Medical and psychiatric treatments contain three indispensable components: a therapeutic relationship, meaning-making and change-promotion. For people who have borderline personality disorder each is problematic. Relationships are chaotically sought or fled from; meaning equates to control or irrelevancy; naive attempts at change invalidate precarious defensive ‘solutions’ to despair or overwhelming affect, such as self-harm or addiction. Conventional approaches thus typically exacerbate rather than alleviate distress. Effective treatments for borderline personality disorder: tolerate and target disruptions to the therapeutic relationship; start from the client's own meaning structures before co-constructing new ones; and validate while simultaneously introducing changes in thought patterns and behaviour.