Part Three

Treatment and Recovery

The treatment of Borderline Personality Disorder has undergone a substantial shift from earlier assumptions of chronicity and therapeutic difficulty towards an evidence-informed recognition that meaningful improvement and, for some people, sustained recovery are possible. This change is supported particularly by longitudinal research, which demonstrates that many people diagnosed with BPD experience substantial reductions in symptoms over time. However, the evidence also shows that symptomatic remission, functional recovery and personal recovery are not synonymous. A person may no longer meet diagnostic criteria while continuing to experience difficulties in relationships, employment, identity, emotional regulation or quality of life. Conversely, improvements in functioning and quality of life may occur alongside residual symptoms. Treatment and recovery must therefore be understood as related but distinct processes.

The evidence does not support the conclusion that BPD is inevitably a lifelong disorder. Longitudinal studies have demonstrated considerable rates of symptomatic remission, although estimates vary according to the population studied, the length of follow-up and the definition of remission employed. Zanarini and colleagues, for example, found high rates of sustained symptomatic remission over ten years in a longitudinal cohort of patients with BPD, while a smaller proportion met their more demanding definition of recovery, which incorporated both symptomatic remission and good psychosocial functioning. These findings are important because they demonstrate the capacity for substantial change, while simultaneously cautioning against reducing recovery to the disappearance of diagnostic symptoms.

The evidence should nevertheless be interpreted carefully. Longitudinal studies demonstrate that remission and recovery occur; they do not, by themselves, establish that a particular treatment caused those outcomes. Similarly, evidence supporting psychological therapies does not justify the claim that one intervention produces recovery for everyone diagnosed with BPD. Treatment research demonstrates improvements in particular outcomes and, in some studies, advantages over treatment as usual, but effects vary according to the intervention, outcome measured, population and methodological quality of the study. An academically responsible account of recovery must therefore hold two positions simultaneously: meaningful change is demonstrably possible, but its course and extent vary between individuals.

This distinction is important because the historical pessimism surrounding BPD has itself influenced professional responses. When a diagnosis is interpreted as a fixed description of personality rather than as a formulation of current difficulties, there is a risk that behaviours become regarded as enduring characteristics of the person. Emotional dysregulation may be interpreted as simply "who the person is"; self-harm may be understood primarily as a symptom to suppress; interpersonal difficulties may be attributed to manipulation or characterological defect; and repeated crises may generate professional hopelessness. Such responses can narrow therapeutic possibilities and obscure the distinction between understanding a pattern and predicting its permanence.

The possibility of recovery does not mean that BPD should be minimised or presented as easily treatable. Individuals may experience severe and persistent emotional distress, recurrent self-harm, suicidal behaviour, dissociation, unstable relationships and significant impairment. Some people experience substantial difficulties for many years, and improvement may be interrupted by periods of deterioration. Recovery therefore should not be represented as inevitable, rapid or linear. The evidence supports possibility rather than guarantee, and hope is most clinically responsible when it is grounded in realistic expectations rather than reassurance unsupported by evidence.

Trauma provides an important context within which some experiences associated with BPD can be understood, although it cannot be treated as a universal or sufficient explanation for the disorder. Research has identified associations between childhood adversity, maltreatment, attachment difficulties and later borderline pathology, but BPD is heterogeneous and arises through the interaction of multiple biological, psychological and environmental influences. Trauma exposure is neither present in every person diagnosed with BPD nor determinative of the outcome for those who have experienced it. A trauma-informed approach therefore requires curiosity about the individual's history without imposing a trauma narrative upon them.

Judith Lewis Herman's work is particularly relevant to the broader question of recovery from trauma. Herman (1992) conceptualised trauma recovery around the restoration of safety, remembrance and mourning, and reconnection. Her work is not a treatment model for BPD, nor does it establish that BPD is caused by trauma. Its importance to this book lies elsewhere: it provides a framework for understanding why recovery may involve much more than the reduction of symptoms. When traumatic experiences have disrupted a person's sense of safety, relationships, agency and identity, meaningful recovery may require attention to these domains as well as to psychological symptoms.

Bessel van der Kolk (2014) has similarly contributed to contemporary trauma scholarship through his discussion of the enduring effects of traumatic experience upon emotional regulation, bodily experience, memory and relationships. His work has influenced trauma-informed thinking and has helped draw attention to the ways in which traumatic experience may be expressed beyond conscious recollection. Nevertheless, his work should be considered alongside the wider empirical literature rather than treated as a single explanatory account of BPD. The relationship between trauma and BPD is complex, and contemporary understanding requires consideration of developmental, attachment, biological, psychological and environmental factors.

Within this broader context, psychological treatment provides an opportunity to develop capacities that may be impaired, overwhelmed or insufficiently developed. The purpose of treatment is not simply to suppress behaviour that professionals find difficult to manage. Effective psychological intervention seeks to understand the function of behaviour, reduce risk, develop alternative strategies for managing distress and strengthen the individual's capacity to participate in relationships and everyday life. The therapeutic approaches considered in this part of the book differ considerably in their theoretical foundations and methods, but each represents a departure from the assumption that the difficulties associated with BPD are beyond meaningful psychological intervention.

The therapeutic relationship provides the context in which this work takes place. For individuals whose developmental histories have included inconsistent caregiving, rejection, abuse, neglect or repeated relational disruption, relationships may be associated with both profound need and profound threat. The therapeutic relationship can consequently activate expectations concerning abandonment, criticism, dependency, mistrust or rejection. Such responses should not automatically be interpreted as manipulation or resistance. At the same time, a compassionate therapeutic relationship does not require the abandonment of professional boundaries. Predictability, clarity, consistency and appropriate limits can provide an important foundation for safety and trust.

The therapeutic relationship is therefore neither an informal friendship nor a relationship without boundaries. It is a professionally structured relationship in which the clinician attempts to understand the individual's experience while maintaining appropriate responsibilities and limits. Validation does not mean agreeing with every interpretation or endorsing every behaviour. Compassion does not mean removing accountability. Understanding why a behaviour developed does not require that the behaviour continues. These distinctions are central to effective practice because they allow clinicians to recognise suffering without reducing the individual to their suffering.

Dialectical Behaviour Therapy, developed by Marsha Linehan, represents one of the most influential structured psychological approaches developed specifically for people experiencing the difficulties associated with BPD. DBT integrates acceptance and change and places particular emphasis upon mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness. Its theoretical model proposes an interaction between emotional vulnerability and environmental factors, while its treatment programme provides explicit skills intended to help individuals respond differently to intense emotional states.

The evidence base for DBT is substantial, although it should not be overstated. Research has identified benefits for several outcomes, particularly self-harm and aspects of borderline symptomatology, but the strength and consistency of evidence varies across outcomes and studies. DBT should therefore be presented as an evidence-supported treatment rather than as a universally effective or curative intervention. Its importance lies partly in demonstrating that behaviours such as self-harm and recurrent crises can be approached as targets for structured psychological intervention rather than simply as evidence of an untreatable personality disorder.

Mentalisation-Based Therapy offers a different theoretical approach. Developed principally through the work of Peter Fonagy, Anthony Bateman and colleagues, MBT focuses upon mentalisation: the capacity to understand behaviour in relation to underlying mental states, including thoughts, feelings, intentions, beliefs and perceptions. Mentalisation may become less reliable under conditions of intense emotional arousal, particularly within relationships that activate attachment-related fears. Treatment therefore seeks to strengthen the capacity to remain curious about one's own experience and the experience of others when certainty and emotional intensity might otherwise dominate interpretation.

The distinction between DBT and MBT should not be presented as though one approach is superior to the other. They arise from different theoretical traditions and emphasise different therapeutic mechanisms. DBT provides a structured framework for developing behavioural and emotional regulation skills, whereas MBT places greater emphasis upon reflective understanding of mental states and interpersonal experience. Both approaches are concerned with increasing the individual's capacity to respond differently to distress rather than simply describing the person's difficulties.

Mentalisation also requires careful application where genuine external danger exists. Not every perception of rejection, hostility or threat is necessarily a distorted interpretation. A person living with domestic abuse, coercive control or another objectively unsafe environment may accurately perceive danger. Encouraging mentalisation should therefore not become a means of persuading an individual to distrust their own perceptions. The therapeutic task is to create greater flexibility in understanding experience while remaining attentive to the external circumstances in which that experience occurs.

The evidence surrounding psychological treatment for BPD is encouraging but should be presented with appropriate caution. Systematic reviews indicate that psychological therapies can improve important outcomes, but the evidence is heterogeneous and the certainty of evidence varies between interventions and outcomes. This means that the appropriate conclusion is not that one therapy has been proven to cure BPD. Rather, the evidence supports the use of structured psychological interventions and challenges the historical assumption that people diagnosed with BPD cannot benefit from treatment.

Recovery consequently needs to be understood as more than symptomatic remission. It may involve developing greater emotional regulation, reducing or stopping self-harm, establishing safer relationships, developing a more coherent identity, improving occupational or educational functioning, increasing independence and developing a sense of meaning and purpose. These changes may occur at different rates and in different combinations. A person may make substantial progress in one area while continuing to struggle in another.

Recovery may also involve learning to relate differently to emotional experience. The goal is not necessarily to eliminate intense emotion. Emotional sensitivity may remain part of an individual's temperament and personality. The more meaningful change may lie in what happens between emotional experience and action: the ability to recognise an emotion, tolerate it, consider what it may mean, assess the situation and choose a response rather than being compelled into an established pattern.

This is where the distinction between treatment and recovery becomes particularly important. Treatment provides interventions, relationships, skills and opportunities for psychological development. Recovery describes the broader process through which those developments become incorporated into a person's life. It may involve relationships that can survive disagreement, the ability to experience distress without immediately resorting to self-harm, greater confidence in one's identity, increased autonomy and the development of goals that extend beyond the management of symptoms.

Recovery is therefore not necessarily the absence of vulnerability. A person may continue to experience emotional intensity, anxiety, grief, interpersonal sensitivity or periods of psychological distress while nevertheless living a substantially different life. Recovery can involve acquiring the capacity to respond to those experiences differently. It may mean recognising an old pattern before acting upon it, tolerating uncertainty rather than immediately assuming rejection, asking for clarification rather than making assumptions, repairing a relationship after conflict, or seeking support before a crisis becomes overwhelming.

The role of professionals is consequently important, but it has limits. Clinicians cannot create recovery on behalf of another person, nor can they guarantee its outcome. What they can provide is a therapeutic environment in which change is considered possible, evidence-based interventions are offered, risk is taken seriously, boundaries are maintained and the individual is treated as an active participant rather than as a passive recipient of treatment. Hope becomes clinically meaningful when it is accompanied by realistic assessment, collaboration and practical opportunities for change.

The chapters that follow examine these issues in greater depth. Chapter 9 asks the foundational question, "Is Recovery Possible?", examining longitudinal evidence concerning remission, recovery and prognosis. Chapter 10 considers the therapeutic relationship and the conditions in which psychological change can occur. Chapter 11 examines Dialectical Behaviour Therapy and the development of skills for emotional and behavioural regulation, while Chapter 12 considers Mentalisation-Based Therapy and the capacity to understand mental states within oneself and others. Chapter 13 then returns to the question of recovery, considering what it means to move beyond symptomatic improvement towards greater agency, connection, identity, functioning and quality of life.

The central proposition of this part is therefore neither that BPD is inevitably permanent nor that recovery is guaranteed. The evidence supports a more nuanced conclusion: substantial change is possible, psychological treatments can help, and many people experience significant improvement over time. The diagnosis describes a pattern of difficulties; it does not establish the limits of a person's capacity for development. Treatment can provide the conditions, skills and relationships through which change becomes possible, while recovery represents the broader process through which those changes become part of a life increasingly defined by choice rather than by the patterns that once served to manage overwhelming distress.

Chapter 9

Is Recovery Possible?

