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 Ideas about the treatment of PD are changing with the development of new approaches, treatment outcome studies, and changing ideas about etiology. The evidence suggests that no single form of therapy is more effective than the rest. At the same time, traditional assumptions on which most treatments are based—that the disorder arises from psychosocial adversity—have been supplemented with an understanding of genetic influences and the complex interplay of genes and environment. These developments question the merits of relying on a specific school of therapy when treating PD. Rather, they point to the need for a more eclectic approach that delivers an integrated combination of pharmacologic and psychotherapeutic interventions from different schools (1). Although there is not enough information to construct evidence-based treatment, it is possible to construct a rational treatment framework based on empirical knowledge about the disorder and about treatment efficacy. Basic PrinciplesThe proposed framework comprises basic principles, strategies, and interventions (2). Principles specify how treatment is to be organized and conducted. Strategies translate principles into therapeutic actions, using a cluster of interventions that share a common objective. For example, the principle of optimizing the nonspecific component of therapy is implemented through such strategies as building a collaborative relationship and maintaining a consistent and validating treatment process. Interventions are the specific techniques used to effect change. They include medications and specific cognitive, behavioural, or psychodynamic techniques. This section considers some of the more important principles and offers a brief rationale for each. Comprehensive Treatment Requires a Combination of Interventions to Treat the Range of Psychopathology Typically Associated With PD Outcome studies suggest that psychodynamic and cognitive therapies are equally effective (3). This implies that, rather than viewing different treatments as competing, it may be more productive to adopt an eclectic approach that combines the most effective components of each—a suggestion consistent with the multidimensional nature of PD. Typical cases exhibit multiple problems that include symptoms, situational problems, emotion and impulse dysregulation, maladaptive traits, maladaptive interpersonal patterns, and a poorly developed self or identity. No single treatment can adequately address this diversity, and these problems are unlikely to respond equally to a given approach (4). Multiple Interventions Should Be Delivered in an Integrated and Coordinated Way An eclectic approach runs the risk of creating confusion about which intervention to use at a given moment. It may also encourage clinicians to change interventions frequently, leading to a chaotic treatment that mirrors rather than changes psychopathology. These eventualities may be mitigated by having a broad framework for coordinating interventions. Integration is also needed to help patients form a more coherent self and incorporate disconnected aspects of personality. Treatment Involves General Strategies to Manage and Treat Core Self- and Interpersonal Pathology and Specific Strategies to Treat Individual Differences in Problems and Psychopathology PD involves core problems (the defining features of PD) common to all cases, as well as specific features that vary across patients and forms of the disorder (for example, the different PDs defined in the DSM-IV) (5). Treatment can be similarly conceptualized. General strategies are used throughout treatment to address core pathology; they form the basic structure that integrates treatment. Specific interventions are added to this framework as required to treat specific problems. The core features of PD involve a poorly developed self-system or identity and chronic interpersonal problems (1). These features underlie most difficulties encountered in treating PD, such as establishing a collaborative relationship, boundary problems, chronic mistrust, and poor motivation. Given the importance of managing and treating core pathology, we need to consider the optimal stance to adopt for this purpose. The Most Appropriate Stance for Treating PD: Provide Support, Empathy, and Validation Although the stance is critical, empirical studies provide little guidance on the optimal approach. The principle proposed is consistent with other conceptions of an effective treatment relationship, such as mirroring (6), optimal responsiveness (7), empathic responding (8), and offering a holding and facilitating environment (9). This stance is adopted because it places minimal strain on the therapeutic alliance (10,11) and reduces the activation of reactive patterns in ways that threaten therapy. Treatment Should Maximize the Effects of Common Factors Evidence that psychotherapy outcome is similar across different therapies (12,13) suggests that treatment should seek to maximize the effects of common factors. These factors have a supportive component based on the therapeutic relationship and a technical component involving new learning experiences (14,15). Given the evidence that supportive interventions effectively achieve change (16,17), it seems that both core pathology and outcome studies point to both the importance of the nonspecific component of treatment and the importance of a supportive, collaborative, and empathic relationship. Treatment Progress Can Be