The specifics of cognitive and behavioral responses to therapy of the patients with borderline personality disorder: overview of foreign studies

Zvonov Petr Anatol'evich Psychologist with a Master's Degree, Science Education Project "99 Thoughts" 109202, Russia, Moscow, Perovskoe highway, 10k2, sq. 28 jchembers@gmail.com

The inability to function normally, the need to solve organizational, personal and interpersonal problems caused by the disease, maladaptation and disorientation – all this continuously accompanies the lives of people with personality disorders, significantly reducing their quality of life. People with a personality disorder have an acute need for treatment with psychotherapeutic and sometimes medicinal methods. Currently, many directions have already been developed and are being developed in the field of providing assistance to patients with personality disorder, but so far no one direction can be called exceptionally effective.

The lack of effectiveness and lack of universality in approaches to psychotherapy of personality disorders are due to many factors. So, at the stage of diagnosis, such factors as: comorbidity of personality disorder with other disorders, concealment of symptoms by the patient and social mimicry, blurring of symptoms, inability to monitor the patient's behavior for a long time, etc. create difficulties. The process of psychotherapy is often complicated by anosognosia, the patient's resistance to therapy, a low level of quality of the therapeutic alliance and alliance breaks, transfers and countertransferences, dropout, lack of compliance and many other factors.

Research in the field of various psychotherapeutic approaches to the treatment of personality disorders and, in particular, borderline personality disorder, shows, on the one hand, the possibility of significant relief of the patient's condition, on the other hand, a fairly low percentage of patients who can lead a full–fledged lifestyle after treatment. So, when using mentalization, and scheme therapy, and alternative approaches to the treatment of borderline personality disorder, the proportion of patients in whose condition no significant and persistent disorders are recorded remains quite high.  Therefore, the study of approaches to the diagnosis and treatment of personality disorders is an urgent scientific task.

Within the framework of this task, it is of interest to study the problems of borderline personality disorder, widespread, according to J. Chapman et al. ^[1], in 1.6% of the population. At the same time, about 10% of people with borderline personality disorder die as a result of suicide [Diagnostic and statistical manual of mental disorders: DSM-5], up to 70% attempt suicide, and about 90% inflict injuries to themselves – such as burns and cuts ^[2,3]. Thus, borderline personality disorder is one of the most life–threatening diseases ^[4].

An analysis of the scientific literature shows that there are a large number of studies of various methods of treating borderline personality disorder, but there is practically no systematic data on the patient's perception of the therapist and the therapy process. Therefore, there is every reason to believe that the primary systematization of information about the most common cognitive and behavioral reactions to therapy in patients with borderline personality disorder will allow us to gain new scientific knowledge. Under cognitive reactions we will understand thoughts, judgments and beliefs that arise as a result of the processing of information by the patient's brain, internal and external stimuli received by him during the therapeutic process.

Such information can be useful in the development of theoretical approaches to the diagnosis and treatment of borderline personality disorder, becoming the basis on which the design of clinical trials can be developed. They can also be useful in the practical field, contributing to the faster finding of effective approaches to treatment, taking into account the individuality of the patient, as well as the preparation of the therapist and the prevention of his emotional burnout.

Thus, the purpose of this article is to expand the understanding of the possibilities of psychotherapy of borderline personality disorders based on the analysis of foreign scientific publications related to the peculiarities of cognitive and behavioral reactions to therapy in patients with borderline personality disorder. The subject of the study is the cognitive and behavioral reactions of patients with borderline personality disorder in the process of psychotherapy. The scientific novelty of the article lies in the systematization of information about cognitive and behavioral reactions of patients with borderline personality disorder obtained as a result of foreign studies.

The methodology of the review is based on approaches to evidence-based psychotherapy. All the analyzed research results are based on scientific facts established as a result of long-term clinical experimental and theoretical work in such forms as randomized clinical trials and meta-analysis. It should also be noted that there are fundamental differences between domestic and foreign psychotherapy, therefore, in order to preserve the comparability of sources in the process of performing a systematic review, it is preferable to consider studies from only one category. In this article, foreign experience will be considered.