For much of the history of Borderline Personality Disorder, the diagnosis was accompanied by pessimistic assumptions about prognosis. BPD was often conceptualised as a deeply entrenched disturbance of personality, and the term itself could become associated with chronicity, instability and therapeutic difficulty. Such assumptions were not simply descriptive; they could influence expectations about what treatment could achieve and how the person diagnosed was understood. A diagnosis that is interpreted as a fixed characteristic of personality risks becoming a prediction about the person's future rather than a description of difficulties that may change over time. Contemporary longitudinal research provides a substantially more nuanced picture. It demonstrates that BPD is not inevitably a lifelong condition and that substantial symptomatic improvement, remission and, for some people, broader psychosocial recovery can occur. (PubMed)

The question posed by this chapter therefore requires a careful distinction between remission and recovery. Symptomatic remission generally refers to a sustained reduction in symptoms to the point that diagnostic criteria are no longer met, whereas recovery has sometimes been defined more broadly to include sustained symptomatic remission alongside satisfactory social and vocational functioning. These definitions are not interchangeable, and different studies have used different operational criteria. Consequently, statements that a particular percentage of people with BPD "recover" must always be understood in relation to the population studied, the length of follow-up and the definition of recovery adopted by the researchers. This distinction is fundamental because the disappearance of diagnostic symptoms does not necessarily mean that every aspect of a person's life has recovered. (PubMed)

One of the most important bodies of evidence comes from the McLean Study of Adult Development conducted by Mary Zanarini and colleagues. In a ten-year prospective study of 290 inpatients who met criteria for BPD, participants were reassessed at two-year intervals. Over the ten-year period, 93% achieved at least two years of symptomatic remission and 86% achieved a sustained remission lasting at least four years. Using a more demanding definition of recovery that required both symptomatic remission and good social and vocational functioning during the preceding two years, 50% of participants achieved recovery. These findings provide strong evidence against the assumption that BPD is necessarily an unchanging condition, while simultaneously demonstrating why remission and recovery must not be treated as synonymous. (PubMed)

The longer-term findings from this cohort provide further evidence of the capacity for change. In the 16-year follow-up, Zanarini, Frankenburg, Reich and Fitzmaurice reported that between 78% and 99% of participants with BPD had achieved symptomatic remission depending upon the duration of remission examined, while recovery rates ranged from 40% to 60% according to the duration of sustained recovery required. Importantly, recovery was slower to occur in the BPD group than in the comparison group and was also less stable, with some participants subsequently experiencing recurrence of symptoms or loss of recovery. The findings therefore provide neither a pessimistic nor an idealised picture. They demonstrate that substantial and sustained improvement can occur, while also showing that vulnerability may persist and that recovery is not necessarily irreversible or linear. (PubMed)

More recent longitudinal evidence supports the broad conclusion that the course of BPD is considerably more changeable than earlier assumptions suggested. A meta-analysis of prospective studies involving 837 participants across 11 studies found that approximately 50% to 70% of participants achieved remission over the long term, alongside significant reductions in depressive symptoms and some improvement in functioning. At the same time, the authors found that functional impairment could remain substantial despite symptomatic improvement. This finding is particularly important because it demonstrates that recovery cannot be inferred solely from the reduction of diagnostic symptoms. A person may experience considerable psychological improvement while continuing to encounter difficulties in employment, relationships or wider social functioning. (PubMed)

The distinction between symptoms and functioning is further illustrated by research examining recovery after longer periods of time. Zeitler and colleagues followed former participants in DBT research for approximately 12 to 18 years and found symptomatic remission in 81% of participants, but only 44% met their specified level of global functioning and 49% reported life satisfaction within the range of the general population. These findings demonstrate that recovery is multidimensional and that objective functioning and subjective wellbeing cannot simply be assumed to follow symptom remission. A person may no longer meet diagnostic criteria and yet continue to experience difficulties that materially affect their quality of life. Conversely, meaningful improvements in relationships, independence, identity or life satisfaction may be experienced even when some psychological vulnerability remains. (PubMed)

This broader understanding of recovery is supported by a systematic review examining symptomatic and personal recovery from BPD. Ng and colleagues identified 19 studies representing 11 distinct cohorts and concluded that the literature provided substantial evidence concerning symptomatic remission but comparatively limited evidence concerning personal recovery and the perspectives of people themselves. This distinction matters because recovery is not solely a statistical outcome. Clinical research can establish whether diagnostic criteria have remitted, but it cannot completely determine whether an individual experiences their life as meaningful, autonomous, connected or worthwhile. Personal recovery therefore complements, rather than replaces, the clinical measurement of symptoms and functioning. (PubMed)

Recovery should consequently not be understood as the complete elimination of emotional vulnerability. Emotional intensity, sensitivity to interpersonal experiences, anxiety, grief, anger or fear may continue to occur after substantial improvement has taken place. What may change is the individual's relationship with those experiences and the capacity to respond differently to them. A person may experience an intense emotion without automatically translating it into self-harm, impulsive behaviour or interpersonal escalation. They may recognise that an emotional response is real without assuming that every interpretation accompanying it is necessarily accurate. They may learn to tolerate uncertainty, seek clarification, communicate their needs and consider alternative responses before acting. In this sense, recovery may involve increasing freedom between emotional experience and behavioural response rather than creating a life entirely free from difficult emotion.

The longitudinal evidence also challenges the idea that recovery follows a simple or uniform trajectory. The 16-year findings from Zanarini and colleagues demonstrate that although remission and recovery become increasingly common over time, some individuals experience recurrence of symptoms and some lose previously attained recovery. The existence of recurrence does not invalidate earlier recovery, nor should a period of deterioration automatically be interpreted as a return to the beginning. Psychological development is capable of containing both progress and vulnerability. The more accurate conclusion is that BPD has a variable long-term course in which improvement is common, but individual trajectories differ. (PubMed)

This evidence has important implications for professional practice. NICE specifically recommends that treatment for BPD should be approached within an atmosphere of hope and optimism and that professionals should explain that recovery is possible and attainable. The guideline also emphasises the importance of a trusting, open, engaging and non-judgemental relationship and recognises that many people with BPD will have experienced rejection, abuse, trauma and stigma. Hope within clinical practice is therefore not simply an expression of kindness; it is consistent with the evidence that meaningful change can occur. At the same time, responsible hope does not mean promising a particular outcome or suggesting that recovery will be rapid or universal. (Nice)

The evidence also requires caution when considering the relationship between treatment and long-term recovery. Longitudinal naturalistic studies demonstrate that many people improve over time, but such studies cannot establish that a particular psychological therapy caused the improvement. Equally, treatment trials can demonstrate the effectiveness of particular interventions for specific outcomes without establishing that treatment is solely responsible for long-term recovery. A scientifically defensible account must therefore avoid the simple equation of treatment with recovery. Psychological therapy may provide important opportunities for change, but recovery is influenced by multiple factors, including the individual's circumstances, relationships, social environment, engagement with treatment and the development of psychological and behavioural capacities over time. The existing longitudinal literature itself indicates that further research is required to determine the long-term effects of particular treatments on broader recovery outcomes. (PubMed)

Trauma is relevant to this discussion but requires equally careful treatment. Childhood adversity, abuse, neglect and disrupted attachment have been associated with BPD, and trauma-informed practice is therefore highly relevant to many individuals diagnosed with the disorder. However, trauma cannot be regarded as either universal or sufficient to explain BPD. People diagnosed with BPD have heterogeneous developmental histories, and the disorder is understood as arising through complex interactions among biological, psychological, developmental and environmental factors. A trauma-informed approach should therefore invite exploration of the individual's experiences rather than assume that a particular history must exist.

Judith Lewis Herman's work provides an important framework for understanding why recovery from psychological trauma may extend beyond symptom reduction. In Trauma and Recovery, Herman (1992) conceptualised recovery as involving the restoration of safety, the remembrance and mourning of traumatic experience, and reconnection with ordinary life. Her framework was developed in relation to psychological trauma rather than specifically as a model of BPD, and it should therefore be used appropriately. Its relevance to BPD lies in demonstrating how recovery may involve rebuilding safety, agency, relationships and meaning where these have been disrupted by traumatic experience. Herman's work consequently complements rather than replaces the longitudinal evidence concerning the course of BPD.

Bessel van der Kolk's work has similarly influenced contemporary understanding of the enduring effects of traumatic experience, particularly in relation to emotional regulation, bodily experience, memory and perceptions of safety. Van der Kolk (2014) has argued that traumatic experience can continue to shape psychological and bodily responses long after the original circumstances have ended. His contribution is relevant to a trauma-informed understanding of some presentations of psychological distress, but it should not be treated as evidence that trauma is the sole cause of BPD or that all people diagnosed with BPD have experienced equivalent forms of trauma. His work is most appropriately considered alongside the wider empirical literature on trauma, development and personality pathology.

The significance of these perspectives becomes clearer when recovery is considered in relation to the person's environment. Psychological change does not occur in a vacuum. Continuing abuse, homelessness, poverty, discrimination, social isolation, unstable relationships or other forms of environmental threat may maintain or intensify distress and can make psychological change more difficult. Conversely, stable relationships, meaningful activity, appropriate healthcare, financial security, education and employment may create conditions in which newly developed capacities can be sustained. This does not mean that environmental adversity explains every difficulty or that psychological treatment is ineffective in difficult circumstances. It means that recovery should be understood within the context of the life in which it has to occur.

The research therefore supports neither the historical assertion that BPD is inevitably chronic nor the opposite claim that recovery is straightforward. The most defensible conclusion is more nuanced. Many people experience substantial symptomatic remission over time, a significant proportion achieve sustained remission, and some achieve broader psychosocial recovery. At the same time, social and occupational difficulties may persist after symptomatic improvement, some people remain vulnerable to recurrence, and individual trajectories differ considerably. Recovery is therefore a genuine and evidence-supported possibility, but it is not an inevitable outcome that can be guaranteed for every individual.

This distinction is important because the word "recovery" can otherwise become either unnecessarily pessimistic or unrealistically optimistic. If recovery means only the complete disappearance of every symptom, many people who have made profound changes in their lives may be excluded from the concept. If recovery is defined so broadly that any improvement is described as recovery, the term loses clinical and scientific precision. A more useful approach recognises several dimensions of change, including symptomatic remission, interpersonal and occupational functioning, autonomy, identity, quality of life and the individual's own understanding of whether their life has become more meaningful. The evidence indicates that these dimensions do not necessarily change simultaneously.

The question posed by this chapter can therefore be answered with confidence, but not with certainty about any individual's future. Yes, recovery is possible. The longitudinal evidence demonstrates that BPD can remit substantially over time and that a significant proportion of people can achieve sustained recovery according to established research definitions. Yet recovery is not synonymous with simply crossing a diagnostic threshold, nor does it necessarily mean the complete disappearance of emotional vulnerability. For some, recovery may mean sustained remission and restored functioning; for others, it may involve living a meaningful and increasingly autonomous life despite residual vulnerabilities. The common feature is not perfection but change.

The significance of this evidence extends beyond prognosis. If BPD is understood as a condition from which meaningful improvement can occur, then therapeutic practice has a responsibility to maintain that possibility rather than allowing the diagnosis to become a ceiling on expectation. The purpose of treatment is not to make the individual conform to an idealised version of psychological normality. It is to support the development of greater capacity, safety, agency and choice, while recognising the individual's circumstances and respecting the pace and direction of their development. Recovery cannot be promised, but neither should it be withheld as a possibility through professional pessimism.

The evidence therefore provides a foundation for credible hope. It tells us that the diagnosis does not establish an immutable prognosis, that remission is common over longer periods, that broader psychosocial recovery occurs for a substantial minority, and that meaningful change can continue over many years. It also tells us that vulnerability may remain, functioning may lag behind symptomatic improvement and recovery can include setbacks. The question "Is Recovery Possible?" should consequently not be answered by promising that everyone will recover in the same way. It should be answered by recognising that the capacity for substantial change is demonstrated in the research and that treatment should be organised around that possibility.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, DC: American Psychiatric Association.

