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Why Doesn't Therapy Work for Borderline Personality Disorder?

I am a specialist in Cluster B personality disorders who has worked with people with disabilities and mental illnesses for over 10 years.

While therapy works for some BPD patients, it doesn't work for everybody.

While therapy works for some BPD patients, it doesn't work for everybody.

Why Therapy Is Difficult for BPD Patients

Many people suffering from borderline personality disorder (BPD) find that therapy works well for them. Unfortunately, however, this is not the case for everybody.

Therapy requires the patient's commitment to wellness and an understanding of their disorder. Because personality disorders heavily affect the way a person thinks about and perceives things, people suffering from BPD often cannot recognize their disorder. To them, it looks like everybody else is the problem. They truly believe that they are a victim.

The truth is that they are a victim—they are a victim of their illness, not of someone else’s cruelty or indifference. They are often master liars and manipulators; even the most astute observer cannot detect their lies. This is because there is no lie to detect—they truly believe what they are saying.

They Often Misperceive Reality

Borderline patients often misperceive reality. Patients will not remember things as they actually occurred, especially when it comes to stressful situations. They will accuse you of saying things you didn’t say or of doing things you didn’t do, and there is no convincing them otherwise.

While most people work their emotions into the facts, people with BPD work the facts into their emotions. Someone without BPD might see that you have been cruel to them, and they will react with hurt feelings, anger, etc. On the other hand, a person with BPD might already be angry or hurt, so they perceive that you have been cruel to them, even if you haven’t. Nothing you say or do will make any difference; they might see rejection and abandonment in anything you say.

There is no reasoning for this. When a person with BPD gets emotionally close to someone, the other person is automatically seen as a threat. They expect that they will be hurt and will react accordingly, punishing their partner for things that never happened.

This translates to therapists too, and it is one of the reasons that therapy often does not work: When the patient sees the therapist as an enemy, therapy is not an option.

Some Therapists May Refuse to Treat Borderline Personality Disorder

Because these patients are challenging, many therapists and doctors simply will not treat people with BPD. Other well-meaning—but misguided—therapists diagnose a less-stigmatized illness, which results in less-effective treatment. Still, others believe that it is not a real illness at all, that it is a "catch-all" diagnosis with no real definition, or that it only occurs in women.

Many BPD patients lie about their stories, and it is important that the therapist knows how to approach this problem.

Many BPD patients lie about their stories, and it is important that the therapist knows how to approach this problem.

It Is Hard to Identify Lies

Much of what the borderline patient says is lies, misunderstandings, and skewed perceptions. They routinely misunderstand things that others have said and attribute the misperceived meaning to the person.

People with BPD may also lie outright, and they often cannot see any of their own wrongdoing. This is especially true if the BPD diagnosis is complicated with other personality disorders, such as narcissistic personality disorder. A therapist who relies on the patient to self-report may receive the wrong information, and this is very dangerous—for both the patient and the people in the patient's life.

There Is No Such Thing as Pure BPD

Complicating therapy even further is the fact that there is no such thing as "pure" BPD. Borderline personality disorder always occurs alongside other disorders and health concerns, such as eating disorders, substance abuse, depression, and more.

It's not uncommon to find that a borderline patient has one or more other personality disorders as well. Narcissistic personality disorder, histrionic personality disorder, and antisocial personality disorder often occur in tandem with BPD, and the presence of these disorders makes treatment significantly more difficult. Narcissistic personality disorder, in particular, can make successful therapy almost impossible.

Therapists Rarely See Patients Outside of the Office

Perhaps the biggest obstacle to treatment is that therapists don't see the BPD patients as they actually are. Therapists see them in a controlled environment for a short period of time, a setting where all the attention is focused on the patient. Since borderline patients have the most difficulty when they feel abandoned or rejected, a therapy session where the patient has 100% of the attention is not an environment in which they will be triggered.