Described as a Series of Phases Integration and coordination are also facilitated by conceptualizing treatment as a series of phases, each addressing different problems with different specific interventions (1). Five broad phases may be recognized. The first phase begins with crisis management, wherein the goal is to ensure the safety of the patient and others. This phase merges rapidly with containment, wherein the goal is to stabilize affects and impulses and restore behavioural control, largely through the use of general treatment strategies supplemented with medication as appropriate. The third stage, control and regulation, focuses on reducing symptoms and learning skills to self-manage affects and impulses. In this stage, general treatment strategies are supplemented with behavioural, cognitive, and pharmacologic interventions. As affect regulation improves, treatment gradually moves to an exploration and change phase with greater emphasis on analyzing maladaptive cognitions, dysfunctional interpersonal patterns, and such maladaptive traits as submissiveness or social avoidance. This typically requires a combination of cognitive, interpersonal, and psychodynamic interventions. The final phase, integration and synthesis, is primarily the work of long-term treatment. This involves the construction of a more adaptive self-system along with integrated representations of others, using more psychodynamic and constructionist techniques. Change Occurs Through a Series of Stages, and Interventions Should Be Appropriate to the Patient’s Stage of Change Changes in personality pathology can be described according to a 4-stage process based on descriptions of naturalistic changes in addictive behaviour (18–20). Change begins with problem recognition and developing a commitment to change—a crucial step. This is followed by exploration, which creates a greater understanding of a given problem and associated feelings and thoughts by examining the sequence of events leading to problem behaviour and the consequences of these behaviours. Exploration covers both historical factors and current cognitive and affective mechanisms that mediate maladaptive behaviour. The third stage, acquisition of alternatives, is essentially a problem-solving stage intended to identify new solutions for old problems. In the final stage, consolidation and generalization, new learning is strengthened and generalized to everyday situations. The Work of Therapy is Collaborative Description of Patient Problems and Psychopathology and Their Effect on the Patient’s Life and Relationships Conceptualizations of the work of therapy differ widely. Classical psychoanalysis emphasizes free association and a neutral therapist who clarifies, confronts, and interprets the patient’s associations. Cognitive therapy advocates collaborative empiricism and a Socratic exchange. Constructivism offers the metaphor of therapy as “conversational elaboration” (21). The treatment of PD requires an approach that facilitates therapeutic work while minimizing the activation of reactive tendencies that may obstruct treatment. This approach can be found in the concept of collaborative description (1), which combines the guided exploration approach of cognitive therapy with Ryle’s collaborative reformulation approach (8). Collaborative description seeks to increase patients’ self-knowledge by helping them to understand how repetitive patterns of action and experience contribute to their problems. As the process proceeds and obstacles to self-knowledge are overcome, new understanding emerges that encourages patients to contemplate new ways of behaving. Collaborative description is a guiding principle that helps therapists understand how to achieve the goals of therapy, address obstacles to treatment, and implement other strategies. The Features of PD Differ in Stability and Potential for Change The features of PD form an approximate hierarchy of stability. Most amenable to change are symptoms, followed by interpersonal patterns, maladaptive modes of thinking, characteristic expressions of traits (although not the underlying disposition), and some self-attitudes (especially, self-esteem). Finally, dispositional traits and core self- and interpersonal pathology are highly stable. This hierarchy suggests that treatment goals and intervention strategies should take into account the stability of personality and the anticipated duration of treatment. Thus the early stages of treatment and briefer treatments should focus on the more changeable components of PD. Traits appear to change little during the adult years (22), probably because they have a substantial heritable component and get consolidated by environmental factors and gene– environment interplay. For these reasons, major traits such as social withdrawal, affective lability, and sensation seeking are unlikely to be changed substantially by available interventions. Rather than seeking radical changes in trait structure, it seems more productive to help patients adapt to, and use, their basic characteristics. This may involve trying to attenuate more extreme forms of expression, promoting more adaptive expressions of basic traits, and helping patients to create a personal niche that allows them to express their traits adaptively. The Core Component of Treatment The general framework for managing core pathology consists of 1) the frame of therapy that provides a context for therapeutic activity, defines treatment boundaries, and creates conditions for change; and 