Herman, J. L. (1992). Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to Political Terror. New York: Basic Books.

Ng, F. Y., Bourke, M. E. and Grenyer, B. F. (2016). Recovery from borderline personality disorder: A systematic review of the perspectives of consumers, clinicians, family and carers. PLOS ONE, 11(8), e0160515. (PubMed)

NICE. (2009, reviewed 2024). Borderline personality disorder: recognition and management (CG78). National Institute for Health and Care Excellence. (Nice)

Panos, C., et al. (2019). Long-term clinical and functional course of borderline personality disorder: A meta-analysis of prospective studies. European Psychiatry, 56, 1–8. (PubMed)

van der Kolk, B. A. (2014). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York: Viking.

Zanarini, M. C., Frankenburg, F. R., Reich, D. B. and Fitzmaurice, G. (2010). Time to attainment of recovery from borderline personality disorder and stability of recovery: A 10-year prospective follow-up study. American Journal of Psychiatry, 167(6), 663–667. (PubMed)

Zanarini, M. C., Frankenburg, F. R., Reich, D. B. and Fitzmaurice, G. (2010). The 10-year course of psychosocial functioning among patients with borderline personality disorder and axis II comparison subjects. Acta Psychiatrica Scandinavica, 122(2), 103–109. (PubMed)

Zanarini, M. C., Frankenburg, F. R., Reich, D. B. and Fitzmaurice, G. (2012). Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: A 16-year prospective follow-up study. American Journal of Psychiatry, 169(5), 476–483. (PubMed)

Zanarini, M. C., et al. (2014). Prediction of time-to-attainment of recovery for borderline patients followed prospectively for 16 years. Journal of Personality Disorders. (PubMed)

Zeitler, M.-L., et al. (2020). How to assess recovery in borderline personality disorder: Psychosocial functioning and satisfaction with life in a sample of former DBT study patients. Journal of Personality Disorders, 34(3), 289–307. (PubMed)

Chapter 10

The Therapeutic Relationship

If recovery is possible, the question of how therapeutic change takes place becomes equally important. Psychological treatment is not delivered into an interpersonal vacuum. Whether the intervention is structured around behavioural skills, mentalisation, psychodynamic principles or another evidence-based approach, treatment is delivered by a person to another person within a relationship that has its own expectations, boundaries, meanings and emotional processes. For people diagnosed with Borderline Personality Disorder, this relational dimension can be particularly important because difficulties involving attachment, abandonment, trust, emotional regulation and interpersonal interpretation may become activated within relationships, including the therapeutic relationship itself. The therapeutic relationship should therefore be understood not as an optional addition to treatment, but as an important context in which treatment is undertaken.

At the same time, the importance of the therapeutic relationship should not be overstated. Evidence does not demonstrate that a good therapeutic relationship, by itself, constitutes a treatment for BPD or guarantees recovery. Rather, research indicates that the quality of the therapeutic alliance is associated with treatment outcome and that this relationship appears to have relevance across different therapeutic approaches. Barnicot and colleagues (2012), in a systematic review examining predictors of psychotherapy outcome in BPD, identified patient-rated therapeutic alliance as one of the consistent positive predictors of symptom change. The authors concluded that alliance appears to be an important common factor even within disorder-specific treatments. (PubMed)

The broader psychotherapy literature provides similar evidence. Flückiger, Del Re, Wampold and Horvath (2018) conducted a meta-analysis of 295 independent studies involving more than 30,000 patients and found a robust positive association between therapeutic alliance and psychotherapy outcome across treatment approaches, patient characteristics and outcome measures. Their findings do not establish a simple causal relationship in which alliance produces recovery; the relationship between alliance and outcome is likely to be reciprocal and influenced by other therapeutic and patient factors. Nevertheless, the consistency of the association provides substantial empirical support for taking the therapeutic relationship seriously within psychological treatment. (PubMed)

The therapeutic alliance is commonly understood as involving collaboration concerning the goals and tasks of therapy together with the development of a therapeutic bond. It is therefore more than whether a patient likes the therapist or feels comfortable with them. A strong alliance involves sufficient trust and collaboration to enable difficult therapeutic work to occur, while also maintaining agreement about what treatment is attempting to achieve. This distinction is particularly important in BPD because effective treatment may require the clinician to validate emotional experience while simultaneously challenging behaviours that increase risk or interfere with the person's goals.

The therapeutic relationship must therefore contain both compassion and structure. Compassion without appropriate boundaries can create uncertainty, inconsistency or dependency, while boundaries imposed without sensitivity can be experienced as rejection, punishment or abandonment. A therapeutic relationship is not one in which every request is granted or every interpretation is accepted. It is a professional relationship in which the person's experience is taken seriously while the clinician retains responsibility for appropriate clinical judgement, risk management, ethical practice and professional boundaries.

NICE guidance for BPD explicitly places treatment within an atmosphere of hope, optimism and trust and recommends structured psychological treatment delivered by appropriately trained professionals. The guidance also emphasises the importance of collaborative care, appropriate supervision and clear treatment structures. Consequently, therapeutic warmth and professional structure should not be regarded as competing principles. Both contribute to a treatment environment in which psychological work can take place. (Nice)

Therapeutic Use of Self

Within this discussion, the concept of therapeutic use of self is particularly relevant to mental health nursing and deserves explicit consideration. Therapeutic use of self refers to the deliberate and reflective use of the practitioner's own interpersonal presence, communication, professional knowledge, emotional awareness and relational capacities within therapeutic practice. The practitioner is not a neutral instrument who simply applies a treatment protocol. They bring themselves into every encounter through their language, tone, facial expression, responsiveness, expectations, emotional reactions and manner of relating to the person receiving care.

The origins of this way of thinking can be traced particularly clearly within psychiatric and mental health nursing. Hildegard Peplau's interpersonal theory placed the nurse–patient relationship at the centre of psychiatric nursing practice and conceptualised nursing as an interpersonal process through which the nurse and patient work together. Peplau's contribution was significant because it positioned the relationship itself as part of nursing practice rather than treating interpersonal interaction as something incidental to clinical care. Her work subsequently influenced generations of mental health nursing practice and the development of relational approaches to care.

Therapeutic use of self should not, however, be confused with simply being friendly, sympathetic or emotionally expressive. Its therapeutic value depends upon intentionality and reflection. The practitioner must be aware of how they communicate, how they respond to the person and how their own assumptions may influence their interpretation of behaviour. The professional is therefore required to consider not only the patient's presentation but also their own contribution to the interaction.

This becomes especially important when working with people diagnosed with BPD. Emotional distress, self-harm, suicidal behaviour, interpersonal conflict and repeated crises can evoke powerful responses in clinicians. Research has identified concerns about negative attitudes towards people with BPD among mental health professionals, and a systematic review of interventions designed to improve nurses' knowledge, attitudes and skills found that professional attitudes are an important area for intervention. Dickens, Hallett and Lamont (2016) specifically noted evidence of negative attitudes among mental health nurses and identified the potential implications for the development of helpful therapeutic relationships. (PubMed)

The concept of therapeutic use of self therefore requires the practitioner to develop reflexive awareness. A clinician may experience frustration when a person repeatedly presents in crisis, anxiety when managing suicidal risk, helplessness when previous interventions appear unsuccessful, or protectiveness when the individual describes abuse or rejection. These reactions are not in themselves evidence of poor practice. They become clinically significant when they remain unexamined and begin to determine how the person is understood or treated.

A reflective practitioner can therefore ask questions such as: What am I experiencing in this interaction? What assumptions am I making about this person's behaviour? Am I responding to the individual in front of me, or to a diagnostic stereotype? Could my emotional response be influencing my clinical judgement? What might the person's behaviour be communicating? Such questions do not require the professional to assume that every difficult interaction is caused by the clinician. Rather, they acknowledge that therapeutic encounters are relational and that the professional is part of the interpersonal environment.

This is particularly important because diagnostic language can shape perception. If a person with BPD is repeatedly described as manipulative, attention-seeking or difficult, subsequent behaviours may increasingly be interpreted through that framework. The result can be a circular process in which behaviour generates negative expectations, those expectations influence professional responses, and the resulting interaction reinforces the original interpretation. Therapeutic use of self provides one mechanism through which the practitioner can interrupt this process by examining their own assumptions and returning to formulation, evidence and the individual's actual circumstances.

Therapeutic use of self does not mean abandoning professional judgement. Indeed, reflective practice should strengthen clinical judgement rather than weaken it. The practitioner remains responsible for recognising risk, responding to self-harm and suicidal behaviour, identifying safeguarding concerns and maintaining appropriate professional boundaries. Reflection asks how these responsibilities can be exercised in a way that remains clinically rigorous without allowing frustration, fear or stigma to become the primary determinants of care.

The Relationship as a Professional Space

The therapeutic relationship is fundamentally different from an ordinary friendship. It is purposeful, time-limited or otherwise structured, governed by professional standards and established around the needs of the person receiving care. The practitioner has responsibilities that do not exist within ordinary interpersonal relationships, including confidentiality, risk management, safeguarding, documentation, professional accountability and appropriate use of power.

These boundaries are not contrary to therapeutic care. Predictable boundaries can themselves contribute to psychological safety. Appointment arrangements, communication expectations, confidentiality, crisis procedures and the limits of professional availability should be sufficiently clear that the individual understands what the therapeutic relationship can provide. Consistency can be particularly important where previous relationships have been characterised by unpredictability, rejection or coercive control.

For this reason, the therapeutic relationship should not be constructed around the idea that the clinician must always prevent the patient from experiencing disappointment. Therapeutic work inevitably involves limits. Appointments end, professionals take leave, services change and treatment eventually comes to an end. The therapeutic task is not to eliminate these experiences but to approach them transparently and thoughtfully.

NICE specifically recognises that changes in relationships, including changes in treatment and transitions between services, can affect people with BPD and recommends careful planning around endings and transitions. This reinforces an important principle: the therapeutic relationship can provide consistency without creating an illusion of permanence. The professional relationship has limits, and communicating those limits clearly may be more therapeutic than creating expectations that cannot ultimately be maintained. (Nice)

Attachment, Trust and Therapeutic Experience

For some individuals, previous relationships may have established expectations that closeness will result in rejection, vulnerability will result in harm, or dependence will result in loss of control. These expectations can influence how the therapeutic relationship is experienced. A delayed response, a change in appointment arrangements or a perceived difference in the practitioner's manner may acquire a significance that would not necessarily be present for another person.

The therapeutic response should neither dismiss such experiences nor automatically confirm the interpretation attached to them. A person may genuinely feel rejected without rejection having actually occurred. Conversely, a person may accurately perceive a change in the clinician's behaviour. The task is therefore to create sufficient space to examine what happened, what the individual perceived, what meaning they attributed to it and what alternative explanations might exist.

This is where the therapeutic relationship can intersect with mentalisation. Under conditions of intense emotional arousal, the ability to hold multiple possible interpretations of an interpersonal event may become more difficult. The clinician can help slow the process down by encouraging curiosity about mental states rather than immediately treating one interpretation as established fact. This does not mean persuading the individual that their perception is wrong. It means supporting the capacity to remain open to uncertainty where uncertainty genuinely exists.

There is, however, an important safeguard. Not every perception of threat, rejection or hostility is a cognitive distortion. Some people with BPD live in objectively unsafe circumstances, including abusive relationships or environments involving genuine coercion, exploitation or violence. A therapeutic approach that automatically reframes perceptions of danger as symptoms risks reproducing the very invalidation that trauma-informed practice seeks to avoid. Therapeutic reflection must therefore remain connected to external reality.

