Borderline Personality Disorder, Revisited

In 1967, a 38-year-old psychoanalyst by the name of Otto Kernberg penned one of the first major assessments of borderline personality disorder (BPD). The piece, which appeared in the Journal of the American Psychoanalytic Association, proposed a theory that would change the course of BPD research forever—and likely shock most therapists today.

“These patients,” he wrote, “must be considered to occupy a borderline area between neurosis and psychosis.” Kernberg went on to describe their “chaotic behavior,” “regression to primitive cognitive structures,” and “consistent devaluation of all human help received.”

Of course, Kernberg was a product of his time. The BPD diagnosis was still in its infancy, and wouldn’t be added to the DSM-III for another 13 years. Until he began shining a light on the relational and attachment aspects of BPD, most clinicians had been referring to it by a completely different name: “pseudoneurotic schizophrenia.”

But even after BPD gained mainstream attention, Kernberg didn’t hold back. Clients with BPD, he wrote in his 1992 book Aggression in Personality Disorders and Perversions, display “an unconscious sense of guilt, the need to destroy what is received from the therapist because of unconscious envy of him,” as well as “the need to destroy the therapist as a good object.”

It’s easy enough to cast stones at Kernberg for his early takes on BPD (which, to be clear, have aged like milk), but consciously or unconsciously, many modern-day clinicians regard BPD with a suspicion or fear that’s not all that dissimilar. How many therapists can confidently say that the prospect of working with a client with borderline traits—the emotional intensity, rapid mood shifts, rejection sensitivity, relationship instability, impulsivity, paranoia, dissociation, and self-harm, to name a few—doesn’t make their stomach sink?

Sure enough, numerous reports show that therapists actively avoid working with BPD, seeing it as much harder to treat than other diagnoses. A 2015 study published in BMC Psychiatry surveying 710 psychiatric hospital staff members found that BPD patients are seen as more difficult and less deserving of hospitalization than those with depression. And a 2022 systematic review of 37 studies, encompassing more than 8,000 clinicians, found that negative attitudes toward BPD are widespread in the mental health field, with strong evidence of stigma, pessimism about outcomes, and emotional distancing. Descriptions like “difficult,” “manipulative,” and “emotionally draining” are common among those surveyed.

But stigma isn’t the only factor thinning the pool of willing clinicians. BPD treatment is highly specialized due to the rarity of the diagnosis: less than three percent of the U.S. population meets the criteria. And individuals with BPD commonly suffer from co-occurring conditions that may divert the treatment focus or contribute to the client’s perceived difficulty, including major depressive disorder, bipolar disorder, PTSD, anxiety disorders, eating disorders, ADHD, and substance use disorders.

Meanwhile, formal, advanced training in Dialectical Behavioral Therapy (DBT)—widely considered the frontline treatment for BPD—is not only rare, with between four and eight percent of the global therapist population trained in it, but time-consuming and expensive. Trainings associated with DBT developer Marsha Linehan and the Behavioral Tech Institute (the world’s leading organization of DBT trainers) typically cost over $15,000 per treatment team and require 60 hours of instruction, usually spread out over several months. To boot, most insurance companies don’t fund full DBT programs.

The state of BPD treatment is bleak, to say the least. Not only is stigma rampant, dissuading many therapists from working with clients with BPD in the first place, but many of those who would step up lack the time, money, or skills to capably do so. Which brings us to a sobering reality: most of what your average clinician has heard about BPD—how it functions and how to treat it—is probably wrong.

The Trauma Connection

Child psychiatrist and neuroscientist Bruce Perry, who specializes in treating the impact of trauma, abuse, and neglect in children, still remembers how his colleagues used the BPD label back when he was a new clinician, almost 30 years ago.

“Clinicians were throwing the BPD label around to describe patients they found difficult,” he says, “patients who one day would think you were the greatest doctor in the world and the next would think you were trying to kill them. You’d hear their doctors say things in passing like, ‘Oh, they’re just borderline.’”

But in the early 1990s, Perry and his colleagues at Yale had found something interesting: similar biomarkers between BPD and PTSD.

