Psychodynamic Therapy for Personality Disorders
Personality disorders present complex clinical challenges. These psychodynamic therapy techniques address core underlying emotional conflicts and relational patterns to bring meaningful change.
Personality disorders such as borderline personality disorder (BPD), narcissistic personality disorder (NPD), and antisocial personality disorder (ASPD) are characterised by deeply ingrained patterns of emotional dysregulation, interpersonal dysfunction, and maladaptive behaviours. These disorders are often resistant to treatment due to the complex and pervasive nature of their symptoms. While DSM-5-TR provides a structured, categorical model for diagnosing these disorders, psychodynamic therapy delves into the underlying emotional conflicts, unconscious processes, and early attachment patterns that sustain these personality pathologies.
Psychodynamic therapy offers clinicians tools to explore patients' unconscious drives, internal conflicts, and the impact of defence mechanisms on their behaviour. This therapeutic approach is valuable for understanding how patients with personality disorders process relationships and manage emotional distress. For instance, in patients with BPD, psychodynamic therapy helps uncover the fears of abandonment, emotional volatility, projection and splitting (the tendency to see things in extremes) that often manifest in their interpersonal relationships.
The application of transference-focused psychotherapy (TFP) and mentalisation-based therapy (MBT) has proven effective in treating patients with borderline and narcissistic personality disorders. TFP, for example, is grounded in the principle that patients project their past relational dynamics onto the therapist, allowing clinicians to address these projections in real time. Similarly, MBT helps patients with personality disorders, especially BPD, develop the capacity to mentalise—to understand and reflect on their own and others' emotional states and how these drive behaviour. This improves emotional regulation and interpersonal functioning, key deficits in these disorders.
This article provides clinicians with an overview of psychodynamic concepts and techniques for treating personality disorders. By focusing on transference, countertransference, defence mechanisms, and object relations, psychodynamic therapy offers a pathway to more profound therapeutic work beyond symptom relief. It addresses the root causes of personality pathology.
- Core Psychodynamic Techniques for Personality Disorder Treatment
- Tailoring Psychodynamic Therapy to Specific Personality Disorders
- Integrating Psychodynamic Therapy with Other Modalities
- Supervision and Reflective Practice for Psychodynamic Work
- In Sum - Key Points
- Resources
Core Psychodynamic Techniques for Personality Disorder Treatment
A. Transference and Countertransference Work
Transference is a central component of psychodynamic therapy, especially in the treatment of personality disorders. It refers to the process by which patients project unresolved elements of their past relationships, particularly unintegrated experiences and conflicts with early caregivers, onto the therapist. This is especially prominent in borderline and narcissistic personality disorders, where patients often recreate patterns of idealisation and devaluation within the therapeutic relationship. For example, a patient with BPD may initially idealise the therapist, viewing them as entirely good, but later shift to devaluation when they feel let down or misunderstood, reflecting the underlying splitting behaviour often seen in BPD.
In narcissistic personality disorder, transference can manifest as grandiosity or entitlement towards the therapist, mirroring the patient’s underlying vulnerability and need for admiration. Addressing transference in therapy allows clinicians to help patients become aware of these patterns and to work through the emotional conflicts driving their behaviour. This real-time interaction within the therapeutic relationship provides an opportunity to explore and modify dysfunctional relational patterns.
Countertransference, on the other hand, refers to the therapist’s emotional response to the patient. Managing countertransference is especially critical when treating antisocial or borderline personality disorders, where patients may evoke strong emotional reactions in the therapist, including frustration, anger, or feelings of helplessness. Recognising and managing these emotions is essential for maintaining therapeutic boundaries and ensuring that the therapist can continue to engage productively with the patient rather than reacting impulsively to the patient's behaviours.
B. Working Through Defense Mechanisms
Patients with personality disorders rely heavily on defence mechanisms—unconscious strategies used to avoid emotional pain or anxiety. Common defences in personality disorders include splitting, denial, and projection. For example, patients with BPD often engage in splitting, seeing others as either all good or all bad, without the ability to integrate these opposing views. This binary thinking contributes to their unstable relationships and emotional turmoil.
In therapy, clinicians help patients recognise these defence mechanisms and develop healthier ways of processing their emotions. For instance, by identifying when a patient is engaging in projection (attributing their negative feelings to someone else), the therapist can help the patient gain insight into their emotional state and take responsibility for their feelings rather than externalising blame.