Judith Lewis Herman's work on trauma is particularly relevant to this distinction. In Trauma and Recovery, Herman (1992) placed the restoration of safety at the beginning of trauma recovery and emphasised the importance of establishing safety, processing traumatic experience and reconnecting with life and relationships. Her framework was developed in relation to trauma rather than specifically as a treatment model for BPD, and it should not be presented as evidence that trauma causes BPD. Its relevance here lies in its recognition that psychological recovery may require the restoration of safety and agency rather than simply the reduction of symptoms.

The therapeutic relationship can support these processes without becoming a substitute for the relationships the person has lost or never experienced. The clinician cannot recreate childhood, repair every attachment injury or guarantee that the person will never again experience rejection. What the therapeutic environment can offer is a structured interpersonal experience in which disagreement does not necessarily mean abandonment, boundaries do not have to mean punishment and difficult emotions can be explored without the person being reduced to those emotions.

Validation Without Endorsement

Validation is therefore an important component of therapeutic practice, but it requires careful definition. To validate an emotional experience is to acknowledge its reality and significance to the person experiencing it. Validation does not require the clinician to agree with every interpretation or approve every behaviour. A clinician can acknowledge that a person feels terrified of abandonment while also exploring whether the feared abandonment is actually occurring. They can understand why self-harm may have provided temporary relief while still working collaboratively to reduce the behaviour and develop safer alternatives.

This distinction is particularly important in relation to personal responsibility. A trauma-informed or formulation-based approach should not imply that because a behaviour developed in response to adversity, the individual has no responsibility for what they do now. Understanding origins and maintaining accountability are not mutually exclusive. Indeed, understanding the function of behaviour can make responsibility more meaningful because it allows the individual to identify the circumstances in which an established response occurs and develop alternative ways of responding.

The same principle applies to behaviour that affects other people. A formulation might explain why anger becomes intense or why perceived rejection generates an urgent need for reassurance. It does not require other people to accept harmful behaviour. Compassion involves understanding suffering; it does not require the removal of interpersonal boundaries or consequences.

Rupture and Repair

No therapeutic relationship will remain perfectly harmonious. Misunderstandings, disagreements and moments of perceived invalidation can occur even within highly effective treatment. The important question is therefore not whether rupture can be eliminated but whether it can be recognised and addressed.

Research examining alliance in BPD has demonstrated that the therapeutic alliance can fluctuate over treatment and that patient and therapist perceptions of the relationship may differ. In a study of 60 patients receiving brief Good Psychiatric Management, Kivity and colleagues examined alliance across ten sessions and found relationships between alliance ratings and symptomatic distress, illustrating the dynamic nature of the therapeutic relationship rather than treating alliance as a fixed characteristic established at the beginning of treatment. (Guilford Journals)

Rupture can therefore become an opportunity for reflection. If an individual believes that the clinician has rejected them, the therapeutic task is not simply to insist that the individual is mistaken. The interaction can be explored: What happened? What did the person experience? What did the clinician intend? What meaning did the interaction acquire? What can each participant learn from the event? Such work may create an opportunity to experience disagreement without inevitable relational collapse.

This does not mean that every rupture can or should be repaired within the same relationship. Some therapeutic relationships become unsafe or clinically unproductive, and appropriate referral or change of clinician may sometimes be necessary. A sophisticated understanding of therapeutic relationships therefore avoids romanticising the relationship itself. The goal is not to preserve every therapeutic relationship at any cost, but to ensure that decisions concerning continuation, change or ending are made thoughtfully and professionally.

Supervision and the Reflective Practitioner

Therapeutic use of self cannot be separated from supervision. A practitioner who works with intense distress must have opportunities to examine their own responses, particularly where those responses may influence formulation or treatment. Supervision provides a structured professional environment in which clinicians can consider clinical decisions, risk, emotional responses, boundaries, treatment fidelity and difficulties within the therapeutic relationship.

This is especially important when delivering structured psychological therapies. NICE guidance emphasises appropriate training, clinical governance and regular specialist supervision for psychological interventions for BPD. Evidence-based treatment is therefore not simply a matter of possessing a manual; competence requires training, supervision and attention to treatment fidelity. (Nice)

Supervision also provides protection against two opposing risks. The first is emotional over-involvement, in which the practitioner becomes so identified with the individual's distress that professional boundaries become blurred. The second is emotional withdrawal, in which repeated exposure to crisis leads the practitioner to distance themselves from the individual. Therapeutic use of self requires neither emotional detachment nor unrestricted emotional involvement. It requires sufficient awareness to remain present, empathic and clinically effective while maintaining the professional position.

The Therapeutic Relationship and Evidence-Based Treatment

The therapeutic relationship should also be located within the wider evidence concerning psychological treatments for BPD. Evidence supports psychological therapies as beneficial for important BPD-related outcomes, although the effects are not uniform and no single psychotherapy has been established as universally superior. A 2017 systematic review and meta-analysis found moderate-quality evidence that specialised psychotherapies reduced overall BPD severity compared with treatment as usual or community treatment by experts, while DBT demonstrated a small-to-moderate effect on self-injury. (PubMed Central (PMC))

More recent evidence reinforces the need for caution about claims of therapeutic superiority. Crotty and colleagues (2024), in a systematic review of 25 psychotherapy studies involving 2,545 participants, concluded that commonly used psychotherapies improved BPD severity, symptoms and functioning, but found no strong evidence that one psychotherapy was more beneficial than another. The certainty of evidence varied considerably between interventions and comparisons. (PubMed)

This evidence has an important implication for the therapeutic relationship. The relationship should not be presented as an alternative to DBT, MBT or other structured interventions. Nor should DBT or MBT be reduced to the quality of the relationship alone. Rather, the relationship and the treatment model operate together. The clinician's interpersonal conduct provides the context in which the intervention is delivered, while the intervention provides the structure through which particular therapeutic goals are pursued.

The evidence concerning alliance in BPD supports this position. Barnicot and colleagues identified patient-rated therapeutic alliance as a consistent predictor of symptom change, while broader psychotherapy research demonstrates a robust alliance–outcome association across therapeutic approaches. These findings justify attention to the relationship, but they do not demonstrate that alliance is the sole mechanism through which treatment works. (PubMed)

Therapeutic Use of Self and the Person Behind the Diagnosis

The concept of therapeutic use of self ultimately returns the discussion to one of the central arguments of this book. Looking beyond the diagnosis requires more than changing terminology. It requires professionals to examine how their own perceptions, assumptions and emotional responses influence the way they encounter the person.

The diagnosis of BPD may provide clinically useful information about a pattern of difficulties, but it cannot tell the practitioner everything about the individual sitting before them. It cannot explain the meaning of a particular relationship, the history behind a particular behaviour, the circumstances surrounding a crisis or the person's aspirations for their future. Those things have to be discovered through assessment, formulation and relationship.

Therapeutic use of self therefore becomes a form of professional reflexivity. The practitioner is required to consider the person, the behaviour, the context and the interaction simultaneously. Rather than asking only what is wrong with the individual, the clinician can ask what has happened, what the behaviour may be attempting to achieve, what maintains it, what resources the individual possesses and how the therapeutic relationship can support the development of alternative responses.

This approach also protects against an important danger: confusing professional emotional response with clinical truth. A practitioner may feel manipulated without the person necessarily attempting to manipulate them. A clinician may feel rejected without the individual actually rejecting them. A professional may feel helpless without the situation being hopeless. These feelings contain information, but they are not automatically evidence. Therapeutic use of self requires the practitioner to notice them without allowing them to become the entire formulation.

The same principle applies to positive responses. Feeling unusually protective of a person does not necessarily mean that they require greater contact or fewer boundaries. Feeling a strong personal connection does not mean that the professional relationship should become more intimate. Therapeutic use of self requires awareness of both attraction and aversion, empathy and frustration, identification and distance.

The practitioner therefore becomes neither invisible nor central. They are part of the therapeutic process but not the focus of it. Their task is to use their professional presence intentionally in the service of the individual's treatment, autonomy and recovery.

Conclusion

The therapeutic relationship occupies an important position within the treatment of Borderline Personality Disorder because psychological interventions occur through relationships, and because the quality of those relationships can influence engagement and outcome. Research indicates that therapeutic alliance is associated with better outcomes in psychotherapy generally and that patient-rated alliance is a consistent predictor of symptom change in BPD. At the same time, alliance should not be mistaken for a stand-alone treatment or treated as proof that a particular therapeutic relationship causes recovery. (PubMed)

Therapeutic use of self adds an important dimension to this understanding, particularly within mental health nursing. It requires the practitioner to recognise that they bring their own communication, emotional responses, assumptions and professional identity into the therapeutic encounter. Used deliberately and reflectively, this awareness can help prevent unconscious responses from becoming embedded within clinical practice. It also provides a framework for recognising how stigma, frustration and preconceived ideas about BPD may influence the relationship.

The therapeutic use of self is therefore not simply about being a "good" or compassionate professional. It is a disciplined form of professional self-awareness. It requires the practitioner to remain empathic without becoming enmeshed, boundaried without becoming punitive, reflective without becoming indecisive, and compassionate without abandoning accountability.

For the person receiving treatment, this can create an important therapeutic environment in which difficult emotions can be explored without shame, harmful behaviour can be challenged without the individual being condemned, and relational difficulties can be examined without assuming that they represent fixed defects of character. The therapeutic relationship cannot erase trauma or guarantee recovery, but it can provide a structured context in which the person is treated as capable of reflection, development and change.

This provides the foundation for the next chapter, which moves from the relationship in which therapy takes place to one of the most extensively studied structured treatments specifically developed for people experiencing the difficulties associated with BPD: Dialectical Behaviour Therapy. The question is no longer simply whether the therapeutic relationship matters, but how a structured treatment can translate that relationship into specific skills, strategies and opportunities for behavioural and emotional change.

References

Barnicot, K., Katsakou, C., Bhatti, N., Savill, M., Fearns, N. and Priebe, S. (2012). Factors predicting the outcome of psychotherapy for borderline personality disorder: A systematic review. Clinical Psychology Review, 32(5), 400–412. (PubMed)

Crotty, K., Viswanathan, M., Kennedy, S., Edlund, M. J., Ali, R., Siddiqui, M., Wines, R., Ratajczak, P. and Gartlehner, G. (2024). Psychotherapies for the treatment of borderline personality disorder: A systematic review. Journal of Consulting and Clinical Psychology, 92(5), 275–295. (PubMed)

Dickens, G. L., Hallett, N. and Lamont, E. (2016). Interventions to improve mental health nurses' skills, attitudes, and knowledge related to people with a diagnosis of borderline personality disorder: Systematic review. International Journal of Nursing Studies, 56, 114–127. (PubMed)

Flückiger, C., Del Re, A. C., Wampold, B. E. and Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. (PubMed)

Herman, J. L. (1992). Trauma and Recovery: The Aftermath of Violence—From Domestic Abuse to Political Terror. New York: Basic Books.

Kivity, Y., Levy, K. N., Kolly, S. and Kramer, U. (2020). The therapeutic alliance over 10 sessions of therapy for borderline personality disorder: Agreement and congruence analysis and relation to outcome. Journal of Personality Disorders, 34(1), 1–21. (Guilford Journals)

National Institute for Health and Care Excellence (NICE). (2009, updated/reviewed subsequently). Borderline personality disorder: recognition and management (CG78). London: NICE. (Nice)

Storebø, O. J., Stoffers-Winterling, J. M., Völlm, B. A., Kongerslev, M. T., Mattivi, J. T., Jørgensen, M. S., Faltinsen, E., Todorovac, A., Sales, C. P., Callesen, H. E., Lieb, K. and Simonsen, E. (2020). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, 5, CD012955.

