DBT for Borderline Personality Disorder

Mental health conditions can be tough to manage, and this is true for personality disorders like borderline personality disorder (BPD). If you are diagnosed with BPD, then you may struggle with intense emotions and maintaining your relationships. You may have heard of dialectical behavior therapy (DBT) as a suitable option for treatment. Using DBT for borderline personality disorder can be quite beneficial, and that is what we’ll be covering in this article.

Understanding Borderline Personality Disorder

Borderline personality disorder is a mental health condition that is characterized by difficulty regulating intense emotions. When an individual with BPD goes through stress over a long period, it can be difficult for them to go back to a “normal” level of functioning. As a result, this feeling may manifest as self-harming behaviors, unhealthy relationships, and impulsive actions. For several decades, clinicians have viewed BPD as a female-specific disorder, with the DSM-5 estimating that 75% of those diagnosed with BPD are female [*]. However, many professionals have suspected that men are often misdiagnosed.

While the characteristics of BPD may show up differently per individual, there are some that are more usual than others. According to the Diagnostic and Statistical Manual (DSM), here are some of the most common BPD symptoms:

• Impulsive or dangerous behaviors
• Extreme mood swings
• Feelings of instability or insecurity
• Unstable relationships
• Intense feelings
• Unstable and distorted self-image
• Fear of abandonment, whether real or imagined

Overview of Dialectical Behavior Therapy

People may often hear about how beneficial dialectical behavior therapy can be for people with BPD. But what exactly is DBT and how does it help treat this particular mental health condition?

Dialectical behavior therapy is a type of talk therapy. It is a type of cognitive behavioral therapy, but it is more focused on people who feel emotions quite intensely. DBT is meant to help people accept and understand difficult feelings, learn how to manage them, and make positive changes in their lives.

The word “dialectical” means “concerned with or acting through opposing forces,” so DBT helps patients do two opposite things at once, such as accepting and changing their behavior simultaneously. Essentially, DBT is about balancing opposites as psychotherapists work with clients to accept things as they are while working to change them for the better. This approach helps to prevent black-and-white thinking and promotes emotional regulation. Tools such as DBT worksheets can be used in and out of therapy to help patients understand the process more thoroughly.

DBT aims to encourage change and radical self-acceptance in a client or patient. This type of talk therapy can be done in one-on-one settings or group therapy. Sometimes, therapists will use a combination of both. There are four stages in DBT:

Stage 1: Behavioral stabilization. The first stage is when the therapist and the client collaborate to get behavior under control and reduce problematic behaviors, life-threatening behaviors, as well as therapy-interfering behaviors.

Stage 2: Reduce trauma-related symptoms. In stage 2, the aim is to reduce trauma-related symptoms, including posttraumatic stress disorder (PTSD) and other traumatic emotional experiences. Any emotional experiences that the patient has had invalidated in the past can also be discussed here.

Stage 3: Learning to live. Once patients have learned to control their behavior and have reduced their trauma-related symptoms to be in an emotionally healthy place, they can then learn how to live a functioning life. Here, patients define goals, develop self-respect, and eventually cope with challenges in a healthy way.

Step 4: Deeper meaning. The fourth stage involves finding deeper meaning through some kind of spiritual fulfillment. Here, clients can form a sense of connectedness from being part of a greater whole. They also gain the capacity to experience joy and freedom.

How Does DBT Help with BPD?

DBT can help patients by first identifying the two factors that contribute to borderline personality disorder. First, people with BPD are particularly emotionally vulnerable — for instance, stress makes them feel extremely anxious. Second, people with BPD often grew up in environments where their emotions were dismissed by other people — for example, parents may have told an individual with BPD that they were “just being silly” when they were actually sad and in distress.

The two factors may cause people with borderline personality disorder to fall into a negative cycle. They may experience intense and upsetting emotions that make them feel guilty or worthless. Upbringing may cause them to think that having such emotions makes them a bad person. This then feeds into the cycle of feeling more upsetting emotions.

DBT’s aim is to break the cycle by introducing two very important concepts. The first is validation, which involves accepting emotions as real, valid, and acceptable. The next is dialectics, which asserts that most things in life are rarely “black or white,” making it important to keep an open mind to ideas and opinions that may differ from your own.

