Journal of Psychotherapy Integration © 2015 American Psychological Association

2015, Vol. 25, No. 1, 13–19 1053-0479/15/$12.00 http://dx.doi.org/10.1037/a0038767

Applying the Principles of Psychotherapy Integration to the

Treatment of Borderline Personality Disorder

Joel Paris
McGill University

The most effective treatments for borderline personality disorder consist of specialized
psychotherapies specifically developed for this clinical population. All current methods
have been described as separate programs, often identified by 3-letter acronyms.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

However, examination of the evidence points to strong commonalities between all

This document is copyrighted by the American Psychological Association or one of its allied publishers.

therapies shown to be effective in clinical trials. This supports the principle of

developing an integrated psychotherapy for borderline personality disorder, combining
the most useful interventions from all sources.

Keywords: psychotherapy integration, borderline personality disorder, personality disorders

Borderline personality disorder (BPD) is a
common and serious mental disorder that can be
diagnosed in about 1% of the general population
(Lenzenweger, Lane, Loranger, & Kessler,
2007), and in 9% of patients in mental health
practice (Zimmerman, Rothschild, & Chelmin-
ski, 2005). BPD symptoms are worrisome and
upsetting: marked affective instability and un-
stable relationships, chronic suicidality, suicide
attempts, and self-harm (Lieb, Zanarini,
Schmahl, Linehan, & Bohus, 2004). Moreover,
BPD patients create clinical problems: poor
compliance, quarrelsomeness, and a failure to
respect therapeutic boundaries (Gunderson &
Links, 2008). Finally, nearly 10% of this pop-
ulation will eventually commit suicide (Paris,
2003). These difficulties help explain why con-
ferences on BPD are often sold out and why
books on the disorder often sell briskly. They
also help explain why psychotherapies claiming
unique effectiveness actively compete for mar-
ket share.
In the past, a diagnosis of BPD was some-
times seen as a predictor of chronicity and
therapeutic failure. But in the last 20 years,
two lines of research have overturned that
verdict. First, several forms of specialized
Correspondence concerning this article should be ad-
dressed to Joel Paris, Institute of Community and Family
Psychiatry, Department of Psychiatry, McGill University,
4333 Cote Ste. Catherine, Montreal Quebec, H3T1E4, Can-
ada. E-mail: joel.paris@mcgill.ca
13
psychotherapy designed for BPD have been
shown to be efficacious (Zanarini, 2009;
Paris, 2010; Stoffers et al., 2012). Second,
long-term follow-up studies of BPD patients,
both retrospective (Paris, 2003) and prospec-
tive (Gunderson et al., 2011; Zanarini, Fran-
kenburg, Reich, & Fitzmaurice, 2012), have
shown that most BPD patients improve with
time and that the prognosis is more favorable
than for other severe mental disorders. In this
light, one might consider an increase in the
speed of naturalistic improvement to be a goal
of therapy.
Evidence-Based Psychotherapies for BPD
The first description of BPD was published
75 years ago (Stern, 1938). One of the origi-
nal features described in that paper was a
failure to respond to psychoanalysis, which
reflects the need of BPD patients for direction
and structure (Gunderson & Links, 2008).
Long-term psychodynamic psychotherapy,
modified for increased therapist activity
(Kernberg, 1976), may still be offered. Yet,
there is no evidence for the efficacy or effec-
tiveness of these approaches, and therapies
can sometimes continue for years without
yielding clinical improvement (Horwitz,
1974). The problem is not unique to a psy-
chodynamic approach: while cognitive–
behavioral therapy (CBT) can be modified for
BPD (Beck & Freeman, 2002), it can also
continue for years.
 14 PARIS
Dialectical Behavior Therapy
A breakthrough occurred more than 20 years
ago with the development of an eclectic variant
of CBT called dialectical behavior therapy
(DBT; Linehan, 1993). A clinical trial (Linehan,
Armstrong, Suarez, Allmon, & Heard, 1991)
found 12 months of DBT to be superior to
treatment as usual (TAU; i.e., management in
community clinics), although differences were
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less prominent at 1-year follow-up (Linehan,
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Heard, & Armstrong, 1993). In a second trial,
Linehan and colleagues (2006) found DBT to be
superior to therapies conducted by experts with
experience treating BPD, although differences
were less marked than with TAU. Replications
of the original trials in other settings have con-
firmed that this treatment is efficacious (Paris,
2010), making DBT a kind of gold standard for
the management of BPD.
DBT is also important for its theoretical in-
novations. The central idea is that the main
feature in BPD that requires modification is
emotion dysregulation, that is, difficulty in
managing emotions that are intense and that do
not easily return to baseline (Linehan, 1993).
This trait, along with impulsivity, underlies
many of the phenomena associated with the
disorder (Crowell, Beauchaine, & Linehan,
2009). To promote emotion regulation, skills in