2) the general therapeutic strategies that put into practice the generic component of treatment and support specific interventions. The Frame of TherapyThe frame is defined by the therapeutic stance discussed above, the treatment context, and the therapeutic contract. Although the treatment environment is often neglected, it has a substantial impact because, in most settings, patients have contact with several professionals, creating opportunities for confusion and inconsistency. These problems can only be avoided if all involved in a patient’s care follow a treatment plan. The contract “defines the purpose, format, terms, and limits of the enterprise” (23). Most therapists agree that a structured agreement is important when treating PD. It contributes to stability and helps to create a safe and consistent environment (24–26). Structure is provided by collaboratively working with the patient to define treatment goals and how they will be achieved. This understanding includes practical arrangements for therapy, including frequency and length of sessions and treatment duration. Discussing the therapeutic contract begins to forge the idea that treatment is a collaborative process for which patient and therapist share responsibility. General Therapeutic StrategiesGeneric interventions are tailored to the treatment of PD according to 4 strategies: build collaboration, maintain consistency, validate, and build motivation. Consistent use of these strategies creates a continuous corrective experience that helps to modify core pathology. Emphasizing collaboration, for example, helps to change distrust and modify problems of working cooperatively with others. Similarly, a consistent therapeutic relationship modifies expectations of unpredictability rooted in earlier dysfunctional relationships. Validation helps to correct self-invalidating ways of thinking that hinder the formation of a coherent self. Finally, efforts to build motivation help to modify passivity and beliefs of powerlessness and limited self-efficacy that contribute to low self-directedness. Strategy 1: Building and Maintaining a Collaborative Relationship Priority is given to the treatment alliance because it is supportive and predicts outcome. Contemporary formulations of the alliance emphasize collaboration. However, a collaborative relationship is not easily achieved—it is often a result, rather than a prerequisite, of treatment. For this reason, careful attention needs to be given to building and repairing the alliance. Two ideas are useful for this purpose: Luborsky’s 2-component description of the alliance (27) and Safran and Muran’s work on repairing ruptures to the alliance (28). Luborsky suggested that the alliance has a perceptual component, wherein patients see their therapist as helpful and themselves as accepting help, and a relationship component, in which patient and therapist work cooperatively to help the patient. The first component is based on the perceived credibility of both therapy and therapist. This is largely achieved through simple interventions that communicate hope, convey understanding and acceptance of the patient’s problems, support treatment goals, acknowledge areas of competence, and recognize progress toward attaining treatment goals. The relationship component is built with interventions that promote the patient’s participation in a joint search for understanding, help the patient learn skills for use outside treatment, encourage the patient–therapist bond, and emphasize the collaborative nature of treatment. Any deterioration in the alliance should be dealt with promptly but supportively. Safran and colleagues suggested a 4-stage process to repair alliance problems (29,30). First, changes in the alliance, such as decreased involvement or disagreement with the therapist, are noted. Second, the patient’s attention is drawn to the event. The reasons for the rupture and the way that it was experienced are explored, and the patient is encouraged to express any negative feelings associated with the rupture. Third—a crucial step—the therapist validates the patient’s description of his or her experience. If these steps are not effective, a fourth step is used, which focuses on how the patient avoids recognizing and exploring the rupture. The value of this approach is that it uses a potentially negative event to change maladaptive cognitions. Strategy 2: Maintaining a Consistent Treatment Process Consistency can be defined as adherence to the frame of therapy. Consistency offers structure to contain instability, along with a stable experience of the self within the relationship. However, maintaining consistency throughout treatment is a challenge. Unstable self-states, labile emotions, distrust, and difficulty with cooperation drive recurrent attempts to alter the frame and challenge the therapist’s resolve to maintain consistency. Success requires skill in setting limits without damaging the empathic stance. This is best achieved by confronting attempts to change the frame immediately while at the same time offering support and understanding. This step involves recognizing and thereby validating the reasons for violating the frame and also pointing out how the violation may adversely affect therapy. Strategy 3: Establishing and Maintaining a Validating Treatment Process Validation involves recognizing the legitimacy of the patient’s experience. Validating responses have multiple functions. They are inherently empathic and supportive and, hence, strengthen the