Patient personality characteristics and therapeutic integration: treating borderline personality and emotionally dysregulated-dysphoric personality features

Submitted: February 11, 2022
Accepted: May 12, 2022
Published: June 30, 2022
Abstract Views: 1926
PDF: 684
HTML: 158
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.


This study examines the relationship between patient personality characteristics and therapeutic integration. Within a sample of patients (N=93) receiving outpatient psychodynamically- oriented psychotherapy, we assessed patient Borderline and Emotionally Dysregulated personality features through the Shedler-Westen Assessment Procedure (SWAP-200), and therapeutic technique using the Comparative Psychotherapy Process Scale (CPPS) during an early treatment session. We examined personality dimensionally, psychotherapy interventions across different theoretical orientations, as well as psychotherapy integration. These analyses revealed an overlap between the Borderline Clinical Prototype and the Emotionally Dysregulated-Dysphoric Q-factor, with the former associated with higher use of integration and the latter associated with higher use of either psychodynamicinterpersonal or cognitive-behavioural interventions. Secondary analyses also indicated the greater presence of interventions oriented towards emotional exploration and to the didactic instruction of effective symptom coping techniques across both of these personality subtypes early in treatment. The key differences between these personality types, as well as the theoretical, empirical, and clinical implications of these findings are discussed.



PlumX Metrics


Download data is not yet available.


Ablon, J. & Jones, E. (1998). How expert clinicians’ prototypes of an ideal treatment correlate with outcome in psychodynamic and cognitive-behavioural therapy. Psychotherapy Research, 8(1), 71-83.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C.: American Psychiatric Association.
Beck, A. T. & Freeman, A. (1990). Cognitive therapy of personality disorders. New York: Guilford Press.
Bender, D. S., Morey, L. C., & Skodol, A. E. (2011). Toward a model for assessing level of personality functioning in DSM-5, part I: a review of theory and methods. Journal of Personality Assessment, 93(4), 332-346.
Biskin, R. S. (2015). The lifetime course of borderline personality disorder. Canadian Journal of Psychiatry, 60(7), 303-308.
Black, D. W., Blum, N., Pfohl, B., & Hale, N. (2004). Suicidal behavior in borderline personality disorder: Prevalence, risk factors, prediction, and prevention. Journal of Personality Disorders, 18(3), 226-239.
Blagys, M. D. & Hilsenroth, M. J. (2000). Distinctive features of short-term psychodynamic- interpersonal psychotherapy: A review of the comparative psychotherapy process literature. Clinical Psychology: Science and Practice, 7(2), 167-188.
Book, H. E. (1998). How to practice brief psychodynamic psychotherapy: The Core Conflictual Relationship Theme method. Washington, DC: American Psychological Association.
Cersosimo, B., & Hilsenroth, M. (2021). Personality Pathology Severity, Cluster Type and Specific Therapeutic Interventions in Outpatient Psychotherapy. Counselling and Psychotherapy Research, 21, 154-163. doi:10.1002/capr.12305.
Chapman, A. L., Gratz, K. L., & Brown, M. Z. (2006). Solving the puzzle of deliberate self- harm: The experiential avoidance model. Behaviour Research and Therapy, 44(3), 371-394.
Colli, A., Gentile, D., Tanzilli, A., Speranza, A. M., & Lingiardi, V. (2016). Therapeutic interventions in the treatment of eating disorders: A naturalistic study. Psychotherapy, 53(2), 152-162.
Colli, A., Tanzilli, A., Dimaggio, G., & Lingiardi, V. (2014). Patient personality and therapist response: An empirical investigation. American Journal of Psychiatry, 171(1), 102-108.
Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. Journal of the American Medical Association Psychiatry, 74, 319-328.
Diener, M. J. & Hilsenroth, M. J. (2004). Multimethod validity assessment of the SWAP-200 dysphoric Q-factor. Journal of Nervous and Mental Disease, 192(7), 479-486.
Dimaggio, G. & Attinà, G. (2012). Metacognitive interpersonal therapy for narcissistic personality disorder and associated perfectionism. Journal of Clinical Psychology, 68(8), 922-934.
Drapeau, M. & Perry, J. C. (2004). Interpersonal conflicts in borderline personality disorder: An exploratory study using the CCRT-LU. Swiss Journal of Psychology, 63(1), 53-57.
Ferrara, M., Terrinoni, A., & Williams, R. (2012). Non-suicidal self-injury (NSSI) in adolescent inpatients: Assessing personality features and attitude toward death. Child and Adolescent Psychiatry and Mental Health, 6(30), Article 12.
