Therapy for Personality Disorders

A personality disorder diagnosis describes long-standing patterns: how a person reads other people, handles strong feeling, and holds relationships together under strain. Talking therapy is the main treatment. The NHS says treatment for a personality disorder usually involves a talking therapy, and may also include other kinds of therapy and medicine.¹

What follows sets out which therapies have evidence and for which conditions, and what a course of treatment involves in practice. It also covers why strong feelings about a therapist are worked with rather than avoided, and how to judge whether a particular therapist is equipped for this work.

Do I need therapy for a personality disorder?

The patterns behind this diagnosis start early, hold across situations, and cost something real: work that keeps breaking down, relationships that end the same way each time, long stretches of feeling flooded or empty. A bad month is not a personality disorder. The question worth taking to a clinician is whether a pattern has run for years and is still doing damage.

Diagnosis is a clinical judgement made with a mental health professional. No online questionnaire settles it, and a label is not a verdict on character.

Two classification systems are in use, and which one your clinician works from depends on the country you are in. The NHS says the way personality disorders are diagnosed is changing: a person may now be diagnosed with mild, moderate or severe personality disorder with particular personality traits, rather than with a named type.¹ NICE guideline CG78 covers recognising and managing borderline personality disorder, and NICE notes that ICD-11 no longer separates the former types of personality disorder, defining it instead as a single condition classified by severity.² Borderline personality disorder is presented as a categorical diagnosis in the DSM-5, present or absent, while dimensional approaches to pathological personality traits have a strong evidence base.³

That difference has a practical edge. If a clinician gives you a severity band and a set of traits instead of a type name, you are being assessed under ICD-11, not being given a vaguer answer. If you are given a type name, such as borderline or emotionally unstable personality disorder, you are in a service working from DSM-5 or from ICD-10, both of which still use named types. Either way, what the therapy does next is much the same.

What therapy can and cannot do

In the American Psychiatric Association's 2001 practice guideline, psychotherapy is recommended as the core treatment for borderline personality disorder.⁴ The US National Institute of Mental Health says effective treatments help people with borderline personality disorder manage symptoms and improve daily functioning.⁵

The long-term picture is better than this diagnosis's reputation suggests. A systematic meta-analysis with follow-up periods of 5 to 15 years showed mean remission rates of 60% in borderline personality disorder.⁶ In a six-year prospective follow-up of adults with borderline personality disorder, more than a third met remission criteria at 2 years, half at 4 years, and over two-thirds at 6 years.⁷

Symptoms and daily functioning, though, do not improve at the same rate. Despite high rates of remission and low rates of relapse, people with borderline personality disorder often have persistent impairment in functional and social recovery.⁶ Two long-running cohorts followed people with borderline personality disorder over many years: the McLean Study of Adult Development and the Collaborative Longitudinal Personality Disorders Study. The McLean study found steady if modest improvement in global functioning over six years of prospective follow-up.⁸ So a page that promises a settled life after a course of therapy is overselling. Fewer crises, less self-harm and steadier relationships come first; work, study and friendship usually take longer, and often need their own attention in the treatment plan.

No medicine treats the personality patterns themselves. The NHS says medicine is sometimes prescribed for the problems that come¹ with a personality disorder: depression, anxiety, psychotic symptoms. For narcissistic personality disorder there is minimal evidence that pharmacotherapy helps unless there is a comorbid psychiatric illness, and no medications are approved by the US Food and Drug Administration for treating it.⁹ Clinicians differ on how large a part medication should play. Bateman and Fonagy view medication as useful in the treatment of personality disorder, and say it is occasionally needed if patients are to be able to participate in psychotherapy.¹⁰

Bateman and Fonagy describe a guarded optimism that personality is changeable and treatable.¹¹ Under the right therapeutic conditions, such as reduced stress, nonviolence and sobriety, everyone can grow in self-directedness.¹²

The therapies with evidence, and for whom

The strongest trial evidence sits with borderline presentations. In a meta-analysis reported by Bateman and Fonagy, psychodynamic therapy yielded a large overall effect size of 1.46, and cognitive behavioural therapy an effect size of 1.00, across studies of personality disorder.¹³ In a one-year randomised trial of transference-focused psychotherapy, dialectical behaviour therapy and a dynamic supportive treatment, patients with borderline personality disorder responded to structured treatments in an outpatient setting with change in multiple domains. In that trial both transference-focused psychotherapy and dialectical behaviour therapy were associated with improvement in suicidality in patients with borderline personality disorder.¹⁴

Away from borderline presentations the evidence is thinner. Gabbard's textbook reports an apparent consensus that psychotherapy produces sizable positive effects in personality disorders, in both dynamic and cognitive approaches. Across eight studies that included only Cluster C personality disorders, avoidant, obsessive-compulsive and dependent, the median treatment length was 22 sessions over 32 weeks.¹⁵ Psychotherapy is likely the most preferable treatment for narcissistic personality disorder, despite limited evidence for its efficacy.⁹

Pages that pair each named type with its matching therapy read tidier than the research is. Take the matching as a starting point for a conversation with a clinician, not as a decision already made. What a therapist has actually trained in, and whether they will work to a stated frame, matters more than the label on the therapy.

