It is, of course, the more difficult patients who test our skills and who remind us of the importance of having a clinical formulation, of having a direction for our work with a patient, and of being thoughtful about our therapeutic technique. For this reason the APA's Treatment Guideline for Patients With Borderline Personality Disorder (8) spells out both the tasks of the patient and the tasks of the therapist. The tasks of the patient include self-reports of important issues, inner thoughts, dysfunctional behavior, and anticipated behavior. The clinician's role includes the provision of understanding, consistency, and empathic feedback and arranging a clear plan for the time and place for meetings and for handling emergencies. All of this may seem obvious, but it is a useful framework to have in mind to help you "keep your head" when, during the vagaries of transference and the eruption of countertransference, "all about you are losing theirs." The guideline also remarks on the importance of making treatment goals explicit—for example, symptom reduction, improved relationships, and improved performance in the workplace. The development of a therapeutic alliance and treatment framework is the foundation of the therapeutic work. However—and this is a big however—as I say to beginning residents, "These are the goals. This is what you, the therapist, need to know and remember that you are working to accomplish." With these patients, achieving a therapeutic alliance, a treatment framework, and a mutual understanding of the direction for change may proceed in fits of starts and stops, but it is important for the clinician to constantly have the overall framework in mind.
The same holds true for psychotherapeutic technique. Two types of psychotherapy—psychoanalytic psychodynamic psychotherapy and dialectic cognitive-behavioral psychotherapy—have proven efficacy in the treatment of borderline personality disorder in randomized controlled trials (9,10,11). Which do you use, when, and for whom? Borderline personality disorder is such a multifaceted illness that there is not one clear-cut answer. Each type of psychotherapy may be of value at different phases of the illness. Psychoanalytic interpretations that are given to provide normalization and understanding of a frightening reaction, in the context of supportive psychotherapy, can provide a grounding reality in an otherwise chaotic emotional state. Cognitive-behavioral techniques may be used to interrupt destructive behaviors. The encouragement in dialectical behavior therapy to be in touch with the feeling that provokes the impulse to cut or to engage in other self-harming behaviors may alert a patient, for the first time in his or her life, to the feelings behind the behavior. A psychodynamic exploration may provide insight into the previously unexplained origin of such a feeling, but it will be the clinician's imperative to appreciate when such an exploration is potentially reparative and when it will, instead, cause the patient to become regressively vulnerable.