Borderline personality disorder (BPD) is a severe but not hopeless condition. Gradual improvement over time can be expected (Paris, 2003), and active psychotherapeutic treatment may be effective (Bateman and Fonagy, 2004; Giesen-Bloo et al., 2006; Linehan, 1993; Perry et al., 1999). However, not all patients respond well: some do not improve at all while others become very self-destructive, drop out of therapy, or worsen. This chapter will focus on treatment strategies and the management of severe, refractory patients.

The refractory borderline patient

Every treatment setting has its own difficult, “refractory” borderline patients: they do not respond well to any treatment, have had multiple therapists, multiple suicide attempts, severely harm themselves, and make frequent use of emergency services. Most are unemployed, and have no stable support system or are still dependent on exhausted parents. Some are left without any treatment at all. Several factors contribute to this unfortunate outcome.

First, BPD in itself is a severe, to some extent chronic, disorder (Paris, 2003). Though recent longitudinal studies on personality disorders show that borderline patients improve on a psychopathological level, their functional impairment improves much less (Skodol et al., 2005). Moreover, since personality psychopathology usually begins in early adulthood or adolescence, the risks of severe, accumulating derailments in psychosocial functioning are substantial: “The possibility of chronic, residual impairment from which a person never completely recovers is real” (Skodol et al., 2005). Psychopathological improvement is less for what seem core dimensions of BPD: affective instability and anger.