Learning Objectives

After reading this article, you should be able to:

1. Describe and interpret the essential qualities necessary for patients to benefit from long-term psychotherapy in the context of BPD.
2. Develop and demonstrate strategies to navigate patient regressions, resistance, and fears while promoting emotional growth and self-discovery in therapy for BPD.

CPTR: People with severe personality disorders are notoriously difficult to treat. Can they benefit from psychotherapy?

Dr. Buie: Nearly all seriously ill patients can benefit from some form of psychotherapy. Supportive psychotherapy, group skills training, and behavioral treatments can be helpful in almost any illness, including psychotic disorders (Markowitz JC, Am J Psychother 2022;75(3):122-128). Patients with severe personality disorders are not “psychotic,” but their characteristic styles of behavior often alienate other people and make them very unhappy. These patients can be very difficult to work with, but some of them can benefit from a deep connection with a therapist over many years, as they learn new ways of seeing themselves and the world. With the right kind of treatment, even these severely ill patients can come to lead full, creative, satisfying lives, managing new stresses with skill and stability (Stone MH, 2016;44(3):449-474).

CPTR: How do you know if someone can make use of that kind of long-term therapeutic relationship?

Dr. Buie: In my experience, there are three qualities people need to benefit from this kind of depth therapy. First, people must love more than they hate. We all hate the people we love from time to time, and that can create a painful conflict. But if overall, hate outweighs love, the treatment relationship will be destroyed, and sometimes the patient, too. Second, they must care about reality, about truth for its own sake. That lets them see the truth that we are real, that we care, and that we want to help them discover themselves. With our help, they can gradually accept the reality of their own good qualities—which often include intelligence, kindness, and love. Finally, they have to be involved in the world in some way that matters to them, that can give their life stability—such as a child, a profession, or a passion for social change.

CPTR: What do we need to become healthy adults?

Dr. Buie: We cannot develop by ourselves; we always need others. What we need most from our parents is to be seen and loved for who we truly are. We need to matter to our parents—not for our accomplishments, but for our true selves. Sadly, often because of deficits in their own upbringing, parents use their children to fulfill their own unmet needs. Children raised this way can have a great deal of trouble feeling that they matter just the way they are. Even as adults, they are vulnerable to feeling desperately alone and worthless, even to the terrifying extent of feeling they are ceasing to exist. People like this can be very accomplished, even loved, but be unable to experience themselves as others see them. A therapist can appreciate the qualities that constitute their humanity and uniqueness, which gradually helps them own and take possession of those qualities.

CPTR: What else do people need to thrive?

Dr. Buie: Well, life throws us curve balls, and we all need to be able to soothe ourselves when we’re in distress. If you have a parent or other caregiver who gently holds and soothes you through childhood’s normal hurts, you will begin to be able to do this for yourself and feel safe enough to let others into your life who can help you. If instead you were not seen for yourself, or were seen as bad—or if you were beaten or sexually abused, or grew up in a war zone—you need to learn in therapy what it feels like to be held and soothed. 

CPTR: Why is that so important?

Dr. Buie: Without the capacity to soothe oneself, there is a terrible aloneness. It is different from loneliness. When you’re lonely, you can still feel the presence of the people you miss. When you’re alone, you are left in a dark, cold, frightening place. This can be so terrifying that suicide seems to be the only way out. Therapists can begin by providing the long-absent holding and soothing, helping patients eventually learn to provide it for themselves, and find it in relationships with others in their lives.

CPTR: We also have to believe ourselves to be worthy, to have a reasonable amount of self-esteem.

Dr. Buie: Indeed. If, as children, we’re surrounded by disapproval and devaluation, we’re likely to grow up loathing our shameful selves (Li W et al, BMC Psychiatry 2023;23(1):179). Because this is what we’re used to, and we believe it to be true, we hold on to the energy of the people who put us down, even when they’re no longer alive. We find new people to treat us poorly. Some people are lucky—they find a mentor or fall in love with someone who sees them for who they really are and treats them well. For many people, therapy is where they are first seen as valuable. That can be anxiety-provoking for people who are used to thinking only ill of themselves, because it is unfamiliar. It’s an uneasy place to be.

CPTR: Some patients have compassion toward others but not themselves. How can they learn to love themselves?

Dr. Buie: People develop the ability to love themselves by growing up well-loved. Parents are key, of course, but sometimes a loving teacher or minister or coach can make a difference. When people don’t love themselves, it’s really important that they feel the therapist’s love for them. That’s the first step in learning to love themselves. Love has gotten a bad rap in the psychoanalytic literature—there’s a confusion between love and sex, and the fear that it’s a slippery slope from one to the other in the treatment room. But therapists who love their patients in their hearts—agape, not eros—are not the ones who transgress our tremendously important sexual boundaries. Love is what lets people change. In fact, Freud himself said in a letter to Carl Jung that analytic treatment is essentially a cure through love (Freud S, 1906). In a therapeutic context, love means, “You really matter to me. Your gaining freedom from pain matters to me.” And the patient can tell.