alliance. Recognizing, acknowledging, and accepting the effects of adverse experiences also have a settling effect early in treatment, when the search for acceptance and understanding is often a major component of crisis behaviour. Consistent validation helps to counter earlier invalidating experiences and thereby promotes self-validation and the development of a more adaptive self- structure. The essential task is to validate experience without validating the causes and consequences of the experience that are invalid. This involves helping the patient to distinguish the experience, the reasons given for it, and the conclusions drawn from it. Strategy 4: Building and Maintaining Motivation for Change Motivation to change is essential if patients are to seek help, remain in treatment, and work on their problems. However, low motivation, passivity, and feelings of helplessness are inherent to PD. Thus motivation cannot be a prerequisite for treatment, and therapists need to make extensive use of motivational interviewing techniques (31) to elicit and reaffirm a commitment to change. This commitment is built on expectations that treatment will be successful. Hope is created by the therapist’s approach to treatment and by reminding patients of their previous successes, no matter how small. Besides building hope, it is also useful to tap any discontent that patients may feel about their problems and thereby increase the perceived discrepancy between the way things are and the way they would like them to be. When motivation is poor, the best course seems to be to maintain a supportive stance and attempt to build motivation by exploring the consequences of maladaptive behaviour. Although it is often tempting to adopt a more confrontational and coercive stance on such occasions, this usually causes further deterioration in the alliance and increases reactivity. General Therapeutic Strategies and the Hierarchy of Interventions As several authors have noted (25,26), interventions form an approximate hierarchy of importance and precedence. Interventions required to ensure safety take priority. Next are interventions based on general strategies. Finally, specific interventions are used only when the conditions that the general therapeutic strategies are designed to create exist. Thus throughout treatment, therapists need to consider whether the alliance is satisfactory, the treatment process is consistent, validation is effective, and there is a commitment to change. If any condition is not met, therapeutic effort should be directed toward remedying the problem before specific interventions are considered. Phases of Treatment and Specific Intervention StrategiesAlthough the psychopathology of PD is too complex to treat in a prescribed sequence and multiple problems are usually addressed at each phase, it is convenient to divide treatment into phases based on the hierarchy of stability mentioned earlier. This brief overview of treatment phases will focus on BPD because it is so prevalent. However, the approach is readily applied to other forms of PD. Phase 1: Safety and Managing Crises The goal in managing crises is to ensure safety and a return to the previous level of functioning as soon as possible. Crisis management begins by evaluating suicidal and parasuicidal risk—a difficult task with chronically suicidal patients for whom suicide is a way of life. Key considerations in evaluating risk are level of intent, whether intent has changed as indicated by a more detailed plan, and level of impulse control. Risk factors associated with suicidality in BPD have limited predictive value (32), and most are relatively nonspecific (33). On the basis of a risk evaluation, the decision may be to admit the individual to hospital, arrange day treatment, treat as an outpatient, organize additional structure and support, or continue with scheduled treatment. Because there is little evidence that hospitalization has lasting benefits or that it is useful in managing parasuicidal behaviour or threats (34), inpatient treatment should only be used when there is no other way to ensure safety. Moreover, many patients appear to regress in inpatient settings. For this reason, admissions should be brief. Partial hospitalization or day treatment programs are effective alternatives (35–38). Further, sufficient support and structure to ensure safety can often be provided by mobilizing family and social support systems or by providing extra appointments and telephone contact between sessions. Phase 2: Containment Following practical steps taken to ensure safety, the next task is to contain emotional and behavioural instability, prevent escalation of psychopathology, and establish or maintain ongoing treatment. Interventions are based on the generic component of therapy, supplemented with medication as appropriate, and are guided by the assumption that in a crisis patients want relief from emotional pain, which comes from feeling a connection to someone who understands (39,40). This means that the therapist’s task is to align with the patient’s distress and convey support and understanding. Containment is weakened by failure to acknowledge distress, by lengthy attempts to clarify feelings, and by interpretations (40). The focus is on affect rather than on content (26) and on the present rather than on the past; however, the task is not to achieve catharsis but, rather, to achieve affect regulation by acknowledging distress. This is best achieved with straightforward, concrete statements