Finch, E. F., Iliakis, E. A., Masland, S. R., & Choi-Kain, L. W. (2019). A meta-analysis of treatment as usual for borderline personality disorder. Personality Disorders: Theory, Research, and Treatment.
Finn, S. E. & Tonsager, M. E. (1997). Information-gathering and therapeutic models of assessment: Complementary paradigms. Psychological Assessment, 9(4), 374-385.
Fleiss, J. L. (1973). Statistical methods for rates and proportions (2nd ed.). New York: Wiley.
Gold, J. & Stricker. G. (2001). A relational psychodynamic perspective on assimilative integration. Journal of Psychotherapy Integration, 11(1), 43-58.
Goldman, R. E., Hilsenroth, M. J., Owen, J. J., & Gold, J. R. (2013). Psychotherapy integration and alliance: Use of cognitive-behavioural techniques within a short-term psychodynamic treatment model. Journal of Psychotherapy Integration, 23(4), 373-385.
Goodman, G., Anderson, K., & Diener, M. J. (2014). Processes of therapeutic change in psychodynamic theory of two inpatients with borderline personality disorder. Journal of Psychotherapy Integration, 24(1), 30-45
Gross, R., Olfson, M., Gameroff, M., Shea, S., Feder, A., Fuentes, M., & Weissman, M.M. (2002). Borderline personality disorder in primary care. Archives of Internal Medicine, 162(1), 53-60.
Groth, T., Hilsenroth, M., Gold, J., Boccio, D., & Tasca, G. (2020). Therapist factors related to the treatment of adolescent eating disorders. Professional Psychology: Research and Practice, 51, 517-526. doi:10.1037/pro0000308.
Hilsenroth, M. J. (2007). A programmatic study of short-term psychodynamic psychotherapy: Assessment, process, outcome, and training. Psychotherapy Research, 17(1), 31-45.
Hilsenroth, M., Baity, M., Mooney, M., & Meyer, G. (2004). DSM-IV Major Depressive Episode Criteria: An Evaluation of Reliability and Validity Across Three Different Rating Methods. International Journal of Psychiatry in Clinical Practice, 8, 3-10.
Hilsenroth, M. J., Blagys, M. D., Ackerman, S. J., Bonge, D. R., & Blais, M. A. (2005). Measuring psychodynamic-interpersonal and cognitive-behavioural techniques: Development of the Comparative Psychotherapy Process Scale (CPPS). Psychotherapy, 42(3), 340-356.
Hilsenroth, M. J., DeFife, J. A., Blake, M. M., & Cromer, T. D. (2007). The effects of borderline pathology on short-term psychodynamic psychotherapy for depression. Psychotherapy Research, 17(2), 172-184.
Hilsenroth, M., Katz, M., & Tanzilli, A. (2018). Psychotherapy Research and the Psychodynamic Diagnostic Manual (PDM-2). Psychoanalytic Psychology, 35, 320-327.
Hilsenroth, M., Kivlighan, D. & Slavin-Mulford, J. (2015), Structured Supervision of Graduate Clinicians in Psychodynamic Psychotherapy: Alliance and Technique. Journal of Counseling Psychology, 62, 173-183.
Hopwood, C. J., Wright, A. G. C., Ansell, E. B., & Pincus, A. L. (2013). The interpersonal core of personality pathology. Journal of Personality Disorders, 27(3), 270-295.
Howe, E. (2013). Five ethical and clinical challenges psychiatrists may face when treating patients with borderline personality disorder who are or may become suicidal. Innovation in Clinical Neuroscience, 10(1), 14-19.
Izard, C. E., Libero, D. Z., Putnam, P., & Haynes, O. M. (1993). Stability of emotion experiences and their relations to traits of personality. Journal of Personality and Social Psychology, 64(5), 847-860.
Katz, M., Hilsenroth, M. J., Gold, J. R., Moore, M., Pitman, S. R., Levy, S. R., & Owen, J. (2019). Adherence, flexibility, and outcome in psychodynamic treatment of depression. Journal of Counseling Psychology, 66(1), 94-103. doi:10.1037/cou0000299.
Keefe, J. R., McMain, S. F., McCarthy, K. S., Zilcha-Mano, S., Dinger, U., Sahin, Z., & Barber, J. P. (2019). A meta-analysis of psychodynamic treatments for borderline and cluster C personality disorders. Personality Disorders: Theory, Research, and Treatment.
Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. New York: Jason Aronson.
Kernberg, O. F., Selzer, M. A., Koenigsberg, H. D., Carr, A. C., & Applebaum, A. H. (1989). Psychodynamic psychotherapy of borderline patients. New York: Basic Books.