C. Exploring Object Relations and Attachment Styles
At the heart of many personality disorders are disrupted early attachment experiences and distorted object relations. Object relations theory posits that the internalised relationships a person forms during early childhood profoundly influence their interpersonal dynamics in adulthood. For patients with borderline personality disorder (BPD), these early attachment disruptions, such as inconsistent caregiving or neglect, often result in a pervasive fear of abandonment and unstable interpersonal relationships. These patients may alternate between intense attachment and emotional withdrawal, reflecting their insecure attachment style.
In psychodynamic therapy, clinicians explore how these early relational experiences continue to shape the patient’s behaviour in current relationships, including the therapeutic relationship. By examining the transference dynamics that emerge during therapy, patients recognise how their past experiences with caregivers are replayed in their present relationships. For example, a patient with BPD may unconsciously expect the therapist to abandon them, leading to heightened anxiety or attempts to control the relationship. The therapist helps the patient develop more secure relational patterns by bringing these unconscious expectations into awareness.
Clinicians can also focus on improving the patient’s capacity for reflective functioning or understanding their and others’ mental states. This is a key target in mentalisation-based therapy (MBT), particularly for patients with BPD, who often struggle to interpret their own emotions and motivations. Strengthening this capacity allows patients to form more stable relationships by reducing their emotional reactivity and improving their ability to mentalise or reflect on the mental states of others.
For patients with narcissistic personality disorder (NPD), early object relations are often marked by fragile self-esteem, resulting from a lack of consistent validation during childhood. In therapy, clinicians work with these patients to explore the grandiosity and defensive self-aggrandisement that serve as protective shields against feelings of inadequacy or shame. Through gradual interpretation of these defences, the therapist helps the patient develop a more cohesive and realistic sense of self that is less reliant on external validation or grandiosity.
Tailoring Psychodynamic Therapy to Specific Personality Disorders
A. Borderline Personality Disorder (BPD)
BPD is often characterised by emotional instability, intense interpersonal relationships, and chronic feelings of emptiness. In treating BPD, psychodynamic therapy is particularly effective because it addresses the underlying emotional conflicts and relational dysfunctions that perpetuate the disorder. Techniques like mentalisation-based therapy (MBT) help patients improve their capacity to mentalise, thereby enhancing their ability to regulate their emotions and form more stable relationships. MBT focuses on teaching patients how to reflect on their mental states and those of others, which helps reduce impulsivity and emotional reactivity—key challenges in BPD.
In addition to MBT, transference-focused psychotherapy (TFP) is another psychodynamic approach that has proven effective for BPD. TFP focuses on exploring the transference dynamics that emerge in the therapeutic relationship, allowing the therapist to address the patient’s unconscious fears of abandonment and experiences of emotional volatility in real time. By working through these transference issues, patients with BPD can develop greater emotional resilience and relational stability.
B. Narcissistic Personality Disorder (NPD)
Narcissistic personality disorder (NPD) is typified by grandiosity, a constant need for admiration, and a lack of empathy, which often mask a fragile sense of self. In psychodynamic therapy, clinicians work to uncover the underlying vulnerability and shame that drive these defences. NPD patients typically use grandiosity as a defence mechanism to protect against deeper feelings of inadequacy, which often stem from early attachment experiences marked by either overvaluation or devaluation by caregivers.
In therapy, clinicians carefully navigate the patient’s defensive grandiosity without directly confronting it in a way that leads to withdrawal or resistance. Gradual interpretation is key. Therapists work to gently expose the patient to the underlying feelings of vulnerability and insecurity, helping them recognise that their grandiose behaviour is a defence rather than an accurate reflection of their self-worth.
Another important aspect of treating NPD is addressing the lack of empathy that is often central to the disorder. Through exploring transference dynamics, the therapist can help the patient become more aware of their impact on others and encourage the development of more genuine emotional connections. Over time, as the patient becomes more willing to confront their vulnerability, they can form a more realistic and cohesive sense of self that is not reliant on the inflated defences of grandiosity and entitlement.
C. Antisocial Personality Disorder (ASPD)
Antisocial personality disorder (ASPD) is characterised by a pervasive pattern of disregard for the rights of others, impulsivity, and lack of remorse. These patients often present as highly resistant to treatment, given their tendency to externalise blame and avoid responsibility for their actions. In treating ASPD, psychodynamic therapy focuses on helping the patient become aware of their emotional defences, such as denial and projection, which they use to avoid confronting their destructive behaviours.
