the expected response to medications.

CASE VIGNETTE

Sara, a 25-year-old woman with a history of repeated cutting and depression, was hospitalized when she took an overdose of an antidepressant after an angry breakup with a boyfriend. Her inpatient psychiatrist diagnosed depression and attempted unsuccessfully to treat her with medications. Electroconvulsive therapy was tried, without any improvement in either her mood or cutting behavior.

Every time Sara threatened to cut herself, the staff responded with increased monitoring. Eventually, she was constantly observed, her clothes were confiscated, and she was required to wear a gown at all times. The treatment team was afraid that without these constraints, Sara would kill herself. When Sara was finally discharged, the psychiatrist’s diagnosis had been changed to BPD, but the patient nonetheless clung to her primary diagnosis of major depressive disorder (MDD). Because the emphasis had been on MDD for so long, her stance toward treatment-passive and expecting a lot from medications-was predetermined. Her outpatient therapist struggled to get Sara to collaborate with her to discuss the events and feelings that preceded her impulses to cut herself. Sara believed that treatment should focus on making her “feel better” and that this depended on getting the right medication. She continually demanded medication changes and perceived the therapist’s questions as “not caring” or a “waste of time.”

For clinicians who lack experience in treating patients with BPD, scenarios like this one are common. Some believe that treatment of a comorbid Axis II pathology can be deferred until after a patient has been discharged, despite the clear relationship between acute symptoms and interpersonal conflicts or other social stressors. In this vignette, Sara’s treatment team diligently attended to her depressive symptoms, but the approach they used encouraged an undue hope that somatic treatments would resolve her depression. It also encouraged a passive role on Sara’s part; she was not held responsible for any part of getting better. Her failure to stop cutting herself could be interpreted as her resistance against treatment, but it was almost certainly related to the misinformed strategies taken by the treatment team. Sara’s treatments reinforced her belief that her problems were outside herself and that she could rely on someone else to fix them.

Clinicians should actively treat both mood/anxiety symptoms and BPD symptoms, but comorbid BPD decreases the likely response to medications. Psychotherapeutic interventions that require activity and responsibility on the patient’s part are most effective. When there are ongoing borderline issues (such as recurrent self-harm and extreme reactivity to interpersonal issues), these issues need to be a central focus in the ongoing treatment from the start.¹¹ By giving such patients tools to manage their anxiety, their affects, and their impulses in lieu of self-harm, we give them the opportunity to manage their own safety. This helps them begin to focus inwardly rather than depend on rescue by others.

Entitlement as a form of resistance

Patients with BPD or narcissistic personality disorder (or both) can feel entitled to special treatment and often seek only approving forms of attention from those who treat them. Such appeals for special treatment may prompt clinicians to worry that gratifying them can reinforce unrealistic interpersonal expectations, but that withholding may elicit reactive worsening of symptoms or dropping out.

CASE VIGNETTE

Kathy is a 52-year-old divorced woman who is referred for treatment following a suicide attempt related to losing her job. Kathy began therapy with the goal of developing more close relationships. Her children don’t speak to her and her family reports walking on eggshells around her because of her volatility. At the start of treatment, Kathy made multiple requests to have her appointment times adjusted to accommodate her schedule and frequently needed to move the furniture in the office to suit her better. The therapist managed this by saying that she understood why such changes were preferred but that she was unfortunately not able to meet Kathy’s requests. The therapist also reminded Kathy that she was very interested in helping her meet her treatment goals.

The greater difficulty was that in therapy, Kathy dwelled on how she was doing better than other people she knew. She reported only her successes in hopes of being praised. Her therapist had a hard time getting Kathy to focus on the problems that brought her into treatment.

In working with patients with BPD, feelings of entitlement and efforts to avoid criticism are common forms of resistance. Clinicians who respond to a patient’s sense of entitlement with efforts to withhold what is demanded or to interpret the unrealistic nature of the patient’s needs are likely to make such a patient feel misunderstood, criticized, and angry. Providing validation for the patient’s needs without gratifying them offers a compromise that acknowledges the patient’s wishes without reinforcing his demands.