“We’d been looking at the development of PTSD in adults, and we started to notice that a lot of the physiological reactivity presentations were very similar in people who had BPD,” he explains. “When we started to look at the history of developmental trauma in that group, it was very, very high. And when we looked at the nature of the developmental trauma, it was frequently relational.”

Perry and his team at the Neurosequential Network, an interdisciplinary clinical community, continued to tug at this thread, eventually concluding that there was, in fact, a relationship between trauma and BPD traits. Just as someone with PTSD from a combat injury or car crash might be triggered by loud noises, Perry says individuals with “relational sensitivity,” where early life experiences were characterized by “unpredictability, inconsistency, or overt humiliation or shaming,” are triggered by close relationships, where the threat of betrayal feels significant. This includes the therapeutic relationship.

“One of the things you hear about when you’re working with someone who has ‘borderline features,’” Perry says, “is that they have this exquisite sensitivity and interpretation of interactive cues. They essentially grew up with a worldview that made intimacy feel overwhelming and even threatening. So it’s understandable that when they do get into relationships with people, they want to have absolute control over the process.”

But how should therapists respond to this behavior? Perry again uses a developmental lens. “In normal childhood development, children are gradually trying on independence—how it works, how it fits—and ultimately develop a sense of mastery and comfort as they separate from the caregiver.” But the therapeutic process with someone with BPD, he says, is the complete opposite. “They feel safest away from people,” he explains, “and as they approach intimacy, they get more dysregulated. So what you need to do is be present, patient, and parallel. You need to give the client control over the process of emotional intimacy in therapy”—what he calls “a ‘desensitizing’ process that slowly builds in the capacity to be comfortable in relational proximity.”

So what does this mean, practically speaking? “Rather than having a conventional face to face with the client, you’d do something regulating in parallel, like walk-and-talk therapy, or working on a piece of art together. There are lots of different ways to do this, but it all involves repetitive, rhythmic regulation paired with relational intimacy and proximity.”

The therapist should prioritize transparency as well, Perry adds. “When our team works with clients, we like to talk about what we think is going on with them, and tell them why we’re doing something. It’s very revealing to have them say, ‘Well that’s not exactly it, it’s more like this,’ and then we get more clarity about the things that get them stirred up or overwhelmed.” Essentially, he says, the client fine-tunes and guides the treatment, becoming a co-therapist in a collaborative process.

“When a relationship is where the injury took place, a relationship is what you need in order to heal,” he explains. “You have to pay a lot of attention to the circumstances under which you begin, grow, and maintain the relationship, but it works. It’s easier for people to do just about anything if they feel safe and in control.”

BPD By Another Name

Renowned trauma expert Janina Fisher has a more pointed name for the type of relational injury Perry is describing: attachment trauma.

“All of the symptoms make sense as those of a traumatic attachment disorder,” she says. “The client’s preoccupation with separation and abandonment is a traumatic attachment response. So is their anger when somebody fails them.” Concerningly, Fisher says the trauma connection is lost on most clinicians.

“The first research that showed a connection between borderline personality disorder and trauma was published in 1990, and then completely ignored,” she says. “Even Otto Kernberg, the godfather of ideas about BPD being manipulation and attention-seeking, said that BPD was often associated with a history of severe trauma, including attachment trauma.”

So what does a trauma-informed approach to BPD look like? Fisher says it starts with a little humanizing. “These clients don’t get diagnosed borderline by me,” she explains. “I diagnose them as traumatized. And when the symptoms are treated not as bad behavior, but as the result of being triggered and having survival defenses constantly activated, clients do much better.”

Fisher’s treatment approach diverges from Perry’s in a notable way: rather than lean into the relational component of the work, she recommends treating BPD using a modality that’s not relational, lest it trigger the client’s desire for attachment or fear of separation, which in turn can stir up anger and self-destructive behavior. She says it’s the non-relational style of DBT, heavily comprised of skill-building techniques, that explains why it works so well for these clients. But Fisher uses her own modality when it comes to treating BPD: trauma-informed stabilization therapy, or TIST, a model that asks the client to notice, with curiosity, their feelings, impulses, and beliefs as expressions of inner parts.