A key therapeutic goal with ASPD patients is cultivating empathy and emotional awareness. This is often achieved by exploring the patient’s relational history and helping them recognise how their early relationships may have shaped their manipulation, control, and detachment from others. While many ASPD patients initially resist exploring their emotions, over time, the therapist can work to help the patient see the value in developing more genuine emotional connections and understanding the impact of their behaviour on others.
Integrating Psychodynamic Therapy with Other Modalities
A. Combining Psychodynamic Therapy with CBT and DBT
For patients with borderline personality disorder (BPD), the combination of DBT and psychodynamic approaches has proven particularly effective. DBT, developed by Marsha Linehan, is structured to help patients manage impulsivity, emotional reactivity, and suicidal behaviours through skills training in mindfulness, distress tolerance, and emotional regulation. However, while DBT addresses these immediate, observable symptoms, it does not directly target the unconscious processes that contribute to relational dysfunctions and deep-seated fears of abandonment—critical features of BPD.
By integrating DBT with psychodynamic therapy, clinicians can offer patients tools to regulate their emotions in the short term while also working through the underlying emotional conflicts that drive their impulsive behaviours and unstable relationships. For example, a patient may use DBT skills to manage an immediate crisis, such as resisting the urge for self-harm. Still, in psychodynamic therapy, they would explore the underlying feelings of abandonment or rejection that triggered the crisis in the first place. This dual approach helps patients gain both behavioural control and emotional insight, leading to more sustainable improvements in their mental health.
In treating narcissistic personality disorder (NPD), CBT can be used to challenge distorted thinking patterns, such as the patient’s tendency to overestimate their abilities or feel entitled to special treatment. CBT helps patients become more aware of these cognitive distortions and develop more balanced, realistic thoughts. However, CBT alone may not address the emotional vulnerability and shame underlying the patient’s grandiosity. By integrating CBT with psychodynamic therapy, clinicians can help patients explore these deeper emotional issues, gradually helping them to confront and accept their vulnerability without needing to rely on grandiosity or defensiveness.
B. Medication and Psychodynamic Therapy
In many cases, patients with personality disorders, particularly borderline and antisocial personality disorders, may also benefit from medication management to address comorbid conditions such as depression, anxiety, or impulse control disorders. Medication can stabilise mood and reduce symptoms that might otherwise interfere with the effectiveness of psychotherapy. For example, mood stabilisers or antidepressants can be prescribed to reduce the emotional volatility seen in BPD, creating a more stable emotional baseline from which psychodynamic therapy can proceed effectively.
However, medication must be viewed as an adjunct to, rather than a replacement for, psychodynamic therapy. The core emotional conflicts driving personality disorders remain, even if some of the symptoms are managed with medication. Therefore, psychodynamic therapy remains necessary for addressing the deeper, unconscious aspects of personality pathology that cannot be resolved with medication alone.
Supervision and Reflective Practice for Psychodynamic Work
A. Importance of Supervision
Supervision is a cornerstone of psychodynamic work, especially when treating complex cases of borderline, narcissistic, or antisocial personality disorders. In supervision, therapists can process their countertransference reactions, which are often strong in cases involving intense emotional dynamics. For example, patients with BPD may evoke feelings of frustration, helplessness, or even anger in the therapist as they vacillate between idealisation and devaluation. Similarly, patients with ASPD may provoke feelings of distrust or manipulation, leading the therapist to distance themselves from the patient unconsciously.
Supervision provides a safe space for therapists to explore these emotional reactions and develop strategies for managing them to keep the therapeutic relationship intact. Additionally, supervision helps clinicians refine their approach to transference and understand how their emotional responses may influence the treatment process. A skilled supervisor can help the therapist recognise when their emotional reactions are informative—highlighting essential dynamics within the therapeutic relationship—and when they may need to be tempered to maintain the therapeutic frame.
B. Developing Reflective Practice
In addition to formal supervision, reflective practice is an essential part of psychodynamic work with personality disorders. Reflective practice involves the therapist regularly examining their emotional reactions, clinical decisions, and the overall progress of therapy. This process helps therapists remain grounded and avoid being reactive or impulsive in response to the patient's behaviour.
For instance, in treating narcissistic personality disorder, a therapist may experience countertransference in the form of feelings of inadequacy or irritation when the patient expresses grandiosity or entitlement. By engaging in reflective practice, the therapist can become more aware of these feelings and understand how the patient's behaviour activates emotional responses. This awareness helps the therapist to remain calm, neutral, and effective in helping the patient work through their defences rather than being drawn into a power struggle or inadvertently reinforcing the patient's narcissistic behaviour.