As noted by A. Beck and A. Freeman ^[5], initially the diagnosis of borderline personality disorder was made in case of difficulty in making a diagnosis with mixed neurotic and psychotic symptoms. With the advent of the DSM-III-R, this uncertainty was eliminated and borderline personality disorder began to be considered as a stable pattern of perception, attitude and thinking, causing problems both in interpersonal communication and in self-perception. People with borderline personality disorder are characterized by extremely intense emotional reactions – especially negative ones, instability of mood and self-esteem, impulsivity, feelings of hopeless emptiness and boredom. Such people can be very effective in some areas of life – and have significant problems in others. In our opinion, the approach of A. Beck and A. Freeman is one of the most deeply and qualitatively scientifically grounded approaches to understanding the essence of personality disorders.

In the article by L. Duike, E. Antonescu et al. ^[6], a patient with borderline personality disorder is described as a person with expressionless facial expressions and gestures, absent-minded, rigid in the field of alternative thinking, with a high level of psycho-emotional lability and rejection of criticism.  The patient herself described herself as shy, emotionally unstable, indecisive, difficult to choose, sensitive to criticism and at the same time a self-critical personality, prone to perfectionism.

In the therapy of borderline personality disorder, methods such as dialectical behavioral therapy, transference-focused therapy, mentalization-based therapy, and scheme therapy are used. All these methods have shown benefits in the treatment of borderline personality disorder ^[7]. Nevertheless, the statistical results obtained in the study of J. Woodbridge, M. Townsend et al. ^[8] indicate that about 48 (forty-eight) percent of patients with borderline personality disorder do not respond to treatment, regardless of its method and duration. In our opinion, this is largely due to the comorbidity of borderline personality disorder with many types of personality disorders and variability in the manifestation of symptoms, which are an obstacle to the diagnosis of borderline personality disorder, especially by traditional psychological testing methods. Of undoubted interest, from our point of view, is the further implementation of this study, the study of the effectiveness of the treatment of borderline personality disorder, depending on gender, age, geographical affiliation of the patient and other factors. We will return to this issue later.

In the study of J. Lobbestael, A. Arntz et al. ^[9] several modes of functioning of the psyche of a patient with borderline personality disorder are considered. The first of them is the "vulnerable child mode", in which the patient feels most helpless and expects help and finding solutions from others. An alternative to this condition is the "impulsive or angry child mode", in which the patient either self-harms himself or actively demands participation from others, without thinking about the consequences of his behavior. Both of these modes can lead to the activation of the "punishing parent mode", which is characterized by acute feelings of shame and guilt. The pain experienced leads to the activation of the "detached defender mode", in which the patient can stay for a long time without having more adaptive ways to protect his own psyche. We believe that the first two conditions have been analyzed and studied very deeply in this study, and practical experience shows that such conditions are indeed often observed in patients with borderline personality disorder. The development of these conditions into a desire for self-punishment and subsequent detachment requires, in our opinion, additional research due to the many possible scenarios for changing the patient's condition.

In a study by V. Suarez and G. Feixas ^[2], it was noted that patients with borderline personality disorder rarely seek help for the borderline disorder itself. Most often, the reason for treatment is the need to alleviate the symptoms of depression, anxiety disorder, eating disorders and other symptoms that significantly reduce the quality of life.

 In the study of K. Dalival and A. Danzig et al. ^[10], patients' dissatisfaction with the focus of therapy on the treatment of borderline personality disorder, and not on the initial request of the patient, was noted. In the article by J. May, T.M. Richardi et al. ^[11] it is also noted that people with borderline personality disorder experience difficulties when seeking psychotherapeutic help, avoid it or demand its provision in ways offensive to others. However, in our opinion, another point of view is also true – patients with borderline personality disorder are the most motivated for treatment compared to all other patients with personality disorders. Their problem often lies in the fact that they do not know what disease they are suffering from, so the diagnosis brings them relief.