“Typically the part that’s afraid of abandonment and wants desperately to be loved is a very young part,” she says. “The angry part that says ‘you’re screwing this up, you’re doing a terrible job’ tends to be more of an adolescent part. What changes the relationship to the feelings and impulses is to notice them rather than react to them, to see them as young and traumatized—and the prognosis for someone treated this way is very good.”

“The Wild Group”

DBT expert Eboni Webb summarizes her introduction to BPD in just a few words. “My first exposure to it was the languaging that my grad school professor used about the cluster of diagnoses where borderline is, referred to as ‘the wild group.’ And that was it.”

As Webb continued her clinical career, working in various community mental health settings, she found that even fellow DBT therapists were unlikely to take on clients with BPD. “They’d get a sense of what was going on and refer out,” she says. “Or they’d get burnt out and wouldn’t have supervision or consultation, so they’d terminate treatment”—which, Webb adds, often communicated to the client that they were unfit for therapy.

Eventually, Webb came across the work of Janina Fisher and Bruce Perry, which she says left an indelible mark on her clinical approach and solidified the BPD-trauma connection. “I think all personality disorders are rooted in relational developmental trauma,” she says. “The primary defense for the borderline client is the attachment cry—the hyperaroused response to abandonment that Fisher talks about—which is a survival defense. That intensity they carry of, Help me or I won’t be able to survive without you can feel so overwhelming, so I knew I’d need the tools to address that.”

The result was what Webb refers to as “embodied DBT”—a blend of neuroscience, trauma theory, and sensorimotor psychotherapy (“the special sauce,” as she calls it). She says one of the hallmarks of her approach is helping clients with BPD rewrite their story, which begins with explicitly naming the attachment trauma.

“Many of them don’t have an awareness of that,” she explains. “I’ll say, ‘You didn’t come in with a blank slate, but you did come in with an open map, and your experiences and your parents and the social environment laid out the territory. We aren’t going to question the strangeness of this map; what we’re learning is this is what it means to be in the world.”

The response, Webb says, is often a kind of softening. “They’ll tell me that nobody has ever said something like this, that it makes so much sense.”

The goal, she adds, is to help her clients finally develop some grace for wherever they are. “I want to lift the inner critic out of them,” she explains. “We know that what drives the success of treatment is having a coherent understanding of your story and how treatment will actually help you. That goes a lot further than just saying, ‘You have borderline personality disorder,’ which doesn’t really tell the client a lot about what’s going on.”

The Diagnosis Problem

In their criticisms of the prevailing thinking around BPD, Perry, Fisher, and Webb have all touched on perhaps its biggest problem: diagnostic bias. It’s not just that the BPD diagnosis is seemingly associated with every mental health issue under the sun—or that it’s sloppily used as a substitute for clients branded as difficult or resistant. Research shows it’s disproportionately applied to women, minoritized populations, and neurodivergent individuals.

In clinical settings, women are two to three times more likely to be diagnosed with BPD than men. “Women will get thrown into a lot of anxiety-based disorders without looking at the trauma that’s informing the presentation,” Webb says, “so there’s a disproportionate number of women who get the BPD diagnosis. We know 80 percent of them actually have childhood trauma, so is their response pathological, or is it the wisdom of trauma survival?”

Meanwhile, transgender and gender-diverse patients are more likely to be diagnosed with BPD than cisgender patients, according to a 2024 report published in the journal Transgender Health, namely due to pathologizing experiences of rejection and discrimination.

And BPD is also the most common misdiagnosis assigned to Autistic people, according to a 2026 report conducted by researchers at the UK’s Department of Population Health and Policy, namely due to overlapping symptoms of emotional dysregulation, social difficulties, sensory overload, meltdowns, and self-harm.

“I’ve frequently observed Autistic patients, mostly women, misdiagnosed with BPD,” says psychiatric nurse practitioner Lindsey Burd, who has specializations in both DBT and autism spectrum disorders. “They may have difficulty maintaining interpersonal relationships, feel chronically misunderstood, or appear emotionally unstable due to rejection sensitivity dysphoria and meltdowns. But taking a deeper look at lifelong patterns like communication difficulties, sensory sensitivities, intense and deep special interests, social masking, social exhaustion, and burnout can help elucidate if autism is the more accurate diagnosis.”