Chapter 11

Dialectical Behaviour Therapy

Dialectical Behaviour Therapy, commonly known as DBT, occupies an important position within the development of evidence-based psychological treatment for Borderline Personality Disorder. Developed by Marsha Linehan and colleagues, DBT emerged from an attempt to address a particular clinical problem: how to work therapeutically with people experiencing severe emotional dysregulation, recurrent suicidal behaviour and self-harm while maintaining a therapeutic position that neither invalidates their suffering nor accepts destructive behaviour as inevitable. The treatment therefore rests upon a central tension between acceptance and change. The person is understood as doing the best they can within their current circumstances while simultaneously being supported to develop the skills necessary to respond differently.

This dialectical position is fundamental to understanding DBT. The approach does not begin from the assumption that the individual simply needs to control their emotions or stop behaviours that professionals find difficult. Instead, it recognises that behaviours such as self-harm may have developed as attempts to regulate overwhelming emotional states and may therefore perform an important function, even when their consequences are harmful. Treatment seeks to understand that function while helping the individual acquire alternative strategies that can meet the same underlying needs more safely and effectively.

The development of DBT represented an important departure from some earlier therapeutic assumptions about people diagnosed with BPD. Rather than conceptualising the person primarily through the lens of resistance, manipulation or treatment difficulty, Linehan's model placed emotional vulnerability, invalidating environments, behavioural learning and skills deficits within a structured therapeutic framework. This did not remove personal responsibility. Instead, it located responsibility within a context in which the individual could be supported to acquire new capacities rather than simply being expected to stop behaviours without understanding what those behaviours were accomplishing.

The evidence base for DBT is substantial compared with many psychological interventions, although it is important not to overstate what the research demonstrates. The 2020 Cochrane review of psychological therapies for BPD included 75 randomised controlled trials involving 4,507 participants and identified DBT as one of the most extensively studied interventions. Compared with treatment as usual, DBT was associated with reductions in BPD severity and self-harm and improvements in psychosocial functioning, although the certainty of evidence for these DBT-specific effects was rated low. (Cochrane)

This qualification is important. Evidence-based practice does not mean that an intervention has been proven to work for every person or that every positive finding is equally reliable. The Cochrane review found that psychotherapy overall produced a clinically important reduction in BPD symptom severity compared with treatment as usual, but the evidence concerning individual therapies was more uncertain. For DBT specifically, the review found a standardised mean difference of −0.60 for BPD severity, −0.28 for self-harm and −0.36 for psychosocial functioning at the end of treatment compared with treatment as usual, with the certainty of these individual findings rated low. (Cochrane)

The findings concerning self-harm also illustrate why precision is necessary when discussing DBT. The Cochrane analysis found a statistically significant reduction in self-harm at the end of treatment compared with treatment as usual, but this difference was not statistically significant at six to twelve months in the limited follow-up data available. Similarly, the review did not find a statistically significant reduction in suicide-related outcomes at the end of treatment compared with treatment as usual. DBT should therefore not be presented as a treatment that eliminates suicidal behaviour or self-harm. Its evidence supports a more measured conclusion: DBT can reduce important aspects of BPD-related distress and behaviour, particularly self-harm, but outcomes vary and continued clinical support may remain necessary. (DOI)

The wider literature reinforces this cautious interpretation. A systematic review and meta-analysis by Cristea et al. (2017) found that specialised psychotherapies for adults with BPD were associated with a moderate effect on overall BPD severity compared with treatment as usual or community treatment by experts. Within that analysis, DBT demonstrated a small-to-moderate effect on self-injury. However, the authors also identified methodological limitations, including risk of bias and concerns regarding the stability of treatment effects. (PubMed)

Similarly, Storebø and colleagues' Cochrane review demonstrates that DBT is not uniquely supported in every outcome. More than sixteen different psychological approaches were represented across the 75 trials, and both DBT and Mentalisation-Based Treatment were among the most extensively researched. The review concluded that psychotherapy as a group may be beneficial, while emphasising that the certainty surrounding particular treatment comparisons remains limited. (Cochrane) This is important because the evidence does not justify presenting DBT as the single definitive treatment for BPD. It is better understood as one of several structured psychological approaches with a meaningful evidence base.

The Dialectical Principle

The word dialectical refers to the attempt to hold two apparently opposing ideas simultaneously. Within DBT, one of the most important tensions is acceptance and change. The individual is accepted as they are in the present while being encouraged to make changes that will reduce suffering and improve their life. These positions are not contradictory. Acceptance provides the foundation from which change becomes possible, while change prevents acceptance from becoming passive resignation.

This distinction is particularly important when working with behaviours such as self-harm. A clinician can acknowledge that self-harm may provide rapid relief from unbearable emotional distress without communicating that self-harm should continue. The behaviour can be understood as adaptive in the context in which it developed while simultaneously being recognised as potentially dangerous or destructive in the person's present circumstances. The therapeutic question consequently becomes not simply, "How do we stop this behaviour?" but, "What function is this behaviour serving, and what other means could fulfil that function?"

The dialectical position also challenges the false opposition between compassion and accountability. Understanding why someone behaves in a particular way does not mean excusing harmful behaviour. Equally, holding someone accountable does not require shaming them. A person can be responsible for developing different responses while being recognised as someone whose existing responses may have developed through understandable processes of learning, emotional vulnerability and adaptation.

Emotional Vulnerability and Invalidation

Linehan's biosocial theory proposes that BPD can be understood through an interaction between biological emotional vulnerability and an invalidating environment. Emotional vulnerability refers to heightened sensitivity to emotional stimuli, greater reactivity and slower return to baseline. An invalidating environment, in this model, is one in which emotional experiences are repeatedly dismissed, punished, trivialised or inconsistently responded to.

This model should not be interpreted as a universal explanation of BPD. Not every person diagnosed with BPD will have experienced the same developmental circumstances, and trauma or invalidation cannot be assumed simply because a person has received the diagnosis. Contemporary understanding recognises considerable heterogeneity in developmental pathways to BPD. The biosocial model is therefore most appropriately understood as a theoretical framework informing DBT rather than as a complete causal explanation for every individual.

Nevertheless, the model provides a useful way of understanding why emotional responses can become so intense and why attempts to suppress them may fail. If an individual has repeatedly learned that emotional expression is unacceptable while simultaneously experiencing emotions with considerable intensity, they may have had limited opportunity to develop effective strategies for identifying, tolerating and regulating those states. Behaviour may consequently become the means through which internal distress is managed or communicated.

DBT responds to this problem by explicitly teaching skills. The treatment is therefore not solely exploratory. It is practical, structured and oriented towards developing capacities that can be used outside the therapy room.

The Four Core Skills Areas

The skills traditionally associated with DBT are mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness. These domains address different aspects of the difficulties that can accompany severe emotional dysregulation.

Mindfulness involves developing the capacity to attend to present experience with greater awareness and less automatic judgement. Within DBT, mindfulness is not simply a relaxation exercise. It provides a foundation for noticing thoughts, emotions, bodily sensations and impulses without immediately acting upon them. This creates a space between emotional activation and behavioural response in which alternative choices may become possible.

Distress tolerance focuses upon surviving acute emotional crises without making the situation worse. This is particularly relevant when emotional intensity reaches a level at which conventional problem-solving may temporarily become difficult. The aim is not to make distress pleasant or to suggest that the individual should simply tolerate harmful circumstances indefinitely. Rather, distress-tolerance strategies are designed to help the individual survive periods of acute emotional activation while reducing impulsive or destructive responses.

Emotion regulation addresses the identification, understanding and modification of emotional responses. This includes developing greater awareness of emotional vulnerability, recognising factors that intensify emotional states and learning strategies that can reduce the likelihood that emotions will become overwhelming. The objective is not emotional suppression. Emotional regulation means increasing the capacity to experience emotion without being completely governed by it.

Interpersonal effectiveness addresses the difficulties that may arise when intense emotion interacts with relationships. Skills are directed towards communicating needs, establishing boundaries, managing conflict, maintaining self-respect and pursuing interpersonal goals. This is particularly relevant where fear of abandonment, sensitivity to rejection or intense emotional responses can contribute to unstable relationships.

Together, these domains reflect an important principle within DBT: behaviour cannot be understood separately from the emotional and interpersonal conditions surrounding it. Teaching a person to stop a behaviour without helping them develop alternative methods of regulating distress risks leaving the original problem unresolved.

DBT and the Therapeutic Relationship

The therapeutic relationship remains important within DBT, but it is structured differently from an unbounded supportive relationship. The therapist is required to maintain a balance between validation and change while helping the individual remain engaged with treatment. This makes the practitioner’s use of self particularly relevant to the discussion in the previous chapter.

The DBT therapist must be able to communicate acceptance while also identifying behaviours that interfere with safety or treatment. The practitioner may validate that a person has experienced profound emotional pain while challenging a behavioural response that places them or another person at risk. The ability to maintain both positions is central to the dialectical stance.

This also means that therapeutic boundaries remain essential. DBT does not depend upon unlimited therapist availability or the removal of professional boundaries. Instead, contact, treatment expectations, crisis procedures and responsibilities are structured within the treatment model. This predictability can help reduce ambiguity while allowing difficult emotional and interpersonal experiences to be explored.

The therapist's own emotional responses therefore remain clinically relevant. Working with repeated self-harm, suicidal crises or intense interpersonal distress can evoke powerful reactions. Therapeutic use of self requires the clinician to recognise these responses without allowing them to become the basis for punitive or dismissive treatment. Supervision and adherence to the treatment model provide important safeguards.

DBT and Self-Harm

Self-harm is one of the areas in which DBT has received particularly significant empirical attention. The treatment was developed partly in response to the difficulties encountered when working with chronically suicidal and self-harming individuals. Rather than treating self-harm solely as a symptom to be eliminated, DBT examines the sequence surrounding the behaviour and identifies the emotional, cognitive and environmental conditions that precede and follow it.

This behavioural analysis can identify points at which intervention may occur. The practitioner and individual may examine what happened immediately before an episode of self-harm, what thoughts and emotions were present, what the behaviour accomplished in the short term and what consequences followed. Such analysis can help transform a seemingly inexplicable act into a sequence that can be understood and potentially interrupted.

The evidence supports caution as well as optimism. The Cochrane review found that DBT reduced self-harm at the end of treatment compared with treatment as usual, but the available follow-up evidence did not demonstrate a statistically significant difference at six to twelve months. This suggests that treatment may produce meaningful change without establishing that risk necessarily disappears when formal treatment ends. (DOI)

This distinction matters clinically. Recovery should not be equated with an assumption that a person will never again experience suicidal thoughts, emotional crises or urges to self-harm. Progress may instead involve increased recognition of warning signs, longer intervals between episodes, reduced severity, greater use of alternative coping strategies and improved ability to seek help before a crisis escalates.

DBT Is More Than a Set of Skills

It would nevertheless be misleading to reduce DBT to a collection of coping strategies. Comprehensive DBT is a structured treatment programme incorporating individual psychotherapy alongside other components, including skills training and therapist consultation structures. Its theoretical framework, treatment hierarchy and behavioural orientation are integral to the intervention.

This distinction is important because individual skills derived from DBT are increasingly used outside comprehensive DBT programmes. Teaching mindfulness or distress-tolerance strategies can be valuable, but this should not automatically be described as delivering full DBT. The evidence base for comprehensive DBT relates to defined treatment models, and the outcomes of adapted or partial interventions should not simply be assumed to be equivalent.

The same principle applies to treatment fidelity. Evidence-based practice requires appropriately trained clinicians and sufficient adherence to the principles of the intervention being delivered. A practitioner cannot reasonably claim that an individual has received DBT simply because several DBT techniques have been incorporated into otherwise unrelated treatment.

What Does the Evidence Actually Tell Us?