In the study of A. Arntz, K. Mensink et al. ^[12], statistical data related to the interruption of therapy in patients with borderline personality disorder were studied. The following results were obtained: the largest share of dropout occurs in the first quarter of treatment; dropout in group therapy occurs more often than in individual therapy; therapy based on mentalization and scheme therapy surpass other methods in the duration of patient retention. There was no effect on the duration of treatment of such factors as the patient's gender, treatment conditions, country and a number of other socio-economic factors. Similar results were obtained by S.A. Ramerkes, R. Verkhoyev et al. ^[13], who established the absence of a statistically significant relationship between the effectiveness of the treatment of borderline personality disorder and the form of treatment, its conditions, pharmacological policy and socio-demographic characteristics of patients, except for their age. At the same time, it is noted that the scheme therapy is appreciated by patients because of the opportunity to establish, on the one hand, a closer relationship with the therapist, to receive more care from him, and on the other hand, directive, precise indication of the scheme of actions is appreciated. We believe that such results have great scientific value, because based on them, it is possible to plan experiments more accurately in future studies, excluding from hypotheses the verification of factors that have little effect on the effectiveness of treatment. Probably, the independence of the effectiveness of treatment from most socio-demographic, economic and political factors is associated with exceptionally deep damage to the patient's personality.

K. Dalival and A. Danzig et al. ^[10], investigating the characteristics of patients with borderline personality disorder, also came to a number of interesting conclusions.  So, one of the most important expectations of the patient from the therapist is to explain to the relatives and friends of the patient the specifics of his disease and condition. We believe this is an important result; probably, if the therapist is trained to tactfully and ethically explain to the patient's relatives the essence of his disease and the prospects for treatment, and at the same time is able to achieve understanding and empathy for the patient on their part, this can have a very beneficial effect on the therapy process. Perhaps communication with the patient's relatives and friends in this way should become an important part of the therapy of patients with borderline personality disorder.

Also, a person with borderline personality disorder may experience fear of not receiving treatment if he does not look sick enough, fear of a biased attitude on the part of the therapist and clinic staff. This implies their desire to hide both signs of improvement in well-being and signs of deterioration. In the first case, this is due to the fear of stopping therapy, in the second - because of the fear of not pleasing the therapist. Patients often misinterpret the therapist's behavior, mistaking anxiety for anger. Also, such patients are characterized by unexplained and unpredictable changes in mood and behavior. Therefore, the variability of symptoms and the variability of the condition are the targets of therapy. This is also an important result, in our opinion, which must be taken into account when building a therapy strategy for a patient with borderline personality disorder. It would be desirable for the therapy to include a check for the presence of such destructive beliefs in the patient and develop a strategy for their neutralization.

The study by H.F. Blyton, L. K. Rosenstein et al. ^[14] examines the therapy of the same patients with borderline personality disorder by different therapists. The expediency of this study is due to the tendency of patients with borderline personality disorder to undergo psychotherapy courses with different therapists, which makes it difficult to assess changes in the patient's condition. The results of the study indicate the patient's desire to comprehend the treatment and participate in it; at the same time, the patient can purposefully test the therapist for his competence, qualifications and responsibility. On the other hand, the patient himself may suddenly become irresponsible and skip therapy sessions.

The need to take responsibility for the result of treatment causes hostility in the patient. In addition, the patient, showing impulsiveness, tends to want immediate satisfaction of his needs. He can interrupt the therapist and shout at him, call him names and scold him. At the same time, the patient does not feel his own rudeness, callousness and hostility, since he is often unable to regulate affect in his behavior. After that, however, the patient feels a sense of shame when thinking about his own behavior, and the defensive reaction here is a complete rejection of alternative points of view. We agree with these conclusions, because we believe that patients with borderline personality disorder tend to transfer responsibility to others and the therapist is a very suitable candidate for them for such a transfer of responsibility. The removal of responsibility probably reduces the moral restrictions on who accepted this responsibility.

