Journal of Rational-Emotive & Cognitive-Behavior Therapy

Volume 12, Number 2, Summer 1994

THE TREATMENT OF B O R D E R L I N E
P E R S O N A L I T I E S WITH RATIONAL EMOTIVE
BEHAVIOR THERAPY
Albert Ellis
Institute for Rational-Emotive Therapy,
New York City

ABSTRACT: The rational emotive behavior therapy (REBT) theory holds

that individuals with severe personality disorders in general, and borderline
personalities in particular usually are biologically different from "normal"
neurotics and are born with a predisposition to be highly vulnerable to stress-
ful environmental conditions. They tend to have cognitive, emotional, and
behavioral deficits or disabilities that handicap them socially, vocationally,
and in other important aspects of their lives. But they also have distinct, and
sometimes exceptionally strong, neurotic tendencies to demand that they ab-
solutely must perform well, that other people have to treat them kindly and
fairly, and that frustrating conditions ought not exist. Their neurosis exacer-
bates their cognitive-emotive-behavioral handicaps, produces even greater
life difficulties, and often interferes with their working hard at therapy. A
summary is presented of how borderline personalities can be treated with
rational emotive behavior therapy (REBT).

I have worked with thousands of people with personalities disorders

for the last 50 years, first as a psychoanalyst and later as a rational
emotive behavior therapist, and I have naturally given much thought
to how these disorders originate and what are some of the best
methods to help people alleviate or cope with this serious problem.
After much thought and experimentation, I have come up with some
hypotheses that seem original to me, but that may merely be restate-
ments of other clinicians' ideas. In any event, I shall try to clearly
state them in the hope that they may be clinically and experimentally
tested.
Reprint requests should be sent to Dr. Albert Ellis, 45 East 65th Street, New York, NY 10021.

101 9 1994Human SciencesPress, Inc.

102 Journal of Rational-Emotive & Cognitive-BehaviorTherapy

My first hypothesis is hardly startling but follows rational emotive

behavior theory: All "emotional" disturbances tend to have strong cog-
nitive, emotive, and behavioral elements, and that this is particularly
true of the personality disorders and of the so-called borderline person-
ality states. Individuals who are afflicted with these conditions usu-
ally have severe dysfunctioning in their thinking, feeling, and behav-
ing, while so-called neurotics have less and so-called psychotics often
have more severe dysfunctioning in these three areas. (American Psy-
chiatric Association, 1987; Beck, Freeman, et al, 1990; Benjamin,
1993; Ellis, 1965; Kernberg, 1984, 1985; Klein, 1984, Kohut, 1971,
1991; Linehan, 1993; Masterson, 1981, Young, 1990).
People with personality disorders almost always have cognitive,
emotive, and behavioral organic deficits for various reasons, including
hereditary predispositions. They (and most properly diagnosed psycho-
tics) have anomalies of their brain and central nervous system as well
(as well as, often, other physiological defects), that significantly con-
tribute, along with other environmental factors, to their personality
disorders (Adler, 1992; Brown, 1991; Ellis, 1965a; 1985; Gottesman,
1991; Gazzinga, 1993; Huessy, 1992; Larsen & Agresti, 1992; Meehl,
1962, Pies, 1992).
As I pointed out in 1956 in my first paper on rational emotive be-
havior therapy (REBT) (Ellis, 1958), thinking, feeling, and behavior
are not separate processes but

t h i n k i n g . . , is, and to some extent has to be, sensory, motor, and

emotional behavior . . . Emotion, like thinking and the sensory-
motor processes, we may define as an exceptionally complex state
of human reaction which is integrally related to all the other per-
ception and response processes. It is not one thing, but a combina-
tion and holistic integration of several seemingly diverse, yet actu-
ally closely related phenomena . . . Thinking and emoting are so
closely interrelated that they usually accompany each other, act in
a circular cause and effect relationship, and in certain (though
hardly all) respects are essentially the same thing, so that one's
thinking becomes one's emotion and emotion becomes one's
thought (Ellis, 1958, pp. 35-36).