Clinical social worker and autism specialist Kory Andreas agrees that BPD misdiagnosis is a problem in the neurodivergent community. “High-masking Autistic adults are frequently mislabeled as BPD when assessed using behavioral observation alone,” she says. “Emotional dysregulation may look like a personality trait in these clients, but it’s actually a nervous system response. When Autistic clients encounter predictability, proper accommodations, and a clinician who can support their unique nervous system needs, the distress that gets misread as behavioral problems often shifts. That’s not what we see in BPD.”

A Cognitive Reframe

Improving BPD treatment isn’t just a matter of rethinking our interventions. Some clinicians say it needs to start with reconceptualizing the problem we’re treating, that the term borderline personality disorder is problematic in itself.

“I’ve long believed that BPD isn’t a personality disorder,” Fisher says. “It’s a trauma-related disorder. But all the research showing that hasn’t budged the way it’s treated a single bit. Until someone with authority definitively says attention-seeking and manipulation aren’t the cause of so-called ‘borderline’ behavior, that’s not going to change.”

Perry agrees that the name is misplaced. “I’m not a fan of any DSM labels,” he says. “I think we have a real problem with how we understand and categorize people when it comes to their mental health struggles. That’s why we think about our work the way we do. We’ll say to clients, ‘Listen, you’ve got this sensitivity to relational intimacy,’ and we’ll talk about where we think it comes from—and we’ll make a correction if they think we’re off.”

Perry, Fisher, and Webb all have novel and effective approaches to treating BPD. But they’re also outliers fighting an uphill battle against stigma, misunderstanding, and outdated treatment approaches. Even so, there’s room for optimism. Slowly, more clinicians seem to be waking up to the reality that BPD isn’t as scary as we’ve been told. Even Otto Kernberg made an about-face as he approached retirement.

“We have made tremendous strides in only a few decades,” he wrote in 2009 in the American Journal of Psychiatry, taking BPD “from a pejorative label for disliked patients to a carefully defined diagnostic category; from the subject of almost no systematic study to one of the most intensively researched personality disorders, and perhaps most important, from a hopeless prognosis to a hopeful one.”

With seemingly little regard for his earlier writings, he added a caveat: “There is also the residue of professional bias against the diagnosis and, unfortunately, stigma for those who suffer from it, that has hampered progress in the field.”

Better late than never, Otto.

In addition to a growing body of research on BPD, powerful organizations are not only calling attention to best practices, but countering old, pessimistic attitudes about the condition. In 2023, the American Psychiatric Association published Practice Guideline for the Treatment of Patients With Borderline Personality Disorder, which not only covers evidence-based psychotherapies, but emphasizes the need to address misconceptions that have contributed to stigma and barriers to care. This marks the first major revision of these guidelines in over two decades.

Individual therapists can do their part, too. Fisher says it starts with taking an honest look at your emotional response to BPD and how you conceptualize it. “If I sent out an email to my closest colleagues today asking if they’d be willing to take such and such client who had BPD, I’d get nothing but no. But if I said I wanted to refer a 30-year-old woman with a traumatic attachment disorder, I’d get lots of yes. Think of them as traumatized, not as personality disordered,” she says.

Yes, Perry acknowledges, BPD is one of the harder issues to work with. But if you find yourself sweating in session with a client who fits the diagnosis, he says one of the most powerful things you can do requires no advanced training, money, or time: just be yourself.

“Positive transference followed by negative transference can make you twist or shift in the way you behave,” he says. “Even experienced clinicians find it difficult. But the more stable you stay as yourself—the more consistent and present and decent you are—the easier it is for the client to organize around you.”

Finally, when in doubt, remember your guiding principles, Webb adds. “What’s helped me immensely isn’t just thinking about borderline personality as an attachment disorder,” she says. “It’s working with a lens of care and compassion.”