What treatment actually looks like

This is not brief work. The NHS puts the length at months to years, set by how severe the condition is and what else the person is carrying. Individual sessions are the usual spine, often with a group alongside. In the NHS, some people are offered treatment at a therapeutic community, where a person visits or stays for an intensive form of group therapy over weeks or months.¹

Good treatment plans name the crisis in advance rather than improvising it. NICE recommends that when a person with borderline personality disorder presents during a crisis, the clinician consults the crisis plan and tries to understand the crisis from that person's point of view.¹⁶ If your therapist raises what you will do at 2am on a bad night before there is a bad night, that is the standard of care, not a sign they expect the worst.

Other conditions are usually treated inside the same plan, not in a queue behind it. NICE advises that where borderline personality disorder comes with depression, post-traumatic stress disorder or anxiety, all of it belongs in one well-structured programme.¹⁶

How you reach any of this depends entirely on where you live. In Northern Ireland a person in crisis may receive intensive home support from a crisis resolution and home treatment team, or be admitted to hospital when they are temporarily unable to manage independently.¹⁷ Elsewhere the route may run through a family doctor, a public mental health service, a university or community clinic, or private practice, and the waiting times differ as much as the routes do. Ask, at first contact, who holds your care between sessions and what happens if you cannot reach your therapist.

Strong feelings about your therapist are part of the work

People leave this treatment most often at the point where the therapist becomes the problem. That moment is predictable, and it is workable.

The therapeutic alliance, meaning the emotional bond between client and therapist together with agreement on the goals and tasks of treatment, is a strong predictor of psychotherapy outcome. People who have experienced trauma may come to therapy with difficulty trusting others and interpersonal hypersensitivity, and may fear abandonment by the therapist or feel negative transference toward them.¹⁸ Forming an alliance is of fundamental importance in work with people with borderline personality disorder, and it is often difficult because fluctuating interpersonal attitudes can infuse the person's engagement with the therapist.⁴

Researchers describe two classes of alliance rupture: withdrawal ruptures, where discontent shows as avoidance or minimal responses, and confrontation ruptures, where the person directly expresses negative feelings about the therapist. Both are common, and neither means the treatment has failed. Resolving a rupture successfully is correlated with good outcome and with greater retention in treatment, across theoretical orientations. Carrying on with the usual technique during a rupture may erode the alliance further, so the therapist may need to turn to the relationship itself.¹⁹

Put plainly: if you find yourself thinking your therapist is cold, incompetent or quietly against you, that thought is material for the session rather than a reason to cancel it. Say it in the room. What happens next tells you a great deal.

Signs the rupture is ordinary and worth working through:

• Your therapist takes the complaint seriously, does not argue you out of it, and asks what it was like from your side.
• Something specific is identifiable afterwards: a missed appointment, a comment that landed badly, a holiday break.
• The feeling loosens once it has been said, even if it returns.
• You recognise the pattern, because other relationships may have ended the same way.

Signs of a genuinely poor fit, worth raising and, if nothing changes, worth acting on:

• Your therapist will not name a treatment frame: what the sessions are for, how often, for roughly how long, what happens in a crisis.
• Raising a problem in the relationship is repeatedly deflected, or treated as your symptom and nothing else.
• They have no training or supervision for this work and will not say so.
• Boundaries are unclear or shifting, or you feel worse after most sessions over a long stretch with no discussion of why.

Ambivalence about the treatment itself belongs in the room too. If you have wanted to stop, say that you have wanted to stop, and let the reason be examined before you decide.

Finding a therapist equipped for this work

General therapy training does not automatically cover personality disorder work. It is fair, and expected, to ask a therapist directly what they have trained in.

• Which specific training do they hold: DBT, MBT, transference-focused psychotherapy, schema therapy, or another structured model?
• How much of their current practice involves people with these difficulties?
• What frame do they work to: session frequency, expected length of treatment, group or individual, and how it is reviewed?
• What is the arrangement between sessions, and in a crisis?
• Do they have supervision or a team for this work?

A therapist who answers these plainly is showing you how they think. A therapist who cannot say what the treatment involves may still be a fine clinician in other work.

Two things make a first session more useful. Bring a short history: previous diagnoses, previous treatments and what happened to them, and any medication. Bring two or three goals in your own words, such as steadier work, fewer crises, or one relationship you want to stop repeating.