mindfulness, distress tolerance, and emotional
regulation are taught in individual and group
therapy. These procedures are designed to help
patients to observe and control intense emo-
tional reactions to life events and to increase
interpersonal skills. Another key element of
DBT is validation, associated with a dialectic
between acceptance and change. DBT even has
a model for transference, reconceptualized as
therapy-interfering behavior (Linehan, 1993).
The basic elements of DBT have been very
influential, and many have since been incorpo-
rated into general management, even outside
specialized clinics. For this reason, there may be
less difference today between formal DBT and
TAU than was the case 20 years ago.
DBT may not be entirely specific. Its effec-
tiveness may not depend on its theory or its
method, but on high levels of external structure,
which are of particular importance for patients
who lack internal structures. This conclusion
was supported by a large trial comparing DBT
to another highly structured form of manage-
ment based on American Psychiatric Associa-
tion clinical guidelines. The study found no
difference in outcome, either at the end of treat-
ment (McMain et al., 2009) or at 1-year fol-
low-up (McMain, Guimond, Streiner, Cardish,
& Links, 2012).
A second problem with DBT is that it is
lengthy and expensive. The treatment has been
tested in clinical trials lasting at least a year and
Linehan (1993) has suggested that a complete
treatment might require several years. When
therapy is long and costly, most patients who
need it lack access to treatment. DBT has be-
come relatively inaccessible, and clinics have
excessively long waiting lists. In this way, the
length of DBT threatens to repeat the story of
psychoanalysis, which began as a therapy last-
ing a few months, but gradually became “inter-
minable,” particularly in patients who did not
improve (Paris, 2005). However, there is evi-
dence that DBT can be shortened (Stanley,
Brodsky, Nelson, & Dulit, 2007) and that other
methods, using similar principles, are effica-
cious within a time-limited framework (Blum et
al., 2008; Davidson et al., 2006). Briefer forms
of treatment for BPD need further testing to
determine which patients can benefit from them
and which patients need more extended periods
of psychotherapy.
Yet almost all other methods make use of
similar concepts and techniques. But DBT has
the most empirical support, and the most orig-
inal ideas. If an integrated psychotherapy is
eventually developed for BPD, it will include
the principles of DBT in an abbreviated and
accessible form.
Mentalization-Based Treatment
A second prominent therapy for BPD is men-
talization-based treatment (MBT; Bateman &
Fonagy, 2009). MBT is based on attachment
theory and the theory of mind and is an amal-
gam of psychodynamic and cognitive therapies,
and the package is an eclectic mix of interven-
tions. While it does not use the specific methods
for training that characterize DBT or have a
formal psychoeducational component, patients
who undergo MBT are taught a number of in-
terpersonal skills. Moreover, in spite of theoret-
ical differences from DBT, MBT may not be
that different in practice. Its main concept is that
BPD patients improve when they learn to rec-
 PSYCHOTHERAPY INTEGRATION AND BPD
ognize their own emotions and those of other
people. Clinical trials of 24 months of therapy
have found MBT to be effective for day patients
(Bateman & Fonagy, 2004), as well as for out-
patients (Bateman & Fonagy, 2009), and a co-
hort followed for 8 years after day treatment
showed a stable level of improvement (Bateman
& Fonagy, 2008).
The main limitation for MBT is a lack of
replication of the original clinical trials outside
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the site where it is was developed. Thus far,
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only one such study (Jorgensen et al., 2012) has
been published, and it found MBT only margin-
ally superior to supportive group therapy. More-
over, because clinical trials last for 2 years,
access to treatment raises the same problems as
in DBT. To their credit, Bateman and Fonagy
(2004) have been interested in shortening MBT
and have encouraged using its principles within
ordinary clinical settings. Finally, although
MBT is derived from a different theory than
DBT, it may not be that different in practice.
Systems Training for Emotional
Predictability and Problem Solving
A third method supported by clinical trials is
systems training for emotional predictability
and problem solving (STEPPS; Blum et al.,
2008). STEPPS was originally designed to be
an add-on to TAU, in the form of group psy-
choeducation, particularly in communities
where specialized therapies are unavailable. But
STEPPS also shows potential as a standalone
treatment. While similar to DBT in focusing on
emotion regulation and improved life skills, it is
much shorter (a few months), making it much
more accessible. These could be the elements of
an integrated psychotherapy for DBT.
Other Methods
Several other methods tested in clinical trials
are a mixture of CBT and psychodynamic meth-
ods. Schema-focused therapy (SFT; Arntz,
2012) is supported by one comparative trial