The evidence supports DBT as an important psychological treatment for BPD, particularly in relation to self-harm and aspects of psychosocial functioning. The 2020 Cochrane review found that, compared with treatment as usual, DBT reduced BPD severity, reduced self-harm and improved psychosocial functioning, although these DBT-specific findings were judged to be based on low-quality evidence. (Cochrane)

A focused systematic review and meta-analysis by Storebø and colleagues, examining adult samples and active or nonspecific control conditions, similarly identified statistically significant effects for DBT on self-harm and psychosocial functioning, while emphasising the low overall certainty of the evidence. (PubMed)

The broader meta-analytic literature provides a further qualification. Cristea et al. (2017) found significant benefits for specialised psychotherapies, particularly DBT and psychodynamic approaches, but also reported that effects became less convincing in better-designed trials and when methodological differences between treatment and control conditions were reduced. The authors concluded that the benefits were significant but modest and that additional independent, well-conducted research was required. (JAMA Network)

The appropriate conclusion is therefore neither that DBT is a miracle treatment nor that the evidence is insufficient to support its use. The evidence occupies the more nuanced position between these extremes. DBT is an empirically supported psychological treatment that can produce meaningful improvements for some people with BPD, particularly in relation to self-harm and psychosocial functioning. However, treatment effects are not universal, the evidence quality varies, and DBT should not be presented as superior to every other evidence-based psychological approach in every outcome.

DBT and Recovery

The significance of DBT ultimately extends beyond symptom reduction. The skills taught within treatment can provide individuals with practical alternatives to behaviours that may previously have functioned as survival strategies. Learning to tolerate distress without immediately acting upon it, recognise emotional vulnerability, communicate more effectively and remain present during intense emotional states can create greater behavioural choice.

This connects directly with the broader concept of recovery introduced earlier in this book. Recovery does not necessarily mean that the person will never experience intense emotion again. Nor does it require the complete absence of vulnerability. A more meaningful definition involves increasing the individual's capacity to respond to internal experience with greater flexibility and choice.

DBT therefore offers a particularly useful illustration of the distinction between emotion and behaviour. The individual may not be able to prevent an emotion from arising, particularly in the early stages of treatment. They may, however, gradually develop greater capacity to determine what they do next. The therapeutic goal is not to eliminate emotional life but to increase the range of possible responses to it.

This is also why the dialectical principle remains so important. The person is not required to become someone entirely different before they can be accepted. At the same time, acceptance does not mean that destructive behaviour must remain unchanged. The individual can be understood in the context of their history while still being supported to construct a different future.

Conclusion

Dialectical Behaviour Therapy represents an important development in the psychological treatment of Borderline Personality Disorder because it combines a strong emphasis on validation and acceptance with structured behavioural change. Its theoretical framework provides a way of understanding emotional vulnerability, invalidation and learned behavioural responses, while its practical components give individuals specific skills through which distress can be managed differently.

The research supports its use, particularly for reducing self-harm and improving aspects of psychosocial functioning, but the evidence requires careful interpretation. The 2020 Cochrane review found beneficial effects for DBT compared with treatment as usual, while rating the certainty of the DBT-specific evidence as low. Broader systematic reviews similarly identify meaningful but generally modest effects and emphasise methodological limitations. (Cochrane)

DBT should consequently be presented neither as a cure for BPD nor as the only legitimate therapeutic approach. It is one evidence-based treatment within a wider field of psychological therapies. Its particular contribution lies in demonstrating that severe emotional dysregulation and recurrent self-harm can be approached through a combination of acceptance, behavioural analysis, skills development, therapeutic structure and collaborative change.

Most importantly, DBT challenges the assumption that intense emotional reactions necessarily have to determine behaviour. The emotion may be real, powerful and sometimes overwhelming, but the development of skills can create a space between feeling and action. Within that space, choice becomes possible.

The next chapter turns to another influential approach, Mentalisation-Based Therapy. Whereas DBT places considerable emphasis upon behavioural change, skills and emotional regulation, MBT approaches BPD through the capacity to understand one's own and other people's mental states, particularly when relationships become emotionally charged. Examining both approaches allows the book to consider not which therapy should be declared universally superior, but how different evidence-based models attempt to address different aspects of the complex experience associated with BPD.

References

Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C. and Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry, 74(4), 319–328. (JAMA Network)

Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.

Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D. and Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48(12), 1060–1064.

Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., Korslund, K. E., Tutek, D. A., Reynolds, S. K. and Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757–766.

Storebø, O. J., Stoffers-Winterling, J. M., Völlm, B. A., Kongerslev, M. T., Mattivi, J. T., Jørgensen, M. S., Faltinsen, E., Todorovac, A., Sales, C. P., Callesen, H. E., Lieb, K. and Simonsen, E. (2022). Psychotherapies for borderline personality disorder: A focused systematic review and meta-analysis. British Journal of Psychiatry, 220(6), 312–321. (PubMed)

Chapter 12

Mentalisation-Based Therapy

Mentalisation-Based Therapy, commonly known as MBT, provides a different but complementary perspective on the difficulties associated with Borderline Personality Disorder. Whereas Dialectical Behaviour Therapy places considerable emphasis upon emotional regulation, behavioural learning and the development of practical coping skills, MBT focuses upon the capacity to understand behaviour in relation to underlying mental states. These mental states include thoughts, feelings, intentions, wishes, beliefs and perceptions in both oneself and other people. The central proposition is that the capacity to mentalise can become less reliable when emotional arousal becomes intense, particularly within attachment relationships, and that strengthening this capacity may help individuals respond to themselves and others with greater flexibility.

The concept of mentalisation is closely associated with the work of Peter Fonagy and colleagues, who developed an attachment-based understanding of the difficulties experienced by people with BPD. Fonagy and colleagues proposed that the capacity to understand behaviour in terms of intentional mental states develops within early interpersonal relationships and can become particularly vulnerable under conditions of attachment-related stress. In BPD, this vulnerability may contribute to rapid changes in how the self and other people are perceived, particularly during emotionally charged interpersonal situations.

Mentalisation should not be understood simply as thinking rationally about emotions. It involves an awareness that one's own interpretation of another person's behaviour may not necessarily represent objective reality. A person may experience a partner's delayed response to a message as evidence of rejection, for example, while another explanation might be that the partner is unavailable, distracted or experiencing difficulties of their own. The ability to hold these possibilities simultaneously represents an important aspect of mentalising. When emotional arousal becomes overwhelming, however, that flexibility can temporarily diminish.

This provides an important framework for understanding some of the rapid interpersonal shifts that can occur in BPD. An individual may experience another person as deeply caring and trustworthy at one moment and subsequently experience the same person as rejecting, hostile or abandoning. Such changes should not automatically be reduced to irrationality or manipulation. They may reflect genuine changes in the individual's subjective experience as emotional states alter the way interpersonal information is processed and interpreted. MBT seeks to create a therapeutic environment in which these interpretations can be explored without immediately assuming that any one interpretation is unquestionably correct.

The Development of Mentalisation

Fonagy and colleagues developed their model from attachment theory, developmental psychology and psychoanalytic thinking. A central proposition was that children develop an understanding of their own and other people's mental states through relationships with caregivers who respond to them as intentional beings. When caregivers consistently and appropriately recognise the child's internal experience, the child has opportunities to develop an understanding of the relationship between feelings, thoughts, intentions and behaviour.

Where relationships are characterised by neglect, abuse, inconsistency or severe invalidation, the development of this capacity may be disrupted. It is important, however, not to convert this developmental model into a universal explanation for BPD. Not everyone with BPD has experienced childhood abuse or insecure attachment, and adverse childhood experiences do not inevitably lead to BPD. Developmental vulnerability arises through complex interactions between biological, psychological and environmental factors.

Mentalisation can also fluctuate within the same individual. A person may demonstrate considerable reflective capacity when calm and then struggle to understand their own or another person's mental state during an emotionally overwhelming interpersonal event. This state-dependent quality is central to MBT. Treatment is therefore not simply an educational exercise in teaching someone what mentalisation is. It involves helping the person recover or strengthen the capacity to mentalise when that capacity becomes disrupted.

Bateman and Fonagy developed MBT specifically for people with BPD and subsequently evaluated it through controlled clinical research. Their early randomised trial compared MBT within a partial hospitalisation programme with structured clinical management and found significant improvements in a range of outcomes, including suicidal behaviour and self-harm, as well as better social and interpersonal functioning during treatment and follow-up. These early findings were influential in establishing MBT as a serious psychological treatment for BPD, although subsequent research has produced a more nuanced picture of the relative effectiveness of specialised therapies.

Mentalising and Emotional Arousal

One of the central principles of MBT is that mentalising becomes particularly vulnerable when emotional arousal is high. This is important because interpersonal situations involving attachment, rejection, conflict or perceived abandonment can generate intense emotional responses. When emotional intensity increases, the individual's capacity to consider multiple perspectives may narrow, making it more difficult to recognise that other people possess minds that may contain thoughts and intentions different from one's own assumptions.

The therapeutic response is therefore not simply to provide reassurance or explain why the individual's interpretation is incorrect. The therapist instead seeks to restore curiosity. What did the person think was happening? What did they feel? What did they believe the other person intended? What evidence supported that interpretation? What alternative explanations might exist? What might the other person have been experiencing? These questions create an opportunity for the individual to examine an interpersonal event without requiring an immediate conclusion.

This approach is particularly relevant to the therapeutic relationship itself. The therapist will inevitably become part of the individual's interpersonal world, and the individual's expectations concerning trust, rejection, criticism and abandonment may become activated during treatment. The therapist therefore needs to remain attentive to their own mental state as well as the patient's. Therapeutic use of self, discussed in the previous chapter, becomes particularly relevant here because the therapist's assumptions and emotional reactions can influence the interaction.

The MBT therapist is consequently encouraged to maintain a stance of curiosity rather than certainty. Instead of assuming that the therapist knows what the patient is thinking, the therapist acknowledges uncertainty and explores possibilities. This position is important because mentalisation is fundamentally undermined when either participant assumes complete knowledge of the other's internal state.

The Therapeutic Stance

The therapeutic stance within MBT differs in important respects from approaches in which the clinician is positioned primarily as an expert providing interpretations. The therapist aims to remain actively engaged while avoiding unnecessary certainty about the patient's internal world. The central attitude is one of "not knowing", in which the therapist remains curious about what the patient is experiencing rather than assuming that they already understand it.

This does not mean that the therapist lacks knowledge or clinical expertise. Rather, it recognises that professional expertise does not provide direct access to another person's mind. The therapist may formulate hypotheses, but those hypotheses remain open to revision. This creates an interpersonal model in which uncertainty is tolerated rather than experienced as failure.

The therapist may therefore ask the patient to clarify what they experienced rather than immediately supplying an explanation. If the patient believes that the therapist has rejected them, for example, the therapist can explore what happened and what led to that interpretation. The objective is not necessarily to persuade the patient that the therapist did not reject them. It is to understand how the interpretation developed and whether other explanations can be considered.

This stance can be particularly valuable where the individual has previously experienced relationships in which their internal experiences were dismissed or defined by other people. The therapist does not claim authority over the patient's subjective experience. Instead, both therapist and patient become investigators of what is occurring.

Mentalising the Self and Others

Mentalisation encompasses both self-reflection and reflection upon other people. Difficulties may occur in understanding one's own emotional states, recognising what one is feeling or connecting feelings with subsequent behaviour. A person may know that they are angry without understanding that the anger developed from fear of rejection, for example. Alternatively, they may recognise distress only after it has become so intense that behavioural action has already begun.

Developing greater awareness of internal states can therefore provide an opportunity to intervene earlier. The individual may gradually become better able to identify emotional changes, recognise triggers and understand the relationship between emotion, interpretation and behaviour. The aim is not to eliminate emotion but to increase the capacity to remain curious about it.

Mentalising other people involves recognising that their behaviour also emerges from internal states that may not be immediately visible. This does not require the individual to excuse harmful behaviour from others. A partner's behaviour can be understood within the context of their own thoughts and emotions while still being recognised as unacceptable. Mentalisation therefore does not mean endless empathy for other people at the expense of self-protection.