As I also pointed out (Ellis, 1991) and as Hayes and Hayes (1992)
and other contextualists have indicated, thought, feeling, and action
always take place in environmental contexts and backgrounds, so that
people and their situations interactively influence and affect each
other. Humans have goals and purposes; and in various environments,
Albert Ellis 103

and especially in their social relationships, construct thoughts, feel-

ings, and behaviors that actualize or defeat themselves, and thereby
create conditions of "mental health" and "emotional disturbance."
Virtually all humans are born with strong, constructive self-chang-
ing and self-actualizing tendencies and even when they are clearly not
in a disordered personality or a psychotic state they also have strong
self-defeating irrational tendencies. To a varying degree they are al-
most always neurotic or needlessly self-destructive; and although they
tend to learn, acquire, or become conditioned to disturbed thoughts,
feelings, and actions, they also have innate tendencies to construct or
create these neurotic conditions. Few, if any, of them are consistently
self-helping and socially appropriate (Brown, 1991; Ellis, 1962, 1965b,
1976, 1985, 1988; Ellis & Dryden, 1990; Gilovich, 1992).
What we call neurosis includes and largely (though not completely)
stems from people's dysfunctional, irrational and self-defeating think-
ing or basic philosophy. As I, Beck, Meichenbaum, and other rational
emotive behavior and cognitive-behavior theorists and therapists have
pointed out since 1955 (Beck, 1976, 1991; Ellis, 1957, 1958, 1962,
1985, 1988, 1992; Meichenbaum, 1977), anxious, depressed and en-
raged people have many dysfunctional ideas or irrational beliefs by
which they largely create their neurotic disturbances; and as the the-
ory of rational emotive behavior therapy (REBT) holds, these beliefs
almost always seem to consist of or be derived from their unrealistic-
ally, illogically, and rigidly raising their nondisturbing wishes and
preferences into godlike absolutist musts, shoulds, demands, and com-
mands. Thus, they tend to create neurotic ego problems, and conse-
quent anxiety and depression, when they strongly insist, "I absolutely
must perform well and be approved by significant others or else I am
an i:aadequate, unlovable person!" They tend to create interpersonal
and social problems, and especially feelings of rage, when they power-
fully demand, "Other people completely must treat me well and fairly
or else they are no damned good!" And they tend to create problems
with the world, low frustration tolerance (LFT), feelings of depression,
when they command, "Things and conditions absolutely must be the
way I want them to be or else it's awful, I can't stand it, and my life is
no good!" (Ellis, 1957, 1962, 1985, 1988; Ellis & Becker, 1982; Ellis &
Harper, 1975).
People's functional and appropriate cognitions, feelings and behav-
iors are rarely, if ever, pure and separate, but instead importantly
interact with and influence each other. Thus, their thoughts tend to
create their feelings and behavior, their emotions and acts lead to
104 Journal of Rational-Emotive & Cognitive-Behavior Therapy

thought and acts, and their actions lead to ideas and feelings (Ellis,
1962, 1985, 1991). REBT, along with most of the other cognitive be-
havioral therapies, theorizes that when people experience Activating
events or Activating Experiences (A), their Beliefs about these A's
largely create their emotional and behavioral Consequences (C), but
REBT also theorizes that A, B, and C often powerfully interact so that
Activating Events (A) influence Beliefs (B) and Consequences (C). B's
influence A's and C's; and C's influence A's and B's. Thus, people's
serious failures and loss of approval (A) often lead to negative Beliefs
(B) and to withdrawal (C). Negative Beliefs (B) often encourage fail-
ures and lack of approval (A) as well as withdrawal (C). And with-
drawal (C) often encourages serious failures and loss of approval (A)
and negative Beliefs (B). It seems to be the nature of virtually all
humans to be importantly affected by both their environment and
their own (partly inherited) biology and to have their thoughts, feel-
ings, and behaviors significantly interact with and to cause and affect
each other.
Thus, following Skinner (1938, 1987, 1989), the radical behaviorists
and contextualists are probably correct in holding that humans (and
other animals) do not function outside of the environment and are in-
evitably and crucially affected by environmental changes (Biglan,
1993; Hayes & Hayes, 1992). But the cognitive-behaviorists are also
correct in holding that humans have interacting thoughts, feelings,
and behaviors, all of which significantly affect each other, and that
their thinking prominently influences and changes their feelings and
their actions. Significant changes in human functioning can therefore
be effected by environmental changes--most of which they have to
plan and execute themselves--but can also be effected by their choos-
ing to work at their thoughts, emotions, and behaviors. Why are both
of these change processes crucial to human functions? Because so-
called human nature has strong hereditary components--which are
also subject to evolutionary environmental influences (Davidson &
Cacioppo, 1992; Ellis, 1992; Eysenck, 1967; Gazzinga, 1993; Ruth,
1992; Wilson, 1975).
All humans seem to be both self-actualizing and self-defeating (or
what I shall call neurotic). The three main neurotic processes may be
seen as (a) self-downing (damning oneself for poor performances and
rejection); (b) hostility and rage (damning others for poor perfor-
mances and unkind reactions); and (c) low frustration tolerance
(damning things and the world for poor, dislikable conditions). These
three main "emotional" disturbances tend to be experienced individu-
Albert Ellis 105