(Giesen-Bloo et al., 2006) and a trial of its
group component (Arntz, 2012). Cognitive an-
alytic therapy has a similar theoretical frame-
work, and has thus far been supported by one
clinical trial (Clarke, Thomas, & James, 2013).
Standard cognitive therapy, lasting about 25
sessions, has also been found effective in one
trial (Davidson et al., 2006).
15
A psychodynamic method subjected to clini-
cal trials is transference-focused psychotherapy
(TFP; Yeomans, Clarkin, & Kernberg, 2002).
However, TFP is not psychoanalysis and may
be more similar to MBT. It differs from open-
ended psychodynamic therapy in that it focuses
mostly on here-and-now distortions affecting
current relationships between a patient and a
therapist. This concept resembles an “observing
ego,” a concept that goes back to Freud (Glick-
auf-Hughes, Wells & Chance, 1996). TFP has
gained some empirical support: While a com-
parative trial (Clarkin, Levy, Lenzenweger, &
Kernberg, 2007) observed only minor differ-
ences from DBT, a second trial (Doering et al.,
2010) found it to be superior to TAU.
Are the Psychotherapies for BPD Unique?
All current psychotherapies for BPD present
themselves as separate and unique. Almost all
are labeled with three-letter acronyms—the ex-
ception is STEPPS, which has five letters. All
developers have promoted their approaches
through conferences, workshops, journal arti-
cles, and books. Psychotherapists who are hav-
ing difficulty with BPD cases could be attracted
to new methods that claim definitive answers.
Livesley (2012) has published a critique of all
“acronym-based” therapies for BPD. He points
out that because the diagnosis is heterogeneous
(and best considered as a clinical heuristic),
each method approaches the problem from a
different perspective without taking the full
range of psychopathology into account. While
Livesley’s approach differs from DBT, it makes
use of many of the same ideas concerning emo-
tion regulation. Thus, in practice, all therapies
for BPD have much in common, and compara-
tive trials find few differences in outcome be-
tween methods (Clarkin et al., 2007; Giesen-
Bloo et al., 2006), particularly when the
comparison is between specific methods and
structured management, rather than with TAU.
Despite these findings, allegiance to specific
methods of treatment remains strong, even
among researchers who have conducted studies
that shed doubt on their uniqueness. (Clinical
trials rarely change the minds of therapists al-
ready committed to a particular method.) The
evidence continues to support the view that the
various psychotherapies for BPD, however dif-
ferent their theories, converge significantly in
 16 PARIS
practice. Let us examine what the efficacious
treatments for BPD have in common.
Emotion Regulation
This psychological construct, derived from
emotion research (Gross, 2009), is crucial for
the treatment of BPD. Also called affective in-
stability (Koenigsberg, 2010), regulating and
stabilizing emotional responses is a crucial ele-
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ment of successful therapy. Linehan (1993a)
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promotes this by teaching skills such as mind-
fulness, a central element of many cognitive
therapies (Segal, Williams, & Teasdale, 2002).
Derived from Buddhist spiritual practices,
mindfulness allows people to observe their
thoughts calmly without acting on them. MBT
promotes emotion regulation by teaching pa-
tients to make more accurate assessments of
emotional states in interpersonal encounters.
STEPPS is similar to DBT, in that patients are
asked to chart their emotional states as a way to
monitor and control them. TFP, by asking pa-
tients to correct distorted responses to the ther-
apist, also promotes self-observation.
Behavioral and Interpersonal Skills
An essential element in all psychotherapies is
to teach patients better ways of managing inter-
personal relations. Therapists must also encour-
age patients to deal with stress through alterna-
tives to cutting, overdosing, or abusing
substances. Skills training is manualized in
DBT (Linehan, 1993b), but MBT teaches pa-
tients to observe the subtleties of interpersonal
relations, STEPPS contains modules for rela-
tionship skills, and TFP teaches skills by mod-
eling them within the therapeutic relationship.
Divergences
Therapies for BPD diverge in relation to tech-
nical procedures, which may or may not make a
unique contribution to outcome. Two examples
are telephone coaching in DBT and exploration
of the past in schema-focused therapy.
DBT therapists carry a pager to be available
by phone to “coach” patients, who are encour-
aged to call when feeling emotionally dysregu-
lated and about to carry out self-harm. (How-
ever, they may have to wait for a return call
after leaving a message on a machine.) Carrying
a pager is a burdensome expectation for thera-
pists, whose work is demanding enough as it is
and who need to protect an outside life to “re-
charge” their own psyche. Moreover, there is no
evidence that contact outside scheduled ses-
sions makes a difference in outcome, given that
the procedure is embedded in a complex treat-
ment package. Only a dismantling strategy
(Wampold, 1997) could determine which com-