that reflect understanding of the current situation and the patient’s experience. Anything more risks overwhelming the patient’s capacity to process information. When treating BPD, it is usually necessary to manage emotional arousal to prevent the destabilizing effects of intense feelings. Containment interventions are useful throughout treatment to manage emotional arousal and behavioural disorganization. Hence, containment interventions are used whenever emotional control appears impaired or there is evidence of cognitive dysregulation in the form of confused thinking or mild dissociative behaviour. With many patients, medication is a useful component of crisis management. Within the framework proposed, medication is simply a form of specific intervention; therefore, it should be used with the same attention to the general treatment strategies as occurs when using other specific interventions. The evidence supports the use of neuroleptics and selective serotonin reuptake inhibitors as first-line agents (41, 42) to manage cognitive disorganization, impulsivity, and aggression, as well as depressed, anxious, and labile mood (42). Phase 3: Control and Regulation Once acute behavioural disorganization settles, albeit temporarily, the focus changes to issues that are the subject of the third phase, that is, control and regulation. Here the goal is to improve self-management of emotions and impulses. This usually requires a continuum of interventions progressing from more structured behavioural and cognitive methods supplemented with medication to less structured interpersonal and psychodynamic interventions. This continuum is based on a description of the behavioural sequence leading to crisis behaviour and deliberate self-harm. The sequence usually begins with a triggering event that typically involves rejection or abandonment. The triggering event activates underlying maladaptive schemata, leading to an escalating dysphoric state that usually culminates in a self-harming act. Such acts are usually attempts to self-regulate distress. Each step in the sequence is a potential target for multiple interventions. Preliminary Interventions to Reduce Self-Harming Behaviour. Although lasting change in deliberate self-harming behaviour depends on finding alternative ways to handle dysphoria and on changing the cognitive and affective structures that underlie dysphoric states, behavioural interventions are often useful early in treatment to reduce the frequency of self-harm. Simple interventions such as distraction, substitution, avoidance, reducing ego-syntonicity of self-harming acts, and promoting adaptive help seeking often settle things sufficiently to allow a focus on underlying problems and the development of better coping strategies. Successful application of these interventions depends on the quality of the therapeutic relationship. Because it is unreasonable to expect long-standing self-harm to stop abruptly, the goal is not to eliminate these behaviours immediately but to delay their onset and reduce their frequency. This modest goal is readily attainable at a time when therapeutic successes are needed to build collaboration and motivation. Controlling and Regulating Dysphoria. A second aspect of treating self-harming behaviour is to improve self- management of distress by using a combination of psychosocial interventions and medication. First, patients often need help identifying and deconstructing complex emotional states. Although this can be taught as a separate exercise with the aid of handouts, it is often more effective to clarify feelings as they emerge in treatment, by slowing down the therapeutic interaction and encouraging patients to reflect on their experience. This reflection enables them to recognize how feelings are avoided, suppressed, or blocked. Second, control is built by slowing down the tendency to move rapidly from impulse to action and by increasing distress tolerance. Most individuals with PD have difficulty tolerating feelings. Tolerance is increased by using the therapeutic relationship to encourage patients to examine and “hold” feelings as they occur in treatment. Third, attempts are made to modify the cognitions that contribute to escalating emotional states, using standard cognitive interventions. Patients frequently tell themselves that they cannot stand their feelings, that the feelings will never go away, and that they could not stand feeling this way again. Many also catastrophize or ruminate over problems. Finally, improved self-management of emotions involves developing skills to regulate emotions that will compensate for regulatory deficits with biological and developmental origins. This typically involves facilitating the use of self-soothing and teaching grounding techniques, simple relaxation exercises, and ways to control attention. The latter are needed because affect regulation requires the ability to switch attention from unpleasant thoughts instead of ruminating about them. Reframing Triggering Situations. When using the above interventions, it may also be possible to work on modifying the way triggering events are perceived. Patients tend to personalize events and assume that their interpretation is obvious and fixed. However, as reactivity settles and the alliance improves, the idea that events can be interpreted differently becomes more acceptable. The possibility of reframing a triggering situation depends on the nature of the trigger. With interpersonal events such as a perceived