ally and/or collectively at times by almost all humans and when two
or more co-exist (which they frequently do) they tend to interact with
other and exacerbate one another. They particularly add to and exac-
erbate personality disorders, as I shall show in detail below (Ellis,
1991; Ellis & Dryden, 1987, 1990, 1991; Ellis & Harper, 1975).
There are many personality disorders, such as narcissism, border-
line personality character disorder, obsessive-compulsive disorder
(OCD), schizoid personality, histrionic personality disorder, narcissis-
tic personality disorder, avoidant personality disorder and dependent
personality disorder. They vary in intensity, often accompany each
other, and often go along with other severe neurotic disorders, such as
neurotic depression, panic states and self-hatred (Ellis, 1965a, 1965b;
Kernberg, 1985; Masterson, 1981).
Because they are so varied and complex, I shall mainly limit myself
in this paper to discussing the borderline personality--which in its
own right is quite complex and varied and which also is often--or
usually--accompanied by serious neurotic disturbances and some-
times includes psychotic episodes. The main characteristics of the bor-
derline personality includes a pattern of unstable relationships, self-
damaging impulsiveness, affective instability, intense, inappropriate
anger, recurrent suicidal threats, marked and persistent identity dis-
turbance, chronic feelings of emptiness or boredom, and frantic efforts
to avoid real or imagined abandonment (American Psychiatric Asso-
ciation, 1987).
How do borderline personalities get to be the way they are? We can
start almost anywhere to examine the main causes of the problems
but let me arbitrarily start with their organic deficits, which I hypoth-
esize they largely inherit. They seem to be born with several innate
tendencies that interact with their experiences to produce several defi-
cits. Thus, cognitively they often have (probably from childhood on-
ward) attention deficit disorders, rigid ways of thinking, inability to
organize well, impulsive thinking, forgetfulness, inconsistent images
of others, inability to maintain a sense of time as an ongoing process,
learning disability, perceptual disability, proneness to be double-
bound, a tendency to exaggerate the significance of things, rigidity,
demandingness, severe self-downing, purposelessness, impairment in
recalling and recognition, deficient semantic encoding, etc. Neurotics
may have all these cognitive organic deficiencies, too. But they usu-
ally have them much less intensively, adjust to and cope with them
better, and exhibit them largely under stressful environmental condi-
tions, while borderline personalities tend to have them more endog-
lO6 Journal of Rational-Emotive & Cognitive-Behavior Therapy

enously and more severely (Barkley, 1990; Benjamin, 1993; Cohen &
Gara, 1992; Cohen & Sherwood, 1991; Gold, et al, 1992; Kazdin, 1992;
Lenzenweger et al, 1991; Linehan, 1993; Nestor et al, 1992; Rhodes &
Wood, 1992, Rosenbaum et al, 1988; Rourke & Fuerst, 1991; Swanson
& Keogh, 1990; Yee et al, 1992).
Emotionally borderline personalities, I again hypothesize, have in-
nate emotional difficulties and deficits. Thus they are frequently dys-
thymic, depressive, easily enrageable, overexcitable, high-strung, eas-
ily panicked, and histrionic (Adler & Buie, 1979; Andreason, 1979;
Barinaga, 1992; Berenbaum & Poltmanns, 1992; Bowlby, 1969; Davis,
1992; Hauser, 1992; Sperline & Sharp, 1991; Pediaditakis, 1991; Plu-
tchik, 1990; Plutchik and Kellerman, 1990).
Behaviorally, borderline personalities, again, are often born with
distinct tendencies to be hyperactive, hypervigilant, impulsive, ob-
streperous, interruptive, excessively restless, temper ridden, and anti-
social, or they often are alienated, addictive, overdependent, inatten-
tive, and purposeless (Cole, 1991; Iocono, 1989).
Again, neurotics may at times and to some degree have the above
emotional and behavioral traits, but borderline personalities tend to
have them more intensely, severely, frequently, consistently, and en-
dogenously (American Psychiatric Association, 1987; Benjamin, 1993;
Ellis, 1965a; Kernberg, 1986; Linehan, 1993; Masterson, 1981).
Let us assume, for the moment, that people with borderline person-
alities have some serious cognitive deficits. How will they neurotically
react to them? First of all, they will, according to REBT theory, on
some levels tend to observe or sense these deficits and put themselves
down for having them. They will often note that they have poor in-
tellectual functioning, demand that they m u s t not act inadequately,
berate themselves for having defects, and more easily feel like inade-
quate people--which borderline personalities often tend to feel any-
way, and which will now be significantly exacerbated.
If, as I theorize, borderline personalities have real cognitive defi-
ciencies, they will often tend to be jealous and hostile toward less dys-
functional people, will insist that these individuals m u s t not have
greater advantages than they themselves have, and will often show,
as DSM III-R notes, "intense anger or lack of control of anger, e.g.,
frequent displays of temper, constant anger, recurrent physical fights"
(American Psychiatric Association, 1987, p. 347).
If borderline personalities, as I again theorize, often have innate
behavioral problems, such as hyperactivity and temper tantrums, they
will tend to create or exacerbate their natural low frustration toler-
Albert Ellis 107