Reflective practice also allows clinicians to assess their use of interventions and make necessary adjustments. In treating borderline personality disorder, for example, a therapist might reflect on a recent session where the patient became emotionally dysregulated. By reflecting on what triggered the dysregulation and how it was managed, the therapist can develop new strategies for addressing similar situations in future sessions, improving the therapeutic process.
In Sum - Key Points
A. Integrating Techniques for Comprehensive Treatment
Incorporating psychodynamic therapy into the treatment of personality disorders offers clinicians a powerful tool for addressing the deeper emotional and relational dynamics that underpin these disorders. While approaches such as CBT and DBT are invaluable for managing symptoms and providing patients with practical coping strategies, psychodynamic therapy goes beyond symptom relief to tackle the unconscious conflicts, attachment disruptions, and defence mechanisms that perpetuate dysfunctional behaviour in personality disorders.
By focusing on techniques such as transference analysis and countertransference management and working through defence mechanisms like splitting and projection, psychodynamic therapy provides clinicians with a comprehensive framework for understanding and treating patients with borderline, narcissistic, and antisocial personality disorders. These techniques allow clinicians to help patients manage their emotions and develop healthier and more stable relationships, both within and outside of therapy.
Moreover, integrating psychodynamic therapy with other modalities such as CBT, DBT, and pharmacotherapy allows for a more holistic approach to treatment. While medications can help stabilise mood and reduce immediate emotional volatility. CBT/DBT can offer concrete skills for managing behaviour, and psychodynamic therapy addresses the root emotional causes of these disorders, promoting long-term change and emotional growth.
B. The Role of Supervision and Reflective Practice
For clinicians, developing expertise in psychodynamic techniques requires regular supervision and reflective practice. These processes ensure that the therapist remains emotionally attuned and avoids becoming overwhelmed by the emotional intensity of working with patients who exhibit extreme behaviours or emotional volatility. Through supervision, clinicians can refine their understanding of transference and countertransference, ensuring that their emotional responses to the patient are constructive rather than reactive.
Supervision provides a platform for therapists to discuss challenging cases, receive feedback, and develop strategies to manage their emotional responses. On the other hand, reflective practice involves ongoing self-examination and professional development, enabling therapists to maintain a high level of self-awareness and emotional resilience. Supervision and reflective practice enhance the therapist's ability to engage effectively with patients, fostering a therapeutic environment conducive to meaningful change.
C. Future Directions in Psychodynamic Therapy
As the field of psychotherapy continues to evolve, psychodynamic therapy remains a vital approach to understanding and treating personality disorders. Future directions may include further integration with technological advancements, such as teletherapy and digital tools for monitoring patient progress. Additionally, ongoing research into the efficacy of psychodynamic techniques will continue to refine and enhance therapeutic practices, ensuring that clinicians are equipped with the most effective strategies for fostering patient growth and healing.
Moreover, there is a growing emphasis on personalised treatment plans that consider each patient's unique emotional and relational patterns. By continuing to innovate and adapt psychodynamic therapy to meet the diverse needs of individuals with personality disorders, clinicians can provide more effective and compassionate care, ultimately leading to better outcomes for their patients.
Psychodynamic therapy offers a unique and profound way to treat personality disorders. By addressing both the conscious symptoms and the unconscious emotional processes, clinicians can provide patients with a deeper and more comprehensive treatment, helping them move beyond immediate symptom management and toward lasting emotional health and relational stability.
Resources
Psychiatry Online - Discusses the use of psychodynamic psychotherapy in clinical settings, focusing on its application for treating personality disorders.
Psychiatric Times - Explores psychodynamic psychotherapy, particularly its effectiveness in addressing personality disorders, including theory, treatment, and challenges.
Medical News Today - Provides an overview of psychodynamic therapy, its principles, techniques, and how it helps individuals understand and resolve deep-rooted emotional conflicts.
Psychology Today - Highlights psychodynamic approaches to treating borderline personality disorder, emphasising the benefits of understanding unconscious processes and past experiences.
Important:
TherapyRoute does not provide medical advice. All content is for informational purposes and cannot replace consulting a healthcare professional. If you face an emergency, please contact a local emergency service. For immediate emotional support, consider contacting a local helpline.
Find a Therapist
Find skilled psychologists, psychiatrists, and counsellors near you.