CPTR: It makes sense that people who are deeply deprived can become deeply troubled. Why are they so hard to treat?

Dr. Buie: When people have been deeply damaged in their earliest important relationships, they are often very resistant to letting anyone help, or even to letting others make contact with who they really are (McWilliams N. Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process. 2^nd ed. Guilford; 2011.). They can put up walls because it’s so frightening even to be cared about. And they need a great deal from a therapist. We’re bound to fail them at some point; as therapists, we can never fulfill all the needs of our patients. When people are wounded or neglected at a young age, our inability to fully satisfy their needs can stir aggression, often expressed in destructive ways. These are some of the patients whose words hurt us, who become the thorns in the side of clinic staff.

CPTR: These patients seem very vulnerable to the vagaries of fortune.

Dr. Buie: People who have been damaged are not resilient. Often there is one thing in their lives that holds them together—a job, a spouse, a religion. If something goes wrong—a layoff, a divorce, a crisis of faith—these vulnerable people can collapse inside. They can find it intolerable to be alive. They can regress developmentally to the point where they genuinely need you in order to stay alive, or to stay sane.

CPTR: What other complications do you encounter in long-term therapy?

Dr. Buie: It’s always hard for people to change. There’s a comfort in functioning the way you always have. You know yourself and recognize yourself. You feel familiar with yourself. As people change, they can get frightened about not being who they were. They don’t recognize themselves. Their very sense of existence is in question. As one patient put it, “If I change, I won’t be me anymore!” Sometimes this causes patients to regress, even to become suicidal. 

CPTR: Can you share an example?

Dr. Buie: I once had a patient who made a great deal of progress internally and began to succeed in the world. But each time she took a step forward, she got scared; it was frightening to experience herself as someone she had never been before, and she returned to being as suicidal as she had ever been. She’d recover and get a little further, but then get scared and race back to where she came from. Eventually–and it took a long time–she stopped regressing. When she was well, she told me it had been like walking across a narrow footbridge. She would go so far, the bridge would begin shaking, and she would get scared and run back to the starting bank. Eventually, she said, she got herself to the other side, finally feeling that the self she had become was truly and comfortably her real self. She was able to experience the truth of herself, which, paradoxically, had always been there. 

CPTR: It seems critical that patients know you care. How can you help them remember that when you’re not together in the room? 

Dr. Buie: Some therapists keep a dish of stones or beads on their desk. Patients can take one and keep it in their pocket to remind themselves that you’re real, you care, and they’ll see you again soon. Maybe you and the patient can decide together on a genuinely encouraging message that you can record on their voicemail. They can play it back when they need to remind themselves of your reality. There are many creative ways we can help people use us to build the scaffolding of personhood.

CPTR: What if the therapist gets angry at patients who act out?

Dr. Buie: Therapists have to be able to forgive themselves. You will make mistakes. Patients will nail you on them. It’s important to be able to empathize, to apologize, and to recognize that patients are sometimes showing you just how bad they feel by making you feel that bad yourself. We have to be able to tolerate a lot of uncertainty and aggression when working with patients like these. We need the confidence to set boundaries to protect our emotional and physical health, as well as our financial well-being. We can be mad, but if we stop caring about a patient, we present a danger to the patient’s life, and it’s time for some consultation. Some therapists are not cut out for this kind of work and shouldn’t be ashamed to refer patients with behaviors like these to therapists with an interest in treating them. But if you’re motivated to help people in this situation, you can grow and learn along with them.

CPTR: Does personal therapy—for the therapist—have a role here?

Dr. Buie: Personal psychodynamic psychotherapy or analysis is critical to understanding your own reactions. It’s especially important to know your own hot buttons and to refrain from retaliating when patients act out. And there’s something we can learn from these treatments. As we recognize the humanity in our most difficult patients, we can also recognize aspects of these patients in ourselves and everyone around us. I’ll leave the final word to Harry Stack Sullivan. “We are all much more simply human than otherwise.”

CPTR: Thank you for your time, Dr. Buie.

*Editor’s Note: This interview originally appeared in The Carlat Psychiatry Report on January 22, 2022, and has since been updated. We republish it here following the passing of Dr. Buie on November 8, 2022. Dr. Zuckerman edited the article before publication.

References in order of appearance in this article

Markowitz JC. Supportive Evidence: Brief Supportive Psychotherapy as Active Control and Clinical Intervention. Am J Psychother. 2022;75(3):122-128. Doi:10.1176/appi.psychotherapy.2021.20210041

Stone MH. Long-Term Course of Borderline Personality Disorder. Psychodyn Psychiatry. 2016;44(3):449-474. Doi:10.1521/pdps.2016.44.3.449 

Li W, Lai W, Guo L, et al. Childhood maltreatment and subsequent depressive symptoms: a prospective study of the sequential mediating role of self-esteem and internalizing/externalizing problems. BMC Psychiatry. 2023;23(1):179. Published 2023 Mar 20. doi:10.1186/s12888-023-04654-7

McWilliams N. Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process. 2^nd ed. Guilford; 2011.