ance by demanding "I m u s t not be as handicapped by and looked down

upon for these handicaps, as I indubitably am!" So they will easily
have and aggravate, as DSM III-R observes, "marked and persistent
identity disturbance" and "frantic efforts to avoid real or imagined
abandonment" (American Psychiatric Association, 1987, p. 347).
If I am right about this, and if people with cognitive, emotional and
behavioral handicaps very often tend to severely down themselves,
hate other people, and hate the world; why should borderline person-
alities, who may well have all three of these handicaps, not come up
with similar--or worse--hatred of themselves and of others? Biolog-
ically, they may be more prone to hating themselves, others and the
world than are the rest of us neurotics. But even if they are not di-
rectly so, their other specific cognitive, emotive and behavioral hand-
icaps would, interacting with their general neurotic tendencies, tend
to produce these grim results.
To make matters still worse, if borderline personalities are, first,
innately handicapped in important ways; if they are naturally neu-
rotic or whining about these handicaps; and if they then directly and
indirectly produce their borderline conditions, these conditions them-
selves are quite cognitively, emotionally and behaviorally handicap-
ping--which, unless they are exceptionally stupid or defensive, they
could hardly fail to observe. If and when they do observe their bor-
derline characteristics and the real handicaps to which they lead in
our society, they will then once again tend to neurotically demand, (a)
"I must do better than I am actually doing!" (b) "Other people abso-
lutely m u s t not treat me unfairly, for my handicaps!" and (c) "The con-
ditions under which I live must not be so handicapping! It's awful and
I can't stand it when they are!" If they neurotically think these ways
borderline personalities will make themselves more disturbed--and
more borderline! (Leaf, Ellis, DiGiuseppe, Mass & Allington, 1991;
Priester & Clum, 1993).
Moreover, they will usually then to tend to take their hatred of
themselves, of others, and of their handicaps into their therapy, upset
themselves about it and about their therapists, and again make their
condition and their improvability much worse. As Benjamin (1993),
Linehan (1993), and other authorities indicate, their extreme social
difficulties will often include interpersonal problems with their often
quite devoted therapists.
I am proposing, then, that borderline personalities (as well as most
other individuals with serious personality disorders) have several
levels of disturbances all of which interact with and affect each other,
108 Journal of Rational-Emotive & Cognitive-Behavior Therapy

and w h i c h had better be considered together if we are to u n d e r s t a n d

w h a t the m a i n causes and effects of borderline personality disorders
are. Let me m a k e a s u m m a r y list of these levels.

Level 1: Borderline personalities usually have cognitive, emotional and

behavioral deficits some of which they are innately (and proba-
bly genetically) predisposed to have. Some of their borderline
behavior may directly stem from these deficits; and some of
their individual and social inadequacies almost certainly do.
Level 2: Borderline personalities (like neurotics) also have innate and
acquired tendencies to demand that they must succeed in
work, love and play and to denigrate themselves when they
fail; and they have innate and acquired tendencies to insist
that they must not be very frustrated or handicapped and to
have low frustration tolerance, anger and self-pity when they
are seriously balked. They therefore tend to be at least as and
probably more neurotic and self-defeating then are individuals
without personality disorders.
Level 3: Because of their innate cognitive, emotive, and behavioral
impairments, and because of their self-downing and low frus-
tration tolerance about these impairments, borderline per-
sonalities became even more psychobiologically impaired and
dysfunctional; and then their neurotic self-deprecation and
discomfort disturbance about their impairment tends to make
them still more impaired, still more disturbed about their dys-
functions, and still more impaired. A vicious cycle ensues, in
the course of which impairment encourage neurosis, neurosis
promotes more impairment, and greater impairment encour-
ages more neurosis.