Klimstra, T. A., Luyckz, K., Branie, S., Teppers, E., Goossens, L., & Meeus, W. H. (2013). Personality traits, interpersonal identity, and relationship stability: Longitudinal linkages in late adolescence and young adulthood. Journal of Youth and Adolescence, 42(11), 1661-1673.
Kuutmann, K., & Hilsenroth, M. (2012), Exploring In-Session Focus on the Patient-Therapist Relationship: Patient Characteristics, Process and Outcome. Clinical Psychology & Psychotherapy, 19, 187-202.
Lavender, J. M., Wonderlich, S. A., Peterson, C. B., Crosby, R. D., Engel, S. G., Mitchell, J. E., & Berg, K. C. (2014). Dimensions of emotion dysregulation in bulimia nervosa. European Eating Disorders Review, 22(3), 212-216.
Leichsenring, F. & Leibing, E. (2003). The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: A meta-analysis. American Journal of Psychiatry, 160(7), 1223-1232.
Leichsenring, F., Luyten, P., Hilsenroth, M. J., Abbass, A., Barber, J. P., Keefe, J. R., & Steinert, C. (2015). Psychodynamic therapy meets evidence-based medicine: A systematic review using updated criteria. Lancet Psychiatry, 2(7), 648-660.
Leichsenring, F. & Salzer, S. (2014). A unified protocol for the transdiagnostic psychodynamic treatment of anxiety disorders: An evidence-based approach. Psychotherapy, 51(2), 224-245.
Liebman, R. E. & Burnette, M. (2013). It’s not you, it’s me: An examination of clinician- and client-level influences on countertransference toward borderline personality disorder. American Journal of Orthopsychiatry, 83(1), 115-125.
Levy, S., Hilsenroth, M. & Owen, J. (2015), Relationship Between Interpretation, Alliance and Outcome in Psychodynamic Psychotherapy: Control of Therapist Effects and Assessment of Moderator Variable Impact. Journal of Nervous and Mental Disease, 203, 418-424.
Linehan, M. L., Dimeff, L., Koerner, K., & Miga, E. M. (2014). Research on dialectical behavior therapy: Summary of data to date. Retrieved from
Lingiardi, V., & McWilliams, N. (Eds.). (2017). Psychodynamic diagnostic manual (2nd ed.). New York, NY: Guilford Press.
Lingiardi, V., Tanzilli, A., & Colli, A. (2015). Does the severity of psychopathological symptoms mediate the relationship between patient personality and therapist response? Psychotherapy, 52(2), 228-237.
Links, P. S. (2015). Advancing psychotherapy integration for treatment of personality disorders. Journal of Psychotherapy Integration, 25(1), 45-48.
Louw, F. & Straker, G. (2002). Borderline pathology: An integration of cognitive therapy and psychodynamic therapy. Journal of Psychotherapy Integration, 12(2), 190-217.
Luborsky, L. B. (1984). Principles of psychoanalytic psychotherapy: A manual for supportive- expressive treatment. New York; Basic Books.
Luyckx, K., Teppers, E., Klimstra, T. A., & Rassrt, J. (2014). Identity processes and personality traits and types in adolescence: Directionality of effects and developmental trajectories. Developmental Psychology, 50(8), 2144-2153.
Lynch, T. R., Chapman, A. L., Rosenthal, M. Z., Kuo, J. R., & Linehan, M. M. (2006). Mechanisms of change in dialectical behavior therapy: Theoretical and empirical observations. Journal of Clinical Psychology, 62(4), 459-480.
McCullough, L., Kuhn, N. S., Andrews, S., Kaplan, A., Wolf, J., & Hurley, C. L. (2003). Treating affect phobia: A manual for short-term dynamic psychotherapy. New York: The Guilford Press.
McWilliams, N. (2011). Psychoanalytic diagnosis, 2nd edition. New York: Guilford Press.
Merced, M. (2015). The beginning psychotherapist and borderline personality disorder: Basic treatment principles and clinical foci. American Journal of Psychotherapy, 69(3), 241-268.
Morey, L. C. (1991). Personality Assessment Inventory. Lutz, FL: Psychological Assessment Resources, Inc.
Morey, L. C., Berguis, H., Bender, D. S., Verheul, R., Krueger, R. F., & Skodol, A. E. (2011). Toward a model for assessing level of personality functioning in DSM-5, part II: Empirical articulation of a core dimension of personality pathology. Journal of Personality Assessment, 93(4), 347-353.