It has been established that often the patient expects help from the therapist in self–determination and self–regulation, and his attitude towards the therapist varies from childish - in relation to the parent - to hostile; the therapist himself is perceived as a holding, then as a rejecting personality. The patient often feels the need for intimacy with the therapist, but at the same time rejects intimacy for fear of being abandoned. Often, a semblance of a parent-child relationship is established between the patient and the therapist.

Infantile behavior of the patient manifests itself in obsession outside of therapy, unwillingness to complete sessions, dependence on therapy at its first stage. Patients with borderline personality disorder often perceive therapy as the last hope for normalizing their lives. These conclusions, in our opinion, are valuable because, on the one hand, they pay attention to the targets of therapy – infantilism and fear of rejection, and on the other – they justify the need for special training of the therapist to treat patients with borderline personality disorder in order to protect him from professional burnout.

Such patients are characterized by a tendency to describe their experience and behavior, but not to reason and not to reflect. A patient with borderline personality disorder tends to avoid thinking about their experiences, thoughts and emotions. The patient's inability to imagine that another person might think differently may cause distrust of the therapist.

In this part of the study, the key idea, in our opinion, is the rejection by patients with borderline personality disorder of alternative points of view. Probably, this is an obstacle to understanding one's own experience, because otherwise it will be necessary to make a critical assessment of it, to consider one's experience from different points of view – namely, the multiplicity of points of view (pluralism of opinions) causes difficulties for such a patient.

Therapy of patients with borderline personality disorder often leads to emotional burnout of the therapist, feelings of inefficiency and rejection in the therapist. A. Bateman and P. Fonagi ^[15] showed that ambivalence of attachment in patients with borderline personality disorder causes an increased emotional burden on the therapist. This is also confirmed in a study by E. Betan and A.K. Heim et al. ^[16], who found that a therapist often experiences feelings of helplessness, inadequacy, depression and excessive involvement when working with patients with borderline personality disorder. The results of these studies once again prove the urgent need for continuous improvement of methods of prevention of professional burnout in therapists working with patients with borderline personality disorder. The unpredictability of the patient's attitude to the therapist and the therapy process causes a strong strain on the therapist's tolerance to uncertainty, and uncertainty, in turn, is itself a source of mental disorders.

Of interest in this regard is the study by P. Bhola and K. Mehrotra ^[17], the purpose of which was to study the features of countertransference in the therapy of patients with borderline personality disorder. The experience of 117 therapists from different countries who conducted psychotherapy of patients with borderline personality disorder was studied. By countertransference, researchers understand the totality of affective, sensory, cognitive and behavioral reactions of the therapist to the patient. In the course of therapy, the complexity of the personalities of patients with borderline personality disorder, the practice of primitive defenses, violation of the regulation of emotions and personal boundaries of the therapist are noted. The authors also refer to data according to which patients with borderline personality disorder tend to withdraw into themselves during therapy.

On the part of therapists, such specific reactions as anxiety, a feeling of powerlessness and insignificance, rage and horror were noted in relation to patients with borderline personality disorder. The consequence of such countertransference reactions is both a reduction in the patient's personal changes during therapy, and, very often, the termination of treatment. The special significance of the therapist's ability not only to imagine the emotional and life experience of the patient, but also to teach the patient the same action, to develop his mentalization skills is indicated. According to the results obtained, therapists most often experienced parental feelings for the patient or considered the patient special, but no less often experienced a state of helplessness in working with a patient with borderline personality disorder; there was also a feeling of underestimation, neglect and detachment of the patient during the session.