This vicious circle can be partially alleviated if borderline person-

alities are helped to minimize t h e i r self-denigration and t h e i r low
frustration tolerance (LFT). But t h e i r original cognitive, emotional,
and behavioral d e f i c i t s - - w h i c h often present t h e m with tendencies to
strongly and rigidly hold on to musturbatory, rigid d e m a n d s t h a t lead
to self-downing and intolerance of f r u s t r a t i o n - - b l o c k t h e i r alleviating
t h e i r neurosis and often seriously exacerbate it. They m a y also be bio-
logically prone to bringing on secondary neurotic symptoms by de-
m a n d i n g t h a t t h e y absolutely must not be anxious and depressed about
(a) t h e i r original cognitive, emotional, and behavioral deficits, about
(b) t h e i r neurotic nonacceptance of these deficits, about (c) t h e i r severe
symptoms, and about (d) t h e i r u n u s u a l difficulty in w o r k i n g in ther-
apy and/or by themselves to improve themselves.
The vicious cycle m e n t i o n e d above can also be p a r t l y or largely alle-
Albert Ellis 109

viated if it is possible to make up for the original biosocial deficits of

borderline personalities. But these deficits are usually so varied and
profound that our present medications and remedial teachings are of-
ten helpful but only partially effective and there is no indication that
they will be truly curative in the near future.
So I think we'd better face the reality and borderline personalities
are not hopelessly and totally incurable but are still so biologically,
psychologically, and socially handicapped that we can rarely help
them achieve what may be called a "real" cure. Sometimes we can
help them minimize their neurosis about their borderline condition,
but even that may be limited because they often rigidly cling to their
self-deprecation and their abysmal low frustration tolerance, and
therefore have to work harder than normal neurotics to give them up.
But the catch 22 is that they rarely work hard at anything consis-
tently, because of their basic cognitive, emotional, and behavioral defi-
c i t s - s u c h as attentional deficit disorder and focusing deficitsqand
because their abysmal LFT and short range hedonism interferes with
sustained discipline.
What, therapeutically, shall we do? Shall we expect very limited
gains? Work mainly on the neurosis about their borderline condition?
Train them to partially overcome or compensate for their basic cogni-
tive, emotional, and behavioral deficits?
Probably all of the above, depending on our own skills and patience
as therapists and on the borderline's highly individual inclination to
get better, to do very hard and persistent therapeutic work, and to
relate to anyone, including their therapist. Here are some therapy
guidelines I would suggest for therapists who have the guts to work
persistently with them.
1. Try for real improvement but expect limited gains with most of
them. Even normal neurotics rarely improve as much as we would like
them to do, and borderline personalities are much more disturbed and
usually much more resistant to changing. Fully accept this reality and
don't discourage yourself when you meet up with it. Have abundant
patience and fortitude!
2. Work on yourself to acquire unconditional acceptance--or what
Rogers (1961) called unconditional positive regard--for your bor-
derline clients. Deplore and even hate their annoying, often hostile
and antisocial traits, but accept them with their poor behavior. Often
confront them with their obnoxious and self-defeating thoughts, feel-
ings and actions, but do so supportively, protectively, and utterly non-
damningly. Forgive the sinner, but not necessarily the sin.
3. Unlike Carl Rogers, while with your manner and verbaliza-
110 Journal of Rational-Emotive& Cognitive-BehaviorTherapy

