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Borderline Personality Disorder and Resistance to Treatment

(PSYCHIATRIC TIMES) - 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

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