Therapists do not see the patient act out, so the former will often inadvertently reinforce the patient's belief that there is nothing wrong, that the accusations against the patient are exaggerated, or that it is everybody else who has the problem. Validating these beliefs is counter-productive because one of the most challenging hurdles to treating BPD is getting the patient to understand that their perception is distorted. If this distorted perception is validated, it becomes even harder to address.

Choose a therapist who understands personality disorders.

Choose a therapist who understands personality disorders.

Find the Right Therapist

Therapy for BPD patients can be positive if approached correctly and if the patient truly wants to get help. Choosing the right therapist is crucial to success, perhaps more so with BPD than with other illnesses. There are many excellent therapists out there, but there are also many therapists who do not understand BPD or personality disorders very well. These therapists can inadvertently make the disorder harder to treat, especially if they are unaware of the manipulative aspects of BPD and the other cluster B personality disorders that often exist with it.

If the therapist your family is working with does not listen to you, does not take your concerns seriously, does not believe what is being said about the borderline patient, takes sides, or in any way seems to make things worse, find a new one. There are great therapists out there, and with a little patience, you can find one who can help you and your loved ones.

This content is accurate and true to the best of the author’s knowledge and does not substitute for diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed health professional. Drugs, supplements, and natural remedies may have dangerous side effects. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.

© 2015 The Little Shaman


Georgia on May 12, 2020:

This article is purely based on stereotypes surrounding BPD without facts or statistics behind it. This only further stigmatises those with the disorder. Also the most common co-occurring mental illnesses with BPD are actually anxiety, depression and eating disorders. Many people with BPD who receive DBT, finish treatment and no longer meet all of the criteria for an official diagnosis. Please stop increasing the stigma

The Little Shaman (author) from Macon, GA on December 20, 2018:

As you can see, the article clearly states that therapy does work for some borderline patients.

Jennifer on December 19, 2018:

This is such an ignorant article. There is plenty of proof that DBT has worked in bpd patients and many have been in recovery. These statements are opinions not facts and only adds to the stigma. I am disappointed that articles like this exist. This only adds to the bpd patients struggle to be understood and gives them no hope that they can be helped. I have been diagnosed for over 20 years and have been been in recovery for 4 years. Recovery means that I no longer have the 9 attributes that are needed to be considered a bpd patient. With any human it holds true if you do not want to help you with not get help. Only those who genuinely want to get better will get better. This is absolutely not facts. There are 3 forms of bpd also. Some of the most loving and loyal people have bpd. Has it ever crossed anyone's mind that the people who manipulate and lie could just be that type of person? Not all bpds are manipulative nor are they all liars. Some people are just horrible human beings and yes we can be manipulative and we can lie but tell me that normal people can't do the same? Also where are your numbers? Your scientific proof that therapy does not work? Where is your facts? All I see I the writers opinion and not one quote or fact....don't believe tgis rubish until you have fact based information i would quit spreading stigma. To all the bpds really this please don't give up on yourself there is help and recovery is possible with DBT and other counciling.

Gregory Zeng from Australian Capital Territory on May 16, 2018:

From YouTube, titled: "Why Doesn't Therapy Work For Borderline Personality Disorder?"

BY: The Little Shaman Healing, Published on Jan 28, 2016

"In this video episode of Meditations & More, The Little Shaman discusses Borderline Personality Disorder and reasons why therapy is often ineffective in treating it for some people."

"After viewing the above video, found this web page. Left my comments on the video on the video page.

"Very good & sensible advice on those seeking therapy or treatment for BPD type of disorders. "Comments earlier than mine suggest: CBT (Cognitive Behavioural Therapy), or another: "STEPPS": "Systems Training for Emotional Predictability and Problem Solving". "Still exploring this ... For people we know.

Seems so much confusion on these very serious disorders. About 40 different terms to describe it. So many unclear treatment options. So many uncertain costs, timings & results.

Being very multi-cultural myself, the research work on so many multi-cultures has not been started, nor reported in any way.

Australian-born-Chinese. Very aged. Retired in the Australian Capital Territory.