tions, you unconditionally accepting borderline personalities but not

some of their worst behaviors, teach them--yes, teach them as well as
you can--specifically how to unconditionally accept themselves. REBT
presents clients with a less elegant and a more elegant solution to this
important human problem.
Less elegantly, you can teach your clients the existential, humanis-
tic philosophy that they can accept themselves unconditionally
whether or not they perform or relate well--just because they are hu-
man, just because they are alive, just because they choose to do so. All
self-acceptance is really a choice and is definitional. When we have
what is usually called self-esteem--probably the greatest emotional
sickness of men and w o m e n h w e wrongly decide to accept ourselves as
"good" or "deserving" individuals on condition that we perform well
and are loveable. This won't really work: Because even when we meet
these conditions today, we may well not meet them tomorrow. So we
are always basically a n x i o u s h m e a n i n g , over-concerned about our
performances.
When we decide to accept ourselves unconditionally with all our
warts and failings, our sense of self or identity is still chosen and still
definitional. But this time our defining ourselves as "good" or "wor-
thy" is more practical and useful. For we will safely accept ourselves--
as long as we are a l i v e - - a n d presumably will only have to worry
about our identity when we are dead!
This solution to the problem of self-worth is somewhat inelegant
however, because it is not falsifiable. Thus, you can firmly say, "I fully
accept myself as a worthwhile person because I am alive and human"
and I (and other people) can object, "But I think that, because you are
alive and human, you are no good and worthless. In fact, all humans
are worthless and only deserve to die!"
Which of us, then, is r i g h t p y o u or I? Answer: Neither of us can
substantiate or falsify our view of h u m a n worth--because both our
views are definitional and tautological. Yours will probably work bet-
ter than mine if your goal is to keep you'and'the'human'race'alivel
healthy and happy. But it is still quite definitional.
REBT has therefore for more than two decades proposed a more ele-
gant solution to the problem of h u m a n worth that you can teach to
your borderline (and other) clients. They can choose to only rate or
evaluate their thoughts, feelings, and behaviors and not fall into the
dangerous error of rating or measuring their self, their essence, their
being, or their totality. Thus, they can say, "Because I choose to stay
alive and be healthy and reasonably happy, many of my acts and traits
Albert Ellis 111

are 'bad,' "harmful" or 'against my purpose,' but I am too complex, too

much of an ongoing process, to give any rating, good or bad, to my self
or being."
This more elegant solution to self-acceptance is, I have found, diffi-
cult for most neurotics and borderline personalities to achieve. Why?
Because, I hypothesize, self-rating has, through the course of human
evolution, some distinct advantages, is biologically predisposed, and is
hard to surrender. But even borderline personalities can minimize it,
if they are unconditionally accepted by their therapists and actively
taught to accept themselves.
4. Borderline personalities, for reasons mentioned above, usually
have both innate and acquired abysmal low frustration tolerance,
(LFT), and LFT includes the irrational, dysfunctional beliefs that
"Conditions absolutely must not be as hard as they are! It's awful and I
can't stand it!" But these beliefs can be clearly revealed and forcefully
disputed. As noted previously, LFT itself will stop clients from think-
ing and working hard to overcome their LFT! But you, as a therapist,
can persist in showing borderline clients how self-defeating their LFT
is, and how to ameliorate it. Don't give up and give into our own LFT
in this respect!
5. Borderline and psychotic clients have many specific dysfunc-
tional cognitions that accompany their delusions, obsessions, compul-
sions, paranoid thinking, suicidalness, and other disturbances. These
can often be successfully reduced with the usual methods of rational
emotive behavior and cognitive-behavioral therapy. Complete cure in
this regard is unlikely, but significant improvement can often be
achieved (Beck, Freeman & Associates, 1991; Benjamin, 1993; Cahill,
1993; Benjamin, 1993; Ellis, 1965a, 1985; Friedberg, 1993; Leaf & Di-
Guiseppe, 1992; Linehan, 1993; Stone, 1990; Yankura et al, 1993;
Young, 1990).
6. The original and partially biological thinking, feeling and be-
havioral deficits of borderline personalities that I mentioned in the
beginning of this paper are not easy to improve, but can often be ame-
liorated by psychotherapists, neuropsychologists, rehabilitation coun-
selors, teachers, and other professionals. You, as a therapist, can try to
help your borderline clients in this respect, or you can refer them to
other suitable professionals. As both Benjamin (1993) and Linehan
(1993) indicate, skill training, which may partially compensate for
their deficits, is almost mandatory with many of them.
7. Borderline clients often think in what may be called "perverse"
or "intentionally self-defeating ways" underneath which may be found
112 Journal of Rational-Emotive & Cognitive-BehaviorTherapy