Mulder, R. T. (2011). The influence of personality on the treatment outcome of psychopathology. World Psychiatry, 10(2), 115-116.
Mullin, A., Hilsenroth, M., Gold, J., & Farber, B. (2017). Changes in Object Relations over the Course of Psychodynamic Psychotherapy. Clinical Psychology & Psychotherapy, 24, 501-511.
Muehlenkampf, J. J., Peat, C. M., Claes, L., & Smits, D. (2012). Self-injury and disordered eating: expressing emotion dysregulation through the body. Suicide and Life-Threatening Behavior, 42(4), 416-425.
Neacsiu, A. D., Herr, N. R., Fang, C. M., Rodriguez, M. A., & Rosenthal, M. Z. (2015). Identity disturbance and problems with emotion regulation are constructs across diagnoses. Journal of Clinical Psychology, 71(4), 346-361.
Ng, W. & Diener, E. (2009). Personality differences in emotions: Does emotion regulation play a role? Journal of Individual Differences, 30(2), 100-106.
Paris, J. (2010). Estimating the prevalence of personality disorders in the community. Journal of Personality Disorders, 24(4), 405-411.
Paris, J. (2015). Applying the principles of psychotherapy integration to the treatment of borderline personality disorder. Journal of Psychotherapy Integration, 25(1), 13-19.
Pitman, S., Slavin-Mulford, J., & Hilsenroth, M. (2014), Psychodynamic Techniques Related to Outcome for Anxiety Disorder Patients At Different Points in Treatment. Journal of Nervous and Mental Disease, 202, 391-396.
Pulford, B. D. & Sohal, H. (2006). The influence of personality on HE students’ confidence in their academic abilities. Personality and Individual Differences, 41(8), 1409-1419.
Raudenbush, S. W., Bryk, A. S., Cheong, Y. F., Congdon, R. T. (2005). HLM6: Hierarchical linear and nonlinear modeling. Lincolnwood, IL, Scientific Software International.
Reeves-Dudley, B. (2017). Borderline personality disorder psychological treatment: An integrative review. Archives of Psychiatric Nursing, 31(1), 83-87.
Rosenbach, C. & Renneberg, B. (2014). Rejection sensitivity as a mediator of the relationship between experienced rejection and borderline characteristics. Personality and Individual Differences, 69, 176-181.
Safran, J. D. & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York: The Guilford Press.
Salzer, S., Streeck, U., Jaeger, U., Masuhr, O., Warwas, J., Leichsenring, F., & Leibling, E. (2013). Patterns of interpersonal problems in borderline personality disorder. Journal of Nervous and Mental Disease, 201(2), 94-98.
Scandell, D. J., Wlazelek, B. G., & Scandell, R. S. (1997). Personality of the therapist and theoretical orientation. Irish Journal of Psychology, 18(4), 413-418.
Schut, A. J., Castonguay, L. G., Flanagan, K. M., Yamasaki, A. S., Barber, J. P., Bedics, J. D., & Smith, T. L. (2005). Therapist interpretation, patient-therapist interpersonal process, and outcome in psychodynamic psychotherapy for avoidant personality disorder. Psychotherapy: Theory, Research, Practice, Training, 42(4), 494-511.
Selby, E. A. & Joiner, T. E., Jr. (2009). Cascades of emotion: The emergence of borderline personality disorder from emotional and behavioural dysregulation. Review of General Psychology, 13(3), 219-229.
Shapiro, D. (1965). Neurotic styles. New York: Basic Books.
Shedler, J. & Westen, D. (1998). Refining the measurement of Axis II: A Q-sort procedure for assessing personality pathology. Assessment, 5(4), 333-355.
Shedler, J. & Westen, D. (2004a). Dimensions of personality pathology: An alternative to the Five Factor Model. American Journal of Psychiatry, 161(10), 1743-1754.
Shedler, J. & Westen, D. (2004b). Refining personality disorder diagnoses: Integrating science and practice. American Journal of Psychiatry, 161(8), 1350-1365.
Skodol, A. E., Clark, L. A., Bender, D. S., Krueger, R. F., Morey, L. C., Verheul, R., & Oldham, J. M. (2011). Proposed changes in personality and personality disorder assessment and diagnosis for DSM-5, Part I: Description and rationale. Personality Disorders: Theory, Research, and Treatment, 2(1), 4-22.
Slavin-Mulford, J., Hilsenroth, M., Weinberger, J., & Gold, J. (2011). Therapeutic interventions related to outcome in psychodynamic psychotherapy for anxiety disorder patients. Journal of Nervous and Mental Disease, 199, 214-221.