The problem of getting a patient focused on talking about difficulties is complicated. One approach involves making attention contingent on it. As a clinician, you can lean back in your chair and look perplexed when the patient dwells on how good he is at things. When the patient shifts to talking about difficulties, you can lean forward and give your undivided attention. Along with these nonverbal reinforcements of behaviors, it can help to note that you already know that the patient is very good, if not exceptional, at the things he is describing. Then add, “I feel our limited time is valuable and want to make sure you have time to discuss the things you are having difficulty with.” This approach avoids confronting the patient’s efforts to support his own self-esteem while also helping him move onto more relevant material.

Family issues as a source of resistance

Another important source of resistance in treating patients with BPD is their notion that change may entail betraying their family in particular ways as well as giving up habits they may feel work well for them in avoiding feelings.

CASE VIGNETTE

Melody is the oldest child in a close-knit family. She has always been athletic, but she also has a long history of recurrent sports-related injuries. Melody is preoccupied with performance and sensitive to criticism. At home, negative feelings were not talked about: her parents thought they were shameful. Recurrent injuries were the only manner in which she could elicit sympathetic reactions from her parents.

When Melody went to college and encountered academic difficulties, she started to fall down stairs and trip over things repeatedly. After each accident, her family came rushing to take care of her. When it was found out that Melody’s accidents were deliberate, she began psychotherapy.

At first, Melody was highly anxious and sat in silence, unable to verbalize her feelings. Over time, however, she began to talk about her accidents as ways to not think about missing home and to explain her failure to excel at school. Whenever she spoke about her fears of parental disapproval, she would have the impulse to hurt herself. Her parents became fearful and encouraged psychiatric hospitalizations every time she spoke about her difficulties. Melody became more anxious and angry as a result. She noted that her old way of hurting herself (accidents) was more effective in diverting her attention away from unwanted feelings and gaining her parents support than talking about feelings.

When her family was asked to be involved in her treatment, both Melody and her parents decided that therapy was not helpful and terminated the treatment.

This vignette illustrates a common situation in which self-harm functions to divert attention away from emotional difficulties and to enlist noncritical caregiving support. The behavioral “acting out” is itself a common form of resistance. Both Melody and her parents resisted the process of replacing self-harm with self-reflection and verbalization of feelings in therapy. When patients like Melody start the difficult tasks of change and confronting negative affects, they will feel worse before they feel better. It is helpful to teach borderline patients and their families that this is expected and is how therapy can work.

Discussion

The vignettes presented here illustrate several forms of resistance that clinicians can expect to encounter in working with patients with BPD. We have not attempted to be comprehensive about all the forms of resistance encountered. A few of the other common resistances include deceit, projection, and “splitting.” Clinicians should appreciate that what may seem like willful deceit can often better be understood as the patient’s defensive ability to dissociate or deny, or to lose his mentalizing abilities, when stressed.

Projection can also become a formidable means of resistance. The clinician needs to seek out that sometimes-modest fraction of the patient’s complaints and attributions that are true and begin to validate them.

This principle is also central in responding to splitting. Clinicians who are idealized by their patients should accept the partial truth of this, while clinicians who are vilified should acknowledge that they did or said something that makes the patient’s angry or avoidant reaction understandable.

Our review is intended to illustrate that the patient’s resistance to treatment can be aggravated by a therapist’s misunderstandings of BPD. It is easy to blame the patient for responding poorly to treatments (being “resistant”) without recognizing that when treatments don’t reflect an understanding of BPD, the treatments can aggravate these resistances.

These comments are not meant to minimize the diverse array of resistances that patients with BPD present. These patients will never be easy to treat, but when their particular forms of resistance to treatment are understood as learned behaviors that have served adaptive function, we can move toward a more empathic and sympathetic therapeutic posture. Resistance can then be replaced by more truly adaptive responses.

References:

References

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