a method to their madness. Thus, at one and the same time, they may
attempt suicide to control others and have them surrender to their
overweening need for attention and support. But they may also try to
kill themselves, as one of my own clients attempted, because she
wanted to convince me how really sick she was and that I was wrong
in trying to show her that she could live and have a happy existence.
Therapists, therefore, had better at times be quite clever at unravel-
ing, revealing, and disputing some of the borderline's dysfunctional
thinking. They may use the kind of dialectical or oppositional persua-
sive techniques of Linehan (1993), the use of the client as a consultant
methods of Benjamin (1993), or the paradoxical and metaphorical
methods that Hayes (Hayes, McMurry, Afari & Wilson, 1991) uses
with agoraphobics but that can also sometimes by used with bor-
derline personalities. Because these clients are often fiendishly clever
in holding onto their disturbances the therapist's equally clever dis-
puting sometimes wins out.
However!--although clever and well calculated therapist ripostes
sometimes win the g a m e - - a n d look marvelous in p r i n t - - t h e meat and
potatoes common diet of regular cognitive-behavior therapy more of-
ten, and especially in the long run, probably is more effective.
8. Because the borderline clients are often so unpredictable and
unique, cognitive-behavior therapy, which is notably multimodal and
multifaceted, seems to be the best general choice. REBT, like Lazarus'
(1990) multimodal therapy, includes a large number of cognitive, emo-
tive, and behavioral methods, so that when the usual ones do not seem
to be working, I try some of the less usual ones, and sometimes find
that they work well. Thus, although I teach my clients that rage is
almost always self-destructive, I induced one of my borderline clients
to give up all thoughts of killing herself because her arch-rival for her
lover's affection would certainly live and be deliriously happy. So I
encouraged my client, at least temporarily, to keep and to vent her
rage against her rival and thereby motivate herself to live and work
for her own happiness.
9. Psychopharmacological treatment sometimes works well with
borderline clients--and often does not work or has poor side effects. I
frequently recommend that my clients experimentally try antidepres-
sants or other medications, and if they don't work and/or find taking
them too obnoxious, they can always return to psychotherapy alone.
My helping them increase their frustration tolerance and decrease
their medication phobias frequently serves to get them to try proper
medication and to put up with the side effects of some medications.
Albert Ellis 113

Conversely, being on an antidepressant and/or a tranquilizer some-

times helps them think better and benefit more from REBT. But, be-
ing tricky, they also may use pharmacological treatment as an excuse
not to work hard to change their thinking, feeling, and acting.
10. Having over the years, tried both psychoanalysis and cognitive-
behavior therapy with many borderline individuals, I have abandoned
the former, except for some of its relationship aspects, and have
heavily used the latter. Other cognitive-behavior therapists, and I
think therapists in general, have found cognitive-behavioral methods
quite useful with borderline personalities (Beck, Freeman & Associ-
ates, 1991; Benjamin, 1993; Ellis, 1962, 1956a, 1985; Linehan, 1993).
As for psychoanalysis, I now feel that it is exceptionally wasteful for
most neurotics and fairly iatrogenic for most borderline personalities.
Kohut's (1971) methods is basically Rogerian and probably less harm-
ful than other psychoanalytic techniques. Kernberg (1984, 1985) and
Masterson (1981) are more confrontative but too sidetrackingly psy-
choanalytic for my prejudiced tastes!
Let me conclude with a presentation of one of my cases, Rona, a
woman of 25, who I saw nine years ago because of what she called
severe depression. She worked as a bookkeeper in a small office, be-
cause she was afraid of human contacts, considered herself "horribly
ugly" (though she was quite attractive), and strongly felt t h a t she was
a basket case, was on one side of the human race, while every other
person was on the other side--the good side. She had no social rela-
tionships and was sure that she couldn't make any because of her ex-
treme shyness, need for love, and self-rejection. She had made suicide
attempts at the ages of 16 and 21 but was saved by her parents each
time and rushed to the hospital. She was briefly hospitalized each
time, refused to take medication after she left the hospital, and went
back to living with her critical parents, whom she hated but couldn't
set herself free from. She felt abandoned by them and was determined
to never risk abandonment again. She also felt continually bored and
empty and spent her leisure hours sleeping or looking at television,
although she was quite intelligent and had achieved an MBA degree
with honors. Typically, Rona made no friends in college and none at
work. Her one relationship, just before she came to see me, was a brief
one with John, who was quite attracted to her, who pushed her for
dates, but who was soon turned off by her intermittent hostility and
dire need to be constantly assured that he really, really loved her and
would never abandon her.
Rona came to see me when she was severely depressed after John
114 Journal of Rational-Emotive& Cognitive-BehaviorTherapy

