Borderline Personality is a Trauma-Based Disorder

By Frank J. Schwoeri PhD

Much evidence now supports the understanding of Borderline  Personality Disorder as a problem rooted in early development in which early misattuned/underresponsive or frightening caregiver interactions are internalized as disorganized attachment, followed by later relational trauma such as neglect or abuse (physical, sexual, emotional). In other words, “The issue isn’t what’s wrong with you; the issue is what happened to you”. The cause is relational/interpersonal, not biological or innate to the individual in the sense of a defect. 

The often intense and chaotic relationship difficulties which are a defining feature of the disorder are a direct effect of abusive or neglectful early caregiving interactions on the development of the self. Typically, a part of the self tries to remain attached to the needed but abusive parent, while another part of the self is reactively angry, avoidant, and fearful of attachment, and these two contradictory relational styles get carried forward into current relationships. Current disappointments by others may be interpreted as unbearable betrayals, fueling anger, and  alternating with clinging and fears of abandonment. The individual is rarely consciously aware of the early roots of their difficulties, and the way that their conflicted behaviors may bring about the feared, but expected, outcomes: “ I always get involved with guys who hurt and disappointment me. Guys are all the same”. 

Early relational traumas also cause problems in managing and tolerating feelings and emotions. Capacities for emotion regulation are not hard-wired at birth, but only develop in the context of a secure attachment relationship with a caregiver who is responsive, available, and attuned to the child’s needs. When this doesn’t happen, the person is left with longstanding difficulties in handling emotions. This can lead to other kinds of partially successful attempts to deal with emotions that feel unmanageable, with risky behaviors such as drugs or alcohol, self-cutting, eating disorders or compulsive sex, often enacted in a dissociated state of mind.  

Individual psychotherapy is the main treatment for BPD, which focuses on relationships and helping with emotion regulation. Early phases of therapy usually work on establishing safety and stability and reducing risky behaviors by finding less dangerous ways to manage feelings. Later phases of therapy are about understanding oneself as a survivor and all that that means, and establishing new and more stable ways of living in relationships. Medications such as antidepressants and mood stabilizers can sometimes help, as well as psychoeducation methods such as Dialectical Behavior Therapy (DBT), but these are helpful adjuncts to the main treatment, individual relational dynamic psychotherapy. As trauma expert Dr. Christine Courtois has written, one needs “relational treatment for relational injury”.

Individual psychotherapy for persons with Borderline Personality usually needs to be fairly intensive (at least once weekly, twice-weekly is often optimal) and fairly long-term (more than a year). Psychotherapy outcome studies show a strong “dose-response relationship”; better outcomes are clearly associated with longer-term therapies. One result of successful treatment is reduced need for acute psychiatric hospitalizations. Many patients are never again hospitalized, whereas it formerly was a frequent occurrence. 

 In summary, then, Borderline Personality Disorder is best thought of as a kind of chronic Post-Traumatic Stress Disorder (PTSD), with roots in early relational trauma, best treated with individual long-term psychotherapy. Significant personal growth, improved relationships and emotional stability can be the result.