This distinction is especially important for people who have experienced abuse. A therapeutic approach must never imply that understanding a perpetrator's mental state requires tolerating abuse. Mentalising can instead help an individual distinguish between understanding why another person behaves as they do and accepting that behaviour.

Mentalisation and Attachment

The relationship between mentalisation and attachment is central to MBT. Fonagy and colleagues proposed that mentalising develops within attachment relationships and may become disrupted when attachment systems are strongly activated. In this context, interpersonal situations involving closeness, rejection or potential abandonment can create precisely the conditions under which mentalising becomes most difficult.

The therapeutic relationship therefore provides an opportunity to observe and work with these processes as they occur. A patient may become convinced that the therapist is angry, disappointed or abandoning them. Rather than immediately reassuring them or interpreting the reaction as irrational, the therapist can explore the experience and attempt to understand what has happened to the patient's capacity to mentalise in that moment.

This can create a different experience of interpersonal uncertainty. The therapist does not have to prove that the patient is wrong, nor does the patient have to prove that the therapist is right. The focus becomes the process of arriving at an interpretation and the possibility that interpretations can change as additional information becomes available.

The Evidence for MBT

MBT has a substantial research literature, although, as with DBT, the evidence needs to be presented cautiously. The early randomised controlled trial by Bateman and Fonagy (1999) found that patients receiving psychoanalytically oriented partial hospitalisation with MBT had better outcomes than those receiving treatment as usual. Follow-up research subsequently suggested that treatment benefits could persist after treatment ended.

A later randomised controlled trial compared MBT with structured clinical management and found that both treatments produced improvements, with MBT showing advantages on some outcomes. These studies contributed to the development of MBT as an established treatment approach for BPD.

However, contemporary systematic reviews do not support the claim that MBT has been conclusively demonstrated to be superior to all other treatments. Storebø et al. (2020), in the Cochrane review of psychological therapies for BPD, identified MBT as one of the better-studied specialised psychotherapies but concluded that the certainty of evidence for many comparisons was low or very low. The review found that psychological therapies overall can produce beneficial effects, while the relative effectiveness of specific approaches remains less certain.

A later focused systematic review and meta-analysis similarly found evidence that MBT can improve important outcomes associated with BPD, while emphasising limitations within the existing evidence base. The appropriate interpretation is therefore that MBT is an evidence-supported psychological treatment, not that research has established it as universally superior to other specialised therapies.

This distinction is important because treatment research in BPD frequently involves different comparators, treatment durations, levels of therapist expertise and outcome measures. A therapy may demonstrate superiority to treatment as usual without demonstrating superiority to another specialist psychological treatment. Evidence-based practice therefore requires attention to the actual comparison being made.

MBT and Self-Harm

MBT has also been investigated in relation to self-harm and suicidal behaviour. The theoretical rationale is that improving mentalisation may reduce the likelihood that intense emotional states and interpersonal interpretations immediately translate into impulsive behaviour. If an individual becomes more able to recognise what they are feeling, consider what they believe is happening and tolerate uncertainty about another person's intentions, there may be greater opportunity to interrupt the sequence leading towards self-harm.

Again, however, the evidence should not be overstated. MBT should not be described as a treatment that eliminates suicidal behaviour. Self-harm and suicide risk are complex phenomena influenced by multiple factors, and treatment requires appropriate risk assessment and safety planning alongside psychological intervention.

The value of MBT may therefore lie partly in helping individuals develop greater reflective capacity around the circumstances in which self-harm occurs. Rather than treating the behaviour as inexplicable or morally problematic, treatment can examine the emotional and interpersonal sequence surrounding it and identify opportunities for alternative responses.

MBT and the Therapeutic Relationship

The therapeutic relationship is particularly central to MBT because mentalisation is practised within the relationship itself. The therapist must model the very process they are attempting to strengthen. This involves remaining curious about the patient's mental state while also acknowledging uncertainty about one's own understanding.

The therapist's willingness to say, in effect, "I may have misunderstood what you meant" can be therapeutically significant. It demonstrates that misunderstanding does not necessarily require blame or rupture and that interpersonal understanding can be revised. The clinician models a form of reflective humility in which certainty is replaced by curiosity.

This is closely connected to therapeutic use of self. The therapist's own emotional reactions become relevant data, but they must not automatically be treated as evidence about the patient's intentions. A therapist who feels rejected, controlled or frustrated may need to explore that response within supervision rather than assuming that the patient deliberately intended to evoke it.

Such reflexivity is particularly important because the therapeutic relationship is itself an interpersonal relationship. The therapist cannot remain outside the relational processes being explored. Their role is instead to participate in the relationship while maintaining sufficient awareness to examine what is occurring within it.

MBT Compared with DBT

MBT and DBT share important characteristics despite their theoretical differences. Both are structured psychological treatments developed specifically for BPD, both recognise the importance of emotional dysregulation and interpersonal difficulties, and both aim to reduce destructive behavioural patterns while improving functioning. Neither approach assumes that the difficulties associated with BPD are immutable.

Their primary emphases nevertheless differ. DBT places substantial emphasis upon behavioural analysis, skills acquisition, distress tolerance, emotional regulation and interpersonal effectiveness. MBT places greater emphasis upon understanding mental states and restoring the capacity to mentalise when emotional arousal disrupts that capacity.

These differences should not be converted into a simplistic competition between the two treatments. Current evidence does not justify claiming that one approach is universally superior. A more defensible interpretation is that both provide structured frameworks for addressing different aspects of the complex difficulties associated with BPD.

The distinction also demonstrates why psychological treatment should not be reduced to a single technique. Effective treatment involves a coherent theoretical model, appropriately trained clinicians, a therapeutic relationship, appropriate supervision and attention to the individual's circumstances and treatment goals.

Recovery and Mentalisation

The potential contribution of MBT to recovery lies in its emphasis upon increasing psychological flexibility. A person who can recognise that their interpretation of an event is an interpretation rather than an unquestionable fact may have greater opportunity to choose how they respond. A person who can identify their own emotional state before it reaches overwhelming intensity may be better positioned to seek support or use alternative coping strategies.

Recovery therefore does not require the permanent elimination of intense emotion. It may involve developing greater capacity to remain mentally present when intense emotion occurs. The individual may still experience fear, anger, grief or rejection, but these experiences may no longer automatically determine how the person understands themselves, other people or what they must do next.

This represents an important connection with the wider argument of this book. Looking beyond the diagnosis means recognising that behaviour is embedded within meaning. The same outward behaviour can arise from very different internal experiences, and understanding those experiences may create opportunities for change that are lost when behaviour is interpreted only through the diagnostic label.

Conclusion

Mentalisation-Based Therapy offers an important evidence-supported approach to BPD by focusing upon the capacity to understand behaviour in relation to mental states. Its central premise is that mentalising can become disrupted during periods of intense emotional and attachment-related arousal and that therapy can help individuals recover greater reflective capacity within those moments.

The research supports MBT as a legitimate psychological treatment for BPD, while contemporary systematic reviews caution against claims that it is universally superior to other specialist therapies. As with DBT, the evidence is meaningful but not definitive, and treatment outcomes vary between individuals and studies. The most defensible conclusion is that MBT represents one structured, theoretically coherent and empirically supported approach within the wider field of psychological treatment for BPD.

Its particular contribution lies in shifting attention towards the processes through which people understand themselves and others. Where an interpersonal event once produced an immediate conclusion, mentalisation creates the possibility of uncertainty. Where emotion once became action, reflection can create a pause. Where another person's behaviour once appeared to have only one possible explanation, curiosity can create alternatives.

This does not mean that mentalisation will prevent all crises, eliminate self-harm or resolve every relational difficulty. Nor does it mean that understanding another person's mental state requires tolerating harmful behaviour. Rather, it offers a framework through which the individual can become increasingly able to understand internal and interpersonal experience without being completely governed by it.

The discussion now returns to the question that began Part Three: whether recovery is possible. Having examined the therapeutic relationship, therapeutic use of self, DBT and MBT, the final chapter can move beyond the question of symptom reduction and consider what recovery actually means. It can examine the longitudinal evidence, the distinction between remission and recovery, improvements in social and occupational functioning, the possibility of meaningful relationships and identity development, and the limitations of defining a person's future by a psychiatric diagnosis.

References

Bateman, A. and Fonagy, P. (1999). Effectiveness of partial hospitalization in the treatment of borderline personality disorder: A randomized controlled trial. American Journal of Psychiatry, 156(10), 1563–1569.

Bateman, A. and Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder: Mentalization-based treatment versus treatment as usual. American Journal of Psychiatry, 165(5), 631–638.

Bateman, A. and Fonagy, P. (2009). Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. American Journal of Psychiatry, 166(12), 1355–1364.

Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide. Oxford: Oxford University Press.

Fonagy, P., Gergely, G., Jurist, E. L. and Target, M. (2002). Affect Regulation, Mentalization, and the Development of the Self. New York: Other Press.

Fonagy, P. and Bateman, A. (2006). Mechanisms of change in mentalization-based treatment of BPD. Journal of Clinical Psychology, 62(4), 411–430.

Chapter 13

Recovery Is Possible?

The question posed by this chapter is deliberately direct: is recovery possible? For many years, the answer given to people diagnosed with Borderline Personality Disorder was shaped less by longitudinal evidence than by pessimistic assumptions about personality disorder itself. BPD was frequently described as enduring, unstable and difficult to treat, and these descriptions could become translated into assumptions about the person: that their difficulties were fixed, that treatment would have limited value, or that meaningful recovery was unlikely. Contemporary longitudinal research presents a substantially more hopeful picture. Recovery is neither guaranteed nor necessarily straightforward, but the evidence demonstrates that substantial and sustained improvement is possible, and that the diagnosis should not be regarded as a lifelong prediction of dysfunction.

The most important distinction in interpreting this evidence is between remission and recovery. These terms are sometimes used interchangeably, but they describe different outcomes. Remission generally refers to a reduction in, or absence of, sufficient symptoms to meet diagnostic criteria for a specified period. Recovery is a more demanding concept because it incorporates not only symptomatic improvement but also functioning. Zanarini et al. (2010), for example, defined recovery as remission of BPD symptoms accompanied by good social and vocational functioning during the preceding two years. Using this definition within the McLean Study of Adult Development, 50% of participants had achieved recovery by the ten-year follow-up, while 93% had achieved a remission lasting at least two years and 86% had achieved a remission lasting at least four years. (PubMed)

These findings are significant because they directly challenge the historical assumption that BPD is necessarily chronic and intractable. They do not, however, mean that every person diagnosed with BPD will recover within ten years, nor that recovery follows a predictable linear pathway. The study involved a particular clinical population, including individuals who had been admitted to hospital, and its definition of recovery was specific to the research methodology. Nevertheless, the findings provide strong longitudinal evidence that sustained remission and recovery occur in a substantial proportion of people.

The Collaborative Longitudinal Personality Disorders Study provides complementary evidence. Gunderson et al. (2011) followed 175 people with BPD for ten years and found that 85% achieved remission. Relapse was relatively uncommon, occurring in 12% of participants, although the study found an important distinction between symptomatic improvement and functioning. Despite the high rate of remission, social functioning remained substantially impaired and improved only modestly. (PubMed) This finding is particularly important because it prevents an overly simplistic interpretation of recovery. A person may no longer meet diagnostic criteria for BPD while continuing to experience difficulties in employment, relationships, social participation or other areas of life.

The longitudinal evidence therefore suggests that recovery has more than one dimension. Symptoms may improve considerably before social and occupational functioning has fully recovered. Interpersonal difficulties may persist after more overt behavioural symptoms have diminished. Conversely, an individual may develop meaningful relationships, employment, education or personal autonomy while still experiencing periods of emotional distress. Recovery cannot therefore be adequately represented by a single diagnostic threshold.