rejection, slight, or abandonment, it may be possible to reframe the way the event is perceived. This largely involves slowing down reactions and encouraging a Socratic questioning of whether “I am seeing this situation appropriately” and whether there are other explanations for what has happened. When the trigger is a stimulus associated with traumatic events, however, restructuring may be less important than desensitization. Phase 4: Exploration and Change As crises decrease and emotional control increases, underlying cognitive and affective structures can be explored in more detail. The goals of this phase are to change maladaptive beliefs, interpersonal behaviour, and cognitive styles such as self-invalidating thinking and to modulate the consequence of trauma. Most therapies share the idea that the cognitive structures used to interpret the world are core components of personality (43,44), whether these are labelled working models, object relationships, self- and object representations, cognitive schemata, or self- or interpersonal schemata. The term schema will be used to refer to these structures because it is a relatively neutral term with a long history in psychology (45,46). Change in maladaptive schemata and associated interpersonal patterns can be managed according to the stages of change model. Schema Identification and Recognition. It is useful to think of the identification of schemata and maladaptive patterns as a 2-stage process. First, the patient’s attention is drawn to a schema or pattern, such as submissiveness. This organizes the patient’s understanding of common events in his or her life by linking events previously thought to be unrelated. For example, feeling neglected, abused, or taken for granted; tolerating unreasonable demands from others; and compulsive caregiving are no longer seen as separate but, rather, as part of a pattern of submissiveness. Second, patients are helped to recognize the nuances of the pattern and the specific ways it is manifested inside and outside treatment. This step is needed because maladaptive cognitions and patterns are often automatic. Also, it is difficult to change broad patterns. However, specific instances, such as always complying with others’ wishes, may be more amenable to change. Schema Exploration. Following schema recognition, events that activate a given schema and the consequences of a given way of acting are explored. This inevitably leads to a discussion of the origins of these patterns. Although the current approach assumes that change arises primarily from modifying personality processes as they occur in the present, patients often need to understand the origins of their difficulties. This frequently means exploring important developmental events and their consequences, which helps to give meaning and perspective to problems. The goal, however, is to enrich the patient’s understanding of current functioning rather than to carry out in-depth exploration or achieve catharsis. Maladaptive cognitions are interconnected: activation of one schema may arouse others. For example, a friend’s action may evoke the schema “People reject me,” which may in turn arouse the schema “People are hostile: the world is against me” and, ultimately, the more distressing core schema “I am unlovable.” The connections create a network that resists change. Maladaptive modes of thinking, such as catastrophizing and externalizing, may also contribute to this network. Thus submissiveness may be increased by a tendency to catastrophize and externalize—thinking styles that increase assumed dependence on others. Change often involves clarifying these relationships. Schema Change and the Acquisition of Alternatives. Cognitive therapy describes cognitive, interpersonal, behavioural, and emotional methods for changing schemata (47–51). Standard cognitive interventions seem to be less useful in treating PD than other disorders (52) because these interventions require a degree of collaboration and motivation that is often lacking. Most interventions work best when they are an experiential part of treatment. Cognitive techniques for challenging dysfunctional thoughts can be introduced early in treatment as a natural extension of collaborative description by encouraging patients to examine the evidence supporting and disconfirming their beliefs. When a belief is recognized to be ill-founded and the patient is able to modify it, it is natural for the therapist to inquire whether the patient could repeat the process the next time a similar thought occurs. Probably the most effective way to change core schemata is by examining patients’ perceptions of their relationship with the therapist (51). The treatment relationship offers 2 strategies to effect change. First, as noted earlier, the generic component of treatment provides a continuous corrective experience that challenges core beliefs. Second, the therapeutic interaction offers many opportunities to identify, explore, and change maladaptive schemata and interpersonal patterns as they occur in relation to the therapist. As treatment progresses, the therapeutic landscape is increasingly dominated by core schemata originating in adversity. Early in treatment, schemata relating to trust, cooperation, and worth exert a major influence. When these issues are addressed sufficiently to form a reasonable alliance, attention rapidly focuses on distress and related problems. When emotional control increases, the focus shifts to the effects of adversity and interpersonal problems. This