had broken off with her. I could see quickly, from her history, her
unstable emotionality, her complete focus on herself, and her phobic
and panicked reactions that she was hardly a nice neurotic and that
she would most probably be a difficult customer, what I call a DC.
I was right. She alternatively was very seductive--and very hos-
t i l e - t o me. She knew about REBT but was very skeptical of it be-
cause of her nine years of previous psychoanalytic therapy which she
considered "deep" but "highly ineffective." She threatened to stop see-
ing me from the first session onward and, during the three years I saw
her she quit twice for a month at a time. She at first identified me
with her hated supercritical father, but later became overattached to
and overdependent on me. She was very resentful when I went out of
town for a few days for talks, workshops, and conferences, and would
insist on phone sessions at the hotels where I was staying.
Following REBT principles, I fully accepted Rona with her difficult-
ness and tried to teach her, over and over again, how to uncondi-
tionally accept herself, accept her critical parents, and accept her bor-
derline, quite handicapped condition. I honestly and firmly kept
showing her that she was probably innately disturbed--as were both
her parents--and that she often behaved hostilely and had better--
not must--change her hostility for own sake.
Although Rona strongly objected to the REBT philosophy of fully
accepting herself and others, I persistently showed her that the results
she was getting from her self-hatred, withdrawal, and hostility,
weren't worth it and that only something like unconditional self-ac-
ceptance would bring better results. My efforts finally prevailed and
within six months of therapy she started to "get it" and to become a
devotee of undamning acceptance. She joined one of my regular ther-
apy groups and consistently came to my regular Friday Night Work-
shop, where I demonstrate REBT with volunteers who have sessions of
public therapy. She also attended a record number of four hour public
workshops that are given every other week at the Institute for Ratio-
nal-Emotive Behavior Therapy in New York. At the group and work-
shop sessions she vigorously kept convincing other participants of the
value of unconditionally accepting themselves and others.
I had greater difficult helping Rona reduce her abysmal low frustra-
tion tolerance, but I was finally able to convince her that demanding
immediate gratification at the expense of later pain wasn't worth it.
So, no matter how uncomfortable she felt, she began to go through
difficult dates, make and keep friendships with somewhat unreliable
people, work in a larger office, force herself to overcome her public
Albert Ellis 115

speaking phobia, accept my absences from her therapy sessions when I

was out of town, stop smoking, and do many other uncomfortable
things for her later satisfaction.
I, her therapy group, and her workshop groups helped Rona acquire
several skills in which she was deficient. In the course of this skill
training she became quite assertive, began to listen more attentively
to others, learned how to actively break the ice and meet new people,
became adept at job interviewing, and took courses that led to her
becoming a CPA. At the same time, her innate and acquired tenden-
cies to be unfocused, to think impulsively, to exaggerate the signifi-
cance of things, to be emotionally labile, and to be purposeless deft-
nitely improved or interfered less with her social and work behavior.
I still see Rona for occasional therapy sessions and as a visitor at
some of my Friday Night Workshops; and I hear about her from sev-
eral of her friends and relatives who she keeps sending to me for ther-
apy. By all visible standards she is now only moderately neurotic--
like most of the human race. But as a trained clinician, I can still see
some of the remnants of her borderline condition showing through her
outward demeanor. She now makes herself angry and depressed on
relatively few occasions, but when she does, she becomes quite discom-
bobulated, stutters and stammers, and for several days is disorganized
and distraught. She has good social relationships but never becomes
too deeply involved with anyone. She displays little overt hostility but
underlyingly is very jealous of successful people and somewhat para-
noid about being exploited by her friends. She is a successful CPA but
sometimes feels that her life is meaningless and purposeless and that
she is not truly integrated into the human race.
Rona, although vastly improved, is not quite whole. I have said for
many years t h a t REBT can help people overcome their neurosis about
their psychosis and about their borderline personality; and by working
very hard to fully accept herself and to acquire higher frustration tol-
erance, Rona has used it to become much less neurotic. B u t I don't fool
myself into believing that she or any of the other psychotic and bor-
derline individuals I have helped with REBT for the last 43 years
have been truly cured. Nor have I seen any other therapists' clients
with borderline and psychotic disorders who, even after many years of
treatment, are now truly healthy. Significantly and even magnifi-
cently improved, yes. But still underlyingly psychotic or borderline.
Being something of an optimist as well as a realist, I think that the
arts of psychotherapy and of psychopharmacology are both in their
infancy stages and that someday they will combine to help borderline
116 Journal of Rational-Emotive& Cognitive-BehaviorTherapy

personalities more than they do today, perhaps even cure them of

their borderline states, and leave them, like the rest of the h u m a n
race, only neurotic. Meanwhile, working with borderline personalities
is damned difficult--but it can also be quite challenging and reward-
ing. Yes, for clients as well as for therapists!

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