The Evidence Across Sixteen Years

The McLean Study subsequently extended its observations beyond the initial ten-year period. Zanarini et al. (2012) examined sustained symptomatic remission and recovery over sixteen years. The importance of this research lies not simply in demonstrating that improvement can occur, but in examining whether improvement is maintained over time. The study found that substantial numbers of participants achieved sustained symptomatic remission and recovery, providing further evidence that improvement in BPD is not necessarily a temporary phenomenon. (PubMed)

This is particularly relevant to the concept of personality disorder because the term itself can imply permanence. If a disorder is conceptualised as an enduring pattern of personality functioning, it can be tempting to assume that meaningful change is inherently unlikely. Longitudinal research challenges that assumption. Personality characteristics can change, behavioural patterns can change, relationships can change and the individual's capacity to regulate emotion can change. The fact that BPD may be persistent for some people does not establish that it is immutable.

The evidence also suggests that different aspects of BPD do not necessarily improve at the same rate. Choi-Kain et al. (2010), examining the interpersonal course of BPD over ten years, found that some behavioural interpersonal features remitted relatively quickly, whereas affective features associated with intolerance of aloneness and dependency were more persistent. (PubMed) This provides a useful explanation for why a person may appear substantially improved in some domains while continuing to experience significant relational vulnerability in others.

Recovery is consequently better understood as a process of change across multiple domains rather than as a single event. The disappearance of overtly dangerous behaviours may represent an important achievement, but it does not necessarily mean that the underlying difficulties have disappeared. Likewise, continuing emotional sensitivity does not necessarily mean that treatment has failed. What matters is how the individual experiences and responds to that sensitivity and how effectively they are able to construct a life around it.

The Twenty-Four-Year Perspective

Longer-term research provides an even more striking challenge to therapeutic pessimism. Zanarini and colleagues have followed the McLean cohort for 24 years, allowing researchers to examine not simply whether participants experienced remission but the pathways associated with better overall outcomes. Their 2023 analysis examined vocational, relational, activity-based and treatment-related pathways reported by participants as contributing to improved functioning or a better sense of self. (PubMed)

The significance of such research is that recovery becomes more than the absence of pathology. People who achieve better outcomes are not simply people who have stopped meeting diagnostic criteria. Their lives contain relationships, occupations, activities, treatment experiences and other sources of meaning that contribute to functioning and wellbeing. Recovery therefore needs to be considered in relation to the person's life as a whole rather than solely through psychiatric symptoms.

This perspective is consistent with the broader recovery movement in mental health, which distinguishes recovery from the simple elimination of symptoms. Personal recovery can involve developing a meaningful and satisfying life, establishing identity beyond illness, developing autonomy and finding ways of living that remain valuable even where some vulnerabilities continue.

Recovery Does Not Mean Never Struggling Again

An important consequence of the longitudinal evidence is that recovery should not be presented as a state of permanent emotional invulnerability. Human beings continue to experience grief, rejection, anger, fear, disappointment and relational conflict whether or not they have ever received a psychiatric diagnosis. Recovery therefore cannot reasonably require the absence of difficult emotions.

For someone with a history of severe emotional dysregulation, recovery may instead involve a transformation in the relationship with emotional experience. An emotion that once resulted automatically in self-harm may become an emotion that can be recognised, tolerated and communicated. A perceived rejection that once produced an immediate relational rupture may become an opportunity for reflection. A period of intense distress may still occur, but the person may increasingly possess the capacity to survive it without returning to behaviours that previously caused significant harm.

This distinction is important because defining recovery as the complete disappearance of emotional difficulty risks creating another form of stigma. It suggests that continued vulnerability represents failure. A more realistic understanding recognises that recovery can involve increased resilience, flexibility and agency rather than permanent immunity from distress.

Recovery and Functioning

The evidence concerning psychosocial functioning requires particular attention. The high remission rates reported in longitudinal studies might initially appear to suggest that BPD resolves relatively straightforwardly. The functional findings tell a more complicated story. Gunderson et al. (2011) found that although remission was common, social functioning remained substantially impaired for many participants. (PubMed) A separate ten-year study similarly found significant improvements in clinical symptoms but relatively limited improvement in social and occupational functioning. (PubMed)

This distinction matters because functioning is influenced by factors that extend beyond psychopathology. Employment opportunities, physical health, socioeconomic circumstances, education, housing, relationships, stigma and access to appropriate treatment can all affect a person's ability to construct a stable life. Symptom remission cannot therefore be assumed to produce immediate restoration of every area of functioning.

The implication for clinical practice is important. Treatment should not end its definition of success at symptom reduction. A person may require support to develop relationships, return to education, obtain employment, establish financial independence, develop social networks or rebuild confidence after years of psychological distress. These are not secondary concerns. They form part of what recovery can mean.

Recovery and Relationships

Relationships occupy a particularly important position within the recovery process because interpersonal difficulties are central to the experience of BPD for many people. Longitudinal research suggests that interpersonal functioning can improve, although some attachment-related difficulties may persist longer than more overt behavioural symptoms. (PubMed)

The possibility of developing stable and meaningful relationships is therefore an important part of the evidence against therapeutic nihilism. Paris and Zweig-Frank's 27-year follow-up found substantial long-term improvement among the cohort studied, with only five participants meeting criteria for BPD at the time of assessment. The study nevertheless also demonstrated that outcomes were not uniformly positive and that comorbid conditions could be associated with poorer outcomes. (PubMed)

Such findings reinforce the importance of avoiding both extremes. It would be inaccurate to tell someone with BPD that their relationships will inevitably remain chaotic throughout life. It would be equally inaccurate to suggest that relational difficulties will automatically disappear simply because symptoms improve. Recovery involves learning, adaptation and the development of new relational experiences, often over considerable periods of time.

Recovery Is Not the Same as Cure

The language of "cure" is problematic when discussing BPD because it implies a binary state in which a disorder is either present or completely eliminated. The longitudinal literature supports a more nuanced model of change. Symptoms can remit, relapse can occur, particular difficulties can persist and functioning can improve gradually.

This does not diminish recovery. On the contrary, it allows recovery to be understood in a way that reflects actual human development. A person can experience substantial and enduring change without becoming a completely different person. Personality does not need to be erased for suffering to diminish. Emotional sensitivity does not have to disappear for emotional regulation to improve. A history of trauma does not have to be forgotten for a person to build a meaningful future.

This is particularly important when considering the concept of personality itself. A diagnosis of BPD does not mean that the individual possesses a defective or permanently disordered identity. It describes a pattern of psychological difficulties that can change over time. The longitudinal evidence demonstrates precisely why the diagnosis should not be treated as a fixed definition of the person.

The Role of Treatment

The evidence for recovery cannot be attributed exclusively to any single treatment. Longitudinal studies do not establish that every individual recovered because they received DBT, MBT or another particular therapy. People change for many reasons, and treatment is only one potential contributor. Some individuals receive different forms of psychological therapy, some receive medication for co-occurring conditions, some experience changes in relationships or employment, and some develop new coping strategies through life experience.

This does not diminish the importance of treatment. Evidence-based psychological therapies can provide structured opportunities for change, while therapeutic relationships can provide experiences of safety, reflection, validation and challenge. What the longitudinal evidence demonstrates is that meaningful improvement is possible; treatment research helps identify approaches that may facilitate that improvement.

The distinction is important because recovery should not become another form of professional ownership. The person does not recover simply because a therapist "fixed" them. Recovery involves the person's own capacities, choices, relationships, circumstances and development. Professional intervention may provide essential support, but the life that emerges belongs to the individual.

Hope Without False Promises

The evidence therefore supports hope, but it does not justify promises. Professionals should not tell every person diagnosed with BPD that they will recover within a particular period. Nor should recovery be presented as inevitable. Individual trajectories vary considerably, and some people experience persistent difficulties despite treatment.

However, uncertainty about an individual's trajectory is very different from therapeutic pessimism. A clinician cannot know at the beginning of treatment whether a person will ultimately achieve sustained remission or functional recovery. What can be known is that longitudinal research demonstrates that substantial change occurs in a significant proportion of people.

This distinction has ethical significance. If professionals communicate that BPD is effectively untreatable, they may inadvertently influence the individual's expectations of themselves and the treatment they receive. Conversely, if clinicians communicate realistic hope while acknowledging uncertainty, they can support engagement without creating false expectations.

Hope should therefore be evidence-informed rather than sentimental. It should arise from what the longitudinal research demonstrates rather than from reassurance unsupported by evidence.

Beyond the Diagnosis

The most compelling conclusion from the longitudinal literature is that the diagnosis does not adequately predict the person's future. The course of BPD is heterogeneous. Some difficulties remit relatively rapidly, others persist for longer, and functional recovery may develop more slowly than symptomatic remission. Nevertheless, the overall trajectory observed across multiple longitudinal studies is considerably more hopeful than the historical image of BPD as inevitably chronic and unchangeable.

The evidence also encourages a reconsideration of what clinicians mean when they speak about "recovery". If recovery is defined exclusively as the absence of diagnostic criteria, important dimensions of human development disappear from view. Relationships, employment, autonomy, identity, purpose, self-respect and participation in ordinary life are equally relevant to whether someone can be said to have recovered.

For this reason, recovery should be understood as multidimensional and individual. One person may define recovery through freedom from self-harm; another may define it through maintaining a stable relationship; another through returning to education or employment; another through living independently; and another through no longer experiencing themselves primarily through the diagnosis they were given. These outcomes are not lesser forms of recovery because they cannot be reduced to a diagnostic checklist.

Conclusion

So, is recovery possible?

The longitudinal evidence provides a clear answer: yes, substantial and sustained recovery is possible for many people diagnosed with Borderline Personality Disorder. Studies following people for ten, sixteen and even twenty-four years demonstrate high rates of symptomatic remission and meaningful evidence of recovery, while also showing that psychosocial functioning may improve more slowly and that some difficulties can persist. (PubMed)

The answer must nevertheless remain qualified. Recovery is not guaranteed, linear or identical for everyone. Remission is not synonymous with complete functional recovery, and improvement in symptoms does not automatically resolve difficulties in relationships, employment or wider social functioning. The evidence therefore supports neither therapeutic pessimism nor unrealistic optimism. It supports a position of realistic hope.

Perhaps most importantly, the research demonstrates why a diagnosis of BPD should never be treated as a verdict. The longitudinal evidence shows that people change. Behaviours can change, relationships can change, emotional regulation can change, functioning can change and the individual's understanding of themselves can change. The diagnosis may describe where someone has been, or the difficulties they are experiencing at a particular point in time, but it cannot reliably tell us where they will ultimately go.

Recovery, therefore, is possible not because the difficulties associated with BPD are insignificant, but because they are capable of change. The task of treatment is not to manufacture a different personality. It is to support the individual in developing greater freedom, agency, connection and capacity to live a life that is no longer organised primarily around survival.

The final chapter of this book can consequently move beyond the question of whether recovery occurs and ask a more meaningful question: what does recovery actually look like? It can consider the movement from symptom reduction towards identity, autonomy, relationships, purpose and a life in which the person is understood as considerably more than the diagnosis.

References

Gunderson, J. G., Stout, R. L., McGlashan, T. H., Shea, M. T., Morey, L. C., Grilo, C. M., Zanarini, M. C., Yen, S., Markowitz, J. C., Sanislow, C., Ansell, E., Pinto, A., Skodol, A. E. and McLaughlin, S. J. (2011). Ten-year course of borderline personality disorder: Psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Archives of General Psychiatry, 68(8), 827–837. (PubMed)

Paris, J. and Zweig-Frank, H. (2001). A 27-year follow-up of patients with borderline personality disorder. Comprehensive Psychiatry, 42(6), 482–487. (PubMed)

Zanarini, M. C., Frankenburg, F. R., Reich, D. B., Fitzmaurice, G., J. et al. (2023). Pathways to health reported by patients with borderline personality disorder with a good overall outcome versus a fair-poor outcome over 24 years of prospective follow-up. Journal of Personality Disorders, 37(4), 456–474. (PubMed)