This study confirms the results of the studies we reviewed earlier. From our point of view, it is of interest to develop this study and identify what exactly is the source of the therapist's negative experiences – the patient himself, his disease, his cognitive and behavioral reactions. These data would make it possible to more accurately select methods to strengthen the therapeutic alliance and prevent burnout of the therapist.

A.A. Sondergaard, S. Juul et al. ^[18] investigated the experience of therapists treating patients with borderline personality disorder, focusing on short-term, five-month therapy based on mentalization. As a result of the study, it was found that therapists agree on the insufficient duration of short-term therapy. This is due to the quantity and quality of problems accumulated during the patient's life and the need for long-term treatment of problems that have existed for a long time. Short-term therapy is suitable for relieving specific symptoms, but not for making personal changes. In addition, the allotted time may not be enough to build a high-quality therapeutic alliance. At the same time, therapists note that patients with borderline personality disorder rarely form an attachment to the therapist himself, although they are glad that there is someone who is ready to listen to them and look for solutions to their problems with them. Therapists also agree that patients with borderline personality disorder intellectualize their emotions, show signs of alexithymia, find it difficult to describe their physical sensations associated with emotions. Therapists consider the problem of completing therapy to be one of the significant difficulties. Fear of rejection is one of the vulnerabilities of patients with borderline personality disorder; the end of therapy may be perceived by such patients as rejection, which increases their fear of being abandoned. Many patients claim that they will be able to recover only in the presence of a therapist.

The key conclusion of this study, in our opinion, is the conclusion that short-term therapy is insufficient to achieve a noticeable improvement in the condition of patients with borderline personality disorder. The totality of the peculiarities of thinking and emotional intelligence of patients with this disease revealed during the study confirms the need for long-term treatment. Patients not only suffer from the personality disorder itself, but also find it difficult to describe their condition, and the ability to self–esteem and self-reflection of the patient is, in our opinion, the most important component of psychotherapy. Therefore, the results of the study indicate that in many cases, the patient must first be taught to undergo therapy, and only then proceed to the treatment itself.

In the study of I.M. Tan, K. U. Li et al. ^[7], the experience of therapy of thirty-six patients with borderline personality disorder who were treated with scheme therapy methods for at least twelve months was studied using qualitative research methods. As a result of the study, it was found that patients attach particular importance to explanations about their condition and training in ways to recognize triggers of deterioration, as well as an individual approach to them. An important expectation from psychotherapy is the prospect of stopping taking medications. Patients expect long-term therapy, but therapy lasting about two years is perceived as insufficient in time; patients also have a hard time experiencing a reduction in the number of sessions. One of the patients argued his need to continue therapy by saying that he had suffered from a personality disorder for forty years and two years of therapy was not enough for him to compensate for it. In addition, patients note that they need a lot of time to feel confidence in the therapist.

At the beginning of therapy, patients often experience fear of both potential changes and the need to immerse themselves in their past experiences, while fearing a collision with their own high demands and self-accusations. The actual process of therapy in the part where it is associated with working with memories, patients called frightening, stunning, painful, exhausting, etc.

At the same time, patients in communication, including with a therapist, tend to intellectualize their experiences, ignoring their emotional side. Many of them had difficulties in performing imagination exercises, feeling in a state of dissociation; nevertheless, they also noted the effectiveness of these exercises. It is interesting to note that many patients were genuinely surprised when they first saw the positive results of using various therapeutic techniques.

More than eighty percent of patients positively characterized their therapists, while, characteristically, many compared the therapist with the adoptive parent. The preference of the therapist of the same sex with the patient is noted – in women because of the possible sexualization of the relationship, if the therapist is a man, in men – mainly because of the fear of offending the female therapist in any way. Patients highly appreciated the therapist's open-mindedness and the absence of imposing his point of view on his part, the formation of a sense of security, empathy and foresight of the patient's condition. As a positive factor forming trust and a sense of security, patients called the opportunity to communicate with a therapist by e-mail at any time. It is also important for patients to pay attention to their personality, and not just to the symptoms of the disease. The therapist's tactics of putting forward hypotheses – with the requirement for the patient to eliminate the corresponding defects - were negatively perceived.