You can search for therapists by country, city and speciality in the TherapyRoute directory. If you would like a fuller guide to choosing between them, read how to find the right therapist.

Family, and what helps between sessions

Families are usually part of the picture, and they carry their own load. Family education, skills and support groups, offered with or without the patient, can be an effective way to support relatives of a person with borderline personality disorder.²⁰ The American Psychiatric Association notes that family members may benefit from talking with a mental health provider who can help them cope with the difficulties.²¹ Family therapy is offered in some services; in others the support is a group for parents or partners.

Self-management helps and has limits, and both halves are worth saying. The American Psychiatric Association's information for families lists steps such as regular exercise, avoiding alcohol and illegal drugs, joining a support group, keeping routine medical care, and staying connected with family and friends.²¹ Sleep, structure and staying off alcohol genuinely change how much a bad week costs.

What these steps do not do is change the patterns themselves. That is what the structured therapies are for. Some people manage at home because services are unavailable, because treatment is unaffordable, or because a previous experience of it went badly. Those are reasonable positions. If one of them applies to you, it is worth telling a clinician exactly that when the chance comes.

Questions people ask

How long does therapy take?

Longer than most people expect, and it varies by presentation and by service. The trials cited above give the spread. The shorter avoidant and obsessive-compulsive studies ran a few months of weekly sessions; structured programmes for borderline presentations commonly run a year or more. Ask for an expected length at the start, and for a review point.

Can a personality disorder be cured?

Remission of symptoms is common, and it is measured. What lags is functioning: work, study and friendships often improve more slowly than the symptoms do, which is why those areas belong in the treatment goals rather than being left to follow on their own.

How can I tell whether the therapy is working?

Feelings about progress swing, so watch the countable things over months rather than weeks: crises, self-harm, hospital contacts, days at work, whether a relationship survived a fight. Review these with your therapist at set points. A stretch that feels awful is not by itself evidence of failure.

What if I keep wanting to quit?

Wanting to quit is common, and it usually arrives at a specific moment rather than at random. Take the wish itself into the next session before acting on it. If you decide to leave, an ending discussed in advance is worth far more than a cancelled appointment and silence.

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References

1. [1] NHS (UK). nhs.uk/mental-health/conditions/personality-disorder.
2. [2] National Institute for Health and Care Excellence (UK). nice.org.uk/guidance/cg78.
3. [3] PubMed Central. pmc.ncbi.nlm.nih.gov/articles/PMC6145127.
4. [4] Gunderson & Hoffman (eds) - Understanding and Treating Borderline Personality Disorder: A Guide for Professionals and Families: Gunderson & Hoffman (eds) - Understanding and Treating Borderline Personality Disorder: A Guide for Professionals and Families, 2 Psychotherapies for Borderline Personality Disorder (pt 1).
5. [5] National Institute of Mental Health. nimh.nih.gov/health/topics/borderline-personality-disorder.
6. [6] NCBI Bookshelf. ncbi.nlm.nih.gov/books/NBK556058.
7. [7] Bateman & Fonagy - Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment: Bateman & Fonagy - Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment, The course of BPD.
8. [8] PubMed Central. pmc.ncbi.nlm.nih.gov/articles/PMC3203735.
9. [9] NCBI Bookshelf. ncbi.nlm.nih.gov/books/NBK556001.
10. [10] Bateman & Fonagy - Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment: Bateman & Fonagy - Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment, Drug treatments.
11. [11] Bateman & Fonagy - Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment: Bateman & Fonagy - Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment, Introduction.
12. [12] Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed (2017, vols 1+2): Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed (2017, vols 1+2), 26. Personality Disorders (pt 6).
13. [13] Bateman & Fonagy - Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment: Bateman & Fonagy - Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment, Chapter 2: Therapy research and outcome.
14. [14] DOI record. doi.org/10.1176/ajp.2007.164.6.922.
15. [15] Gabbard's Treatments of Psychiatric Disorders (2007): Gabbard's Treatments of Psychiatric Disorders (2007), Print: Chapter 55. Cluster C Personality Disorders: Avoidant, Obsessive-Compulsive, and Dependent (pt 1).
16. [16] National Institute for Health and Care Excellence (UK). nice.org.uk/guidance/cg78/chapter/Recommendations.
17. [17] Source hosted at www.nidirect.gov.uk. nidirect.gov.uk/articles/mental-health-support.
18. [18] PubMed Central. pmc.ncbi.nlm.nih.gov/articles/PMC12238290.
19. [19] PubMed Central. pmc.ncbi.nlm.nih.gov/articles/PMC5966286.
20. [20] Zanarini (ed) - Borderline Personality Disorder: Zanarini (ed) - Borderline Personality Disorder, 15 Family Interventions for Borderline Personality Disorder (pt 1).
21. [21] American Psychiatric Association. psychiatry.org/patients-families/personality-disorders/wh....