ponents of DBT are necessary and which are
dispensable.
Giving time and attention to exploring child-
hood events has always been a central differ-
ence between CBT and psychodynamic therapy,
and doing so is specifically recommended in the
hybrid model of SFT (Arntz, 2012). Most ther-
apies take a compromise position. In DBT,
Linehan (1993) has suggested (but not tested)
continuation of therapy beyond a year to deal
with posttraumatic symptoms. MBT, although
developed by two psychoanalysts, considers
early adversity in the context of misreading
social cues. TFP assumes that transference dis-
tortions in therapy are rooted in earlier life
events but focuses on the here-and-now. In con-
trast, SFT identifies “schemas” based on child-
hood experiences and recommends detailed ex-
ploration to modify them. But while early
adversities are common in BPD patients (Paris,
2008), there could be disadvantages in focusing
on the past in patients who have so many prob-
lems in the present. There is no evidence that
dealing with problematic schemas has a specific
effect, or that examining childhood experiences
in BPD makes any difference in outcome. Ther-
apists should always validate painful feelings
about the past, but need not necessarily make
them their main focus.
In summary, there is no evidence that specific
techniques make a difference in treatment out-
come among BPD patients. Comparative trials
do not demonstrate differences, particularly
when both arms are structured. Thus, research
has not supported the idea that technical proce-
dures or theoretical principles lead to specific
therapeutic effects in BPD. Rather, patients ben-
efit from coherent and well-structured methods
that can involve different techniques and differ-
ent theories (Gunderson & Links, 2008). At-
tachment to a single approach may also prevent
therapists from taking unique characteristics of
patients into account (Livesley, 2012).
 PSYCHOTHERAPY INTEGRATION AND BPD
Treating BPD in the Light of
Psychotherapy Integration
The movement for psychotherapy integration
(Norcross & Goldfried, 2005) takes a skeptical
view of the uniqueness of specific theories or
specific methods. Integrated therapy is much
more consistent with what research shows about
how treatment works, which is that common
factors play the most crucial role (Wampold,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
2001). Patients of all kinds do best when treat-
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ment is based on a clear conceptual model,
when there is a strong working alliance, when
therapists provide empathy and validation, and
when the emphasis is on problem-solving in the
present (Castonguay & Beutler, 2006). The
most effective therapy would be one that opti-
mizes all these ingredients. This principle has
also been the subject of journal articles promot-
ing an integrated approach to the treatment of
personality disorder (Dimaggio & Livesley,
2012; Nelson, Beutler, & Castonguay, 2012).
Developing a common-factors model could
be particularly important for the clinical chal-
lenges presented by BPD. It is time to drop all
the acronym-based therapies and develop a
practical model that clinicians can use without
undergoing extensive training. Given the ab-
sence of differences in comparative trials, doing
so could make the treatment of BPD more evi-
dence-based and more efficacious.
Psychotherapy integration has been widely
supported by comparative trials in common
mental disorders, such as depression, in which
differences between methods are not found (El-
kin et al., 1989). But it has not been applied
consistently to the treatment of BPD. Weinberg,
Ronningstam, Goldblatt, Schechter, and Malts-
berger (2011) have described common factors
that can be scored using a standardized scale. A
clear treatment framework, attention to affect, a
focus on treatment relationship, an active ther-
apist, as well as exploratory and change-
oriented interventions characterized all meth-
ods. This conclusion is consistent with the
psychotherapy integration literature as a whole.
Livesley’s (2012) recommendations follow
similar guidelines. Based on a general theory of
personality disorder treatment, one can derive
five general principles— establishing a basic
frame, maintaining a collaborative treatment al-
liance, maintaining a consistent treatment pro-
cess, building motivation for change, and pro-
17
moting self-reflection—as well as five specific
goals— ensuring safety; containing symptoms,
emotions, and impulses; regulating and control-
ling emotions and impulses; changing maladap-
tive behavior and interpersonal patterns; and
integrating a more adaptive self-structure.
These principles parallel the psychotherapy re-
search literature, maximizing common factors
(Wampold, 2001). They also resemble DBT,
without its more idiosyncratic elements. Acro-
nym-based therapies are usually better than
TAU because they are more structured, but cli-
nicians do not have to adopt them wholesale. It
makes more sense to include their most useful
elements and adapt them to one’s existing mode
of clinical practice.
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Received April 24, 2013
Revision received December 7, 2013
Accepted March 19, 2014 䡲