With regard to group therapy, the following dynamics of patients' cognitions were noted – from feeling like the only strange person to the formation of a sense of security after patients were convinced that they were not alone in their problems. This allowed the majority of patients not to feel vulnerable in the process of group psychotherapy, to behave freely and openly discuss their experiences and experiences. The additional support of the group members allowed the patients to feel more confident than during individual therapy. A smaller part of the patients, however, adjusted to the rest of the group, fearing to cause unpleasant emotional reactions in others. The disadvantage of group therapy for a third of patients was the regular comparison of themselves with other patients and the dynamics of changes in them. But for a quarter of the patients, the progress of the rest of the group members became a motivating and inspiring factor, confirmation of the effectiveness of therapy.  Most patients believe that it is best to study ways to improve their condition during group therapy, and during individual therapy to analyze specific examples and focus on understanding the need for therapy itself.

So, this study contains conclusions about a number of features of patients with borderline personality disorder. The results obtained, in our opinion, are in good agreement with the results of other studies. Firstly, patients with borderline personality disorder have a need to understand what is happening to them. Secondly, patients, on the one hand, have an acute conscious need for treatment, they want it to last as long as possible; but, on the other hand, they have a fear of change. In our opinion, paradoxically, patients with borderline personality disorder, having an insufficiently developed identity, are afraid of losing it in the course of therapy. Thirdly, the results were obtained confirming the need of a patient with borderline personality disorder for a "fulcrum", which for them is a therapist. This circumstance also opens up a direction for the development of tools for building such a strategy of relations between the therapist and patients, in which the therapist can give the patient confidence in constant support, while maintaining their personal boundaries. Fourthly, we consider it an undoubtedly important result to prove the effectiveness of group therapy for patients with borderline personality disorder. Belonging to a community of people with similar problems protects such patients from the fear of loneliness and rejection. Group therapy is also a great opportunity to train patients with borderline personality disorder to perceive and accept someone else's point of view.

The study by O. De Ujald Brand, S. Clark et al. ^[19] is related to the study of the perception of regular feedback based on the severity index of borderline disorder from patients with borderline personality disorder during therapy. Within the framework of the results obtained, the following inclinations and needs of patients are noted: the desire to avoid their feelings, the expressed need for mentoring in the field of self-improvement, the search for a therapist qualified enough to form trust, the need for an individual approach and the opportunity to personally explain their characteristics, the opportunity to explain their condition to close people, relying on the support of a therapist, the need to control and to regulate the goals, objectives and content of therapy, the need to stay in the therapy process as long as possible, because this is a safe place and a place where you can speak out. Patients often see motivation to continue treatment in the results of self-analysis of the progress achieved.

The results of this study are also, in our opinion, consistent with the results of other studies. In our opinion, the key result of this study is that as borderline personality disorder progresses, the patient increasingly needs a person accompanying him at all stages of therapy and assuming the functions of not only a therapist, but also a "social representative" of the patient.

In a review of the problems of people with borderline personality disorder, A. Smith and D. McDougall ^[20] consider their perception of therapy. First of all, it is noted here that people with borderline personality disorder often get relief when receiving a diagnosis, since this opens the way to improving their condition, but this path is initially perceived by them as long and difficult. Complicating the situation is the lack of such people's experience of living in a normal mental state, i.e. recovery for them is not identical to returning to normal, but the essence of acquiring a new state. Also, many patients have a fear of losing their identity as the symptoms of borderline personality disorder disappear during therapy; there is also a fear of condemnation, especially in group therapy. The severity of therapy and the development of new ways of thinking and behavior causes aggressive reactions in some patients – such as the desire to break something or attack someone. A special role for these people is played by: the opportunity to work out new acquired skills in a safe environment; the opportunity to professionally inform loved ones about their disease and its treatment; the opportunity to access therapy at any time, to have support through communication by phone or through another means of communication; the opportunity to feel that they are not alone with their problems; the therapist's lack of rigor and authoritarianism.