Smith, S. W., Hilsenroth, M. J., & Bornstein, R. F. (2009). Convergent validity of the SWAP-200 dependency scales. Journal of Nervous and Mental Disease, 197(8), 613-618.
Soloff, P. H., Lynch, K. G., Kelly, T. M., Malone, K. M., & Mann, J.J. (2000). Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: A comparative study. American Journal of Psychiatry, 157(4), 601-608.
Speranza, M. (2013). Borderline personality disorders: The central role of emotional dysregulation. European Psychiatry, 28(8, Suppl), 61.
Stein, M., Pinsker, J., & Hilsenroth, M. (2007). Borderline pathology and the personality assessment inventory (PAI): an evaluation of criterion and concurrent validity. Journal of Personality Assessment, 88, 81-89.
Storebø, O.J., Stoffers-Winterling, J.M., Völlm, B.A., Kongerslev, M.T., Mattivi, J.T., Jørgensen, M.S., Faltinsen, E., Todorovac, A., Sales, C.P., Callesen, H.E., Lieb, K., & Simonsen, E. (2020). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, 5.
Stricker, G. & Gold, J. (1996). Psychotherapy integration: An assimilative, psychodynamic approach. Clinical Psychology: Science and Practice, 3, 47-58.
Thoma, N. C. & Cecero, J. J. (2009). Is integrative use of techniques in psychotherapy the exception or the rule? Results of a national survey of doctoral-level practitioners. Psychotherapy Theory, Research, Practice, Training, 46(4), 405-417.
Thompson-Brenner, H., Eddy, K. T., Satir, D. A., Boisseau, C. B., & Westen, D. (2008). Personality subtypes in adolescents with eating disorders: Validation of a classification approach. Journal of Child Psychology and Psychiatry, 49(2), 170-180.
Thompson-Brenner, H. & Westen, D. (2005a). Personality subtypes in eating disorders: validation of a classification in a naturalistic sample. British Journal of Psychiatry, 186, 516-524.
Thompson-Brenner, H. & Westen, D. (2005b). A naturalistic study of psychotherapy for bulimia nervosa, Part 2: Therapeutic interventions in the community. Journal of Nervous and Mental Disease, 193(9), 585-595.
Turner, B. J., Dixon-Gordon, K. L., Austin, S. B., Rodriguez, M. A., Rosenthal, M. Z., & Chapman, A. L. (2015). Non-suicidal self-injury with and without borderline personality disorder: Differences in self-injury and diagnostic comorbidity. Psychiatry Research, 230(1), 28-35.
Wachtel, P. L. (1993). Therapeutic communication. New York: The Guildford Press.
Wachtel, P. L. (2010). Psychotherapy integration and integrative psychotherapy: Process or product? Journal of Psychotherapy Integration, 20(4), 406-416.
Westen, D. & Harnden-Fischer, J. (2001). Personality profiles in eating disorders: rethinking the distinction between axis I and axis II. American Journal of Psychiatry, 158(4), 547-562.
Westen, D. & Muderrisoglu, S. (2003). Assessing personality disorders using a systematic clinical interview: Evaluation of an alternative to structured interviews. Journal of Personality Disorders, 17(4), 351-369.
Westen, D. & Muderrisoglu, S. (2006). Clinical assessment of pathological traits. American Journal of Psychiatry, 163(7), 1285-1287.
Westen, D. & Shedler, J. (1999a). Revising and assessing Axis II, Part 1: Developing a clinically and empirically valid assessment method. American Journal of Psychiatry, 156(2), 258-272.
Westen, D. & Shedler, J. (1999b). Revising and assessing Axis II, Part 2: Toward an empirically based and clinically useful classification of personality disorders. American Journal of Psychiatry, 156(2), 273-285.
Westen, D., Thompson-Brenner, H., & Peart, J. (2006). Personality and eating disorders. Annual Review of Eating Disorders, 2, 97-112.
Zielinski, M. J. & Veilleux, J. C. (2014). Examining the relation between borderline personality features and social support: The mediating role of rejection sensitivity. Personality and Individual Differences, 70, 235-238.
Zimmerman, M., Chelminski, I., & Young, D. (2008). The frequency of personality disorders in psychiatric patients. Psychiatric Clinics of North America, 31(3), 405-420.

How to Cite

Levy, S. R., Hilsenroth, M. J., Conway, F., & Owen, J. (2022). Patient personality characteristics and therapeutic integration: treating borderline personality and emotionally dysregulated-dysphoric personality features. Research in Psychotherapy: Psychopathology, Process and Outcome, 25(2).