The ultimate objective of DBT is to help people with BPD “break free” from seeing the world, relationships, and life in a rigid and narrow way that may lead to harmful and self-destructive behavior.

How Does DBT for Borderline Personality Disorder Work?

DBT often includes a mix of individual and group sessions, classroom instruction, and phone coaching. There are four types of skills involved in dialectical behavior therapy for borderline personality disorder.

Mindfulness Meditation Skills

Mindfulness meditation skills involve being grounded and present. It places emphasis on being mindful of the present moment rather than focusing on the past or the future. This is helpful for those with BDP because they can often feel trapped in challenging emotions by ruminating on the past or worrying about the future. Practicing this skill in various ways (e.g., through mindfulness exercises) can help people with BPD manage their symptoms and find new ways to cope [*].

Interpersonal Effectiveness Skills

Interpersonal effectiveness skills are abilities that allow people to become aware of how their behavior affects their relationships. Interpersonal skills help us interact with others in a more healthy, positive, and productive way. They also ensure that our needs our met, our relationships flourish, and our self-worth is improved. This skill helps people with BPD form more positive relationships with others.

Distress Tolerance Skills

Distress tolerance skills are actions that can help you cope in healthier ways when facing strong negative feelings, such as anger or anxiety. These skills can prevent you from taking part in risky behaviors by building up your coping mechanisms.

Emotion Regulation Skills

Emotional regulation skills are all about managing your thoughts, feelings, and behaviors. People with BPD often struggle with self-regulating due to poor childhood experiences, trauma, or abuse. Emotion regulation skills make a difference in how people with BPD deal with stressful emotions and potential triggers.

Effectiveness of DBT for Borderline Personality Disorders

DBT has proven effective in treating individuals who have a history of non-suicidal self-injury and suicidal behavior [*]. This makes it the preferred first-line treatment for BPD. It also reduces the following:

• Hospital stays
• Substance abuse
• Psychiatric hospitalizations
• Worsening of symptoms

While DBT may not be able to cure BPD, it has been found to be very effective at reducing and managing symptoms.

Considerations and Challenges in DBT for BPD

DBT may not be effective for everyone even though it can have numerous advantages. Possible limitations of the therapy include its requirement for a sizable time investment in terms of attendance and homework. Not everyone can or will accept doing their homework from therapy on a regular basis.

What if DBT Doesn’t Help?

Some people with borderline personality disorder may not experience the positive effects and progress that they want with dialectical behavior therapy. Fortunately, there are many other BPD treatment options, including CBT, schema-focused therapy, humanistic approaches, and family therapy.

Cognitive behavioral therapy (CBT). Cognitive behavioral therapy can be particularly helpful for borderline personality disorder when it comes to understanding distorted thoughts related to the self and others. There are also other CBT approaches, including acceptance and commitment therapy (ACT), which may help patients distinguish their thoughts and behaviors from the self while establishing their identity.

Schema-focused therapy. Schema-focused therapy can help people with BPD identify needs and how to get them met. Therapists help patients identify relevant schemas that they can link to past events and connect to current symptoms. By doing so, it is possible to process emotions related to the schemas and change any unhealthy coping styles that result from maladaptive schemas.

Humanistic approaches. Humanistic approaches focus on the client-therapist relationship. By doing so, it can improve symptoms in those with BPD as they work with the therapist to find meaning in their life. Meaningfulness in life has been found to decrease symptoms of borderline personality disorder.

Family therapy. In some cases, family therapy has been shown to be a significant help to those with BPD by strengthening support systems, which are sorely needed due to the social discord present in the disorder as well as genetic or environmental causes.

The Bottom Line

Overall, DBT has been the most effective form of treatment for those with borderline personality disorder. This is especially true for individuals who have experienced suicidal thoughts and inclinations to self-harm. It can also be very helpful for those who want to reduce their anger and manage their intense emotions. DBT for borderline personality disorder can help with relationships, self-management, and one’s overall quality of life.

References:

1. Qian X, Townsend M, Tan W, et al. Sex differences in borderline personality disorder: A scoping review. 30 December 2022.
2. Linehan M, Korslund K, Harned M, et al. Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis. May 2015.
3. Keng S, Lee C, Eisenlohr-Moul T. Effects of brief daily mindfulness practice on affective outcomes and correlates in a high BPD trait sample. October 2019.