In this study, in our opinion, it is especially important to emphasize that the normal state of the psyche is a fundamentally new experience for recovering patients with borderline personality disorder. Therefore, it is desirable that the therapy of this disorder includes methods that contribute to the "soft" adaptation of the patient to his new state from both psychological and social points of view.

Let us summarize further, based on the above review, the peculiarities of thinking and behavior of patients with borderline personality disorder. We will also put forward a number of hypotheses, concretizing the generalizations obtained. At the same time, we will take into account that each patient with borderline personality disorder is unique in its own way and it is not necessary to extrapolate such conclusions to the entire population of people with this disease. However, it is possible to identify common features and causes of some cognitive and behavioral reactions of patients with borderline personality disorder to the therapy process. So, they relate to:

- therapy itself as a treatment process – it seems to the patient to be the only possible way to get rid of suffering, since it creates a safe psychological environment for him, "constructed" according to the rules known and understandable to him. Therefore, the patient takes an active part in the treatment process – after all, therapy does not eliminate the symptoms of the disease, but radically changes his personality, which is a guarantee of getting rid of suffering. The unwillingness to feel them again leads the patient to the desire to extend the therapy courses for as long as possible, and sometimes to an obvious "obsession" with this;

- to the subject of therapy: the patient is aware of the need for a therapist as a leader with a directive management style, which is obviously due to distrust of himself, since in practice it was confirmed by failures in attempts to relieve his condition on his own; at the same time, in the person of the therapist, the patient also needs a mentor at each therapy session convincing him of his the ability to solve his problems, to save him from suffering, and at the same time – in the safe nature of communication with him. The patient always has a contradictory combination of the need for care from the therapist with the fear of being rejected by him, which is a manifestation of one of the symptoms of borderline personality disorder. Nevertheless, the risk of experiencing suffering again and unwillingness to do so creates an acute need for the patient to constantly follow the therapist and for this he needs to be able to be constantly in touch with him even outside of therapy sessions, thereby repeatedly confirming his confidence in the safety of communication with the therapist. In general, the therapist is perceived by the patient as a kind of psychological support, replacing unhealthy elements of the patient's personality.

The patient is characterized by: establishing a relationship with the therapist similar to the relationship between children and parents, which is associated with the possibility of realizing in this case his own infantile behaviors and thereby requiring the therapist to fully assume full responsibility for the results of treatment in the process of such relationships; striving for the duration of establishing a therapeutic alliance, most likely related to, with the need to repeatedly convince oneself of the stability of the established relationship with the therapist; aggression towards the therapist during painful experiences, most likely associated with the process of incipient transference; violation of the therapist's personal boundaries, based on infantile ideas about his over-need for therapy; incorrect interpretation of the therapist's behavior, associated with insufficiently developed emotion recognition skills; finally, the patient is characterized by awareness of the need for the therapist's participation in explaining to relatives and friends the specifics of his disease and current condition, which probably allows him to more easily tolerate feelings of shame and guilt in front of loved ones;

- self-feelings and fears in the course of therapy: therapy as a treatment process is highly appreciated by the patient and he is initially characterized by a feeling of inability to eliminate problems on his own and thereby improve his condition, which is associated with the ever–present fear of the therapist's disappearance - after all, in this case, the ongoing therapy will immediately end; however, it is present and periodically manifests itself and distrust of their own abilities in terms of therapy to alleviate their condition; at the same time, the patient is aware of the need for an informed explanation to relatives and friends of the specifics of their disease and state of health at a particular time, which is probably due to the disappearance in this case of a sense of shame and the removal of guilt in front of loved ones; the detailed nature of explanations about his condition and the process of therapy as a whole is probably due to the fact that such awareness reduces the patient's level of psychological uncertainty and related anxiety.