brings core schemata to the fore once more, offering new opportunities for clarification and change. Behavioural interventions involve changing habitual behaviours that help to maintain maladaptive schemata. These methods include challenging behavioural avoidance with graded tasks, acting against schema-based rules to test the reality of fears and negative expectations, making environmental changes and seeking out experiences that modulate maladaptive beliefs, and behavioural rehearsal and role-playing (48,51). Emotional strategies involve defusing the intense emotions that maladaptive schemata often evoke. Although emotive techniques are effective, they need to be used cautiously because intense affects can be destabilizing. This suggests that interventions likely to generate strong emotions, such as a focus on traumatic experiences, should not be used until affect regulation skills have improved. A history of severe childhood trauma and deprivation, regressive and dissociative behaviour, poor affect tolerance, and limited psychological mindedness are reasons for minimizing the use of emotional strategies. The occurrence of confusion and (or) dissociative reactions are reasons to switch to containment interventions. Consolidation and Generalization. Translating an understanding of maladaptive cognitions and interpersonal patterns into lasting behavioural change is often difficult and frustrating. The schemata involved are usually well entrenched; moreover, the patient’s life situations often reinforce these patterns and undermine efforts to change. Consequently, patients need active support as they attempt to apply new learning to everyday life. Successful change is more likely if accompanied by changes in the life circumstances that contributed to the maladaptive patterns. Hence it is often necessary to encourage patients to seek situations that are conducive to new schemata and to learn ways of relating to their social environment that avoid confirming old schemata or undermining new ones. At this stage, it is often important to validate the difficulties encountered in generalizing learning to everyday life and to help patients deal with others’ reactions to their attempts to change. In some cases, conjoint interviews with significant others are needed to help them adjust to the changes in the relationship. Phase 5: Integration and Synthesis An impoverished and poorly developed self-structure or fragmented self-states are core features of PD. The task of long-term treatment is to help patients develop a more differentiated and coherent self. This involves establishing clearly delineated interpersonal boundaries, promoting differentiation in self- and interpersonal schemata, developing more cohesive and integrated representations of self and others, enhancing autonomy and agency, and developing a more adaptive autobiographical understanding of the self. These developments are achieved indirectly through the use of nonspecific components of therapy and directly through specific interventions designed to facilitate integration and self-directedness. The process of collaborative description, with its emphasis on increasing self-knowledge and self-observation, is basic to integration and synthesis. Although the descriptive process is essentially concerned with clarifying targets for specific interventions, it gradually imposes structure and organization onto self-experience by repetitively linking feelings, thoughts, and actions and reformulating self-knowledge. Clinicians can facilitate this process by offering broad synthesizing statements of their understanding of the patient’s problems, beginning with the formulation that is the end point of assessment. The consolidation of a new sense of self also often requires clinicians to take an active interest in new activities and to help patients set and work toward goals. Broad goals, such as lifestyles to be achieved and becoming the self one hopes to be, promote unity and purpose. The importance of goals and self-directedness grows during treatment. As maladaptive patterns change, patients often become frustrated because they cannot envisage how their lives can be different. Having lived largely in the present, they find it difficult to change perspective. A major task for this phase is to help patients to imagine future possibilities and martial resources to achieve them. Concluding CommentsThe ideas proposed for treating PD are not intended to form an evidenced-based approach because the evidence needed for this purpose is not available. They do aim, however, to provide a coherent framework that is consistent with current empirical knowledge about the structure and origins of PD and treatment outcome—a framework that can be readily modified as new information becomes available. 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Sarasota (FL): Professional Resource Exchange; 1990. 51. Young JE. Cognitive therapy for personality disorders: a schema-focused approach. Revised ed. Sarasota (FL): Professional Resource Exchange; 1994. 52. Layden MA, Newman CF, Freeman A, Morse SB. Cognitive therapy of borderline personality disorder. Needham Heights (MS): Allyn & Bacon; 1993. Author(s)Manuscript received and accepted April 2005. 1. Professor, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia. Address for correspondence: Dr J Livesley, Department of Psychiatry, 2255 Wesbrook Mall, Vancouver, BC V6T 2A1 e-mail: ivesley@interchange.ubc.ca
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