The patient has a need to be aware of the fact that there are other people in a similar state to him – but he proceeds from the fact that these "companions in misfortune" will never leave the patient, since they themselves are afraid of being abandoned; sometimes the patient has an incorrect interpretation of the therapist's behavior, which is associated with insufficiently developed emotion recognition skills; when at the same time, there may be sudden changes in mood and behavior that complicate the therapist's work and increase the emotional burden on him. In general, all the painful experiences of the patient are most likely associated with the process of incipient transfer.

In addition, the patient has infantile ideas about his excessive need for therapy; he also has accusations of himself when communicating with the therapist, to whom he demonstrates a sense of guilt, and all this serves to explain his own poor condition; the patient avoids reflection on his emotions and past negative experiences, because they are complex, energy-intensive and painful, since they are associated with the repeated experience of traumatic events; it is difficult for the patient to accept the fact of the existence of alternative points of view, since it is associated with the repetition of the process of comprehension and formation of his own opinion, and it is also difficult for him to intellectualize emotions, their description during therapy, which is most likely due to limited emotional intelligence, which could not develop sufficiently due to traumatic events or the conditions of the patient's existence.

Concluding the consideration of the features of cognitive and behavioral responses of patients with borderline personality disorder to therapy, we summarize our review. So, therapy itself appears to such a patient as an alternative way of changing his personality, which results in the elimination of his mental suffering. Having "fit in" after therapy into a different system of mental coordinates created taking into account his ideas, the patient feels quite comfortable. At the same time, his fears about the possibility of relapse, i.e. the return of an uncomfortable mental state, do not disappear, therefore, the desire on the part of the patient to conduct therapy for as long as possible can be observed even after the required therapeutic effect is fully achieved.

In the course of therapy, the patient behaves quite rationally in relation to the person performing it. At the same time, in the "patient – therapist" system, the patient's desire to consciously occupy and maintain a humiliated position during the entire process of therapeutic influence on him is quite clearly visible in order to achieve the greatest and constant attention from the therapist – and even when it is superfluous for the patient; nevertheless, he considers it necessary again and again draw the therapist's attention to themselves in order to "consolidate" the therapeutic effect achieved in the course of treatment. Hypertrophied overestimated desire for this kind of mental infantilism on the part of the patient can be combined with a sharp increase in negative attitude towards the therapist and even aggressive manifestations against him in cases when at least the slightest deviations from the effective, from the patient's point of view, course of the therapy process begin to be observed.

A patient with borderline personality disorder feels therapy as the most significant value in his life – at least at the time of its implementation. This is due to the experience of mental suffering and deep experiences before the start of treatment, as well as the realization of the impossibility of independently eliminating the existing problem without therapeutic procedures. That is why one of the most acute negative experiences of the patient is the recurring fear about the possible loss of the therapist and the completion of treatment, which cannot be ignored due to the over-demand for therapy in patients in some cases, the reason for which is their infantile attitude towards themselves during treatment. This infantilism also manifests itself in relation to the need for "companions in misfortune" for the patient, when such a patient seeks in any way to obtain confirmation of the presence of people with the same disease. Thus, he gets the opportunity to reduce the level of anxiety and consequently increase the level of his mental comfort; the same goals are served by the patient's desire to inform his loved ones about the course of his disease by involving a therapist for this purpose – in this case, the patient more easily tolerates the guilt he has and is aware of before relatives and acquaintances for his painful condition.

Everything we have discussed above allows us to hypothesize that therapy becomes a "new" way of life for patients with borderline personality disorder, a kind of artificial mental environment in which the basic need for security is satisfied.

Thus, the generalization of their cognitive and behavioral reactions to therapy, carried out on the basis of a review of a set of scientific articles on the therapy of patients with borderline personality disorder, can become an element of theoretical justification and a basis for the subsequent development of research methods for the purpose of conducting an empirical study of various personality disorders in the future.