Dialectical Behavior Therapy For BPD

Borderline personality disorder (BPD) can be a challenging condition to manage. This mental health condition is characterized by intense emotional instability, impulsivity, a fear of abandonment, and difficulty maintaining relationships. However, those living with BPD can learn to better manage their emotion control skills through therapeutic modalities like dialectical behavior therapy (DBT). 

To understand this modality, it can be helpful to review the main principles of DBT, helpful behavioral skills commonly taught in DBT sessions, and studies demonstrating the effectiveness of dialectical behavior therapy for bpd.

What is borderline personality disorder?

Borderline personality disorder (BPD) is a mental illness characterized by patterns of instability in emotional reactions, interpersonal relationships, self-image, and emotions. It is considered a cluster B personality disorder in the current version of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5. Individuals that have the diagnostic criteria for BPD often experience intense and unstable emotions, have difficulty managing their emotions, and may engage in impulsive and risky behaviors such as self harm or suicidal behaviors.

Symptoms of BPD can include but are not limited to the following: 

• Fear of abandonment or rejection, leading to intense efforts to avoid both
• Biological risk factors for major depressive disorder
• Unstable relationships, often characterized by alternating between idealizing and devaluing their partner
• Identity disturbance, including an unstable sense of self
• Impulsivity, including reckless driving, substance abuse, or binge eating disorder
• Suicidal or self injurious behaviors
• Emotional instability, including intense and rapidly changing moods
• Chronic feelings of emptiness or boredom
• Difficulty controlling anger or irritability
• Paranoia or dissociation in response to stress

If you are experiencing suicidal thoughts or urges, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or text 988 to talk to someone over SMS. Support is available 24/7.

BPD can interfere with a person's ability to maintain meaningful relationships, keep a job, and navigate daily life. However, with the right treatment, individuals with BPD may learn to manage their symptoms and improve their quality of life through a combination of DBT skills. DBT may be one of the most effective treatments for  treating BPD. 

What is DBT and how does it work?

Dialectical behavior therapy (DBT) is a type of psychotherapy originally developed by psychologist Marsha M. Linehan in the late 1980s to begin treating borderline personality disorder. Marsha Linehan also has borderline personality disorder, inspiring her decision to develop a first line treatment like DBT. 

DBT has since been adapted and modified for use in treating other mental health conditions, including for treating substance use disorders, eating disorders like bulimia nervosa, and post-traumatic stress disorder (PTSD). Many mental health clinicians still consider it the gold standard treatment for BPD.

Just like cognitive behavioral treatment it focuses on teaching individuals the skills for managing their emotions, develop coping strategies, and improve their relationships with others whilst maintaining self-respect. DBT treatment may be more intensive than other forms of psychotherapy and often calls for a high degree of communication between the therapist and the client.

Types of individual and group counseling

• Individual therapy: Individual psychotherapy calls for one-on-one sessions between the individual and a DBT therapist. The therapist may help individuals identify their specific challenge areas and teach them skills to manage their emotions and behaviors. 
• Group skills training: Group skills training calls for a focus on specific skills to manage emotions and behaviors through group sessions. Group therapy may be led by a trained DBT therapist covering four key areas: mindfulness, distress tolerance, and interpersonal effectiveness. 
• Coaching: Coaching is done between sessions and can help individuals apply skills in real-life situations. Through coaching, a therapist may be able to provide immediate assistance to a client during a difficult situation or emotion. A therapist can support a client through phone coaching when they are not in the immediate vicinity.
• Consultation: Consultation allows for DBT therapists to discuss cases with other therapists and receive support. A DBT consultation team may help therapists effectively manage their caseload and provide better client care.

Four skill modules of DBT for BPD

DBT uses a dialectical approach to balance opposing ideas or perspectives. In DBT, dialectics can involve balancing acceptance and change with challenging emotions. Therapists work with individuals to accept their current emotions and behaviors while encouraging them to make changes to improve their quality of life and relationships. Since borderline personality disorder can cause interpersonal challenges, this approach is often vital in DBT. 

DBT treatment often calls for four distinct modules: mindfulness, distress tolerance, emotional control, and interpersonal effectiveness. Dialectical behavioral therapists can teach clients techniques in each of these areas to reduce instances of reactivity and help them navigate challenging circumstances.

Mindfulness skills

Mindfulness is a core component of DBT. It involves being present in the moment and non-judgmentally observing one's thoughts, feelings, and sensations. Mindfulness can help individuals with BPD learn to control their emotions and reduce impulsive behaviors. 

Through DBT, clients may develop mindfulness skills to help them observe their thoughts and feelings without acting upon them. They may learn to approach situations calmly and non-judgmentally while utilizing breathing and awareness exercises to help them cope with challenging events. 

Distress tolerance

Distress tolerance involves relaxing the mind and body when faced with intense emotional responses. Distress tolerance skills can be helpful for those living with BPD, particularly those who may find it challenging to manage intense emotions without resorting to self-destructive behaviors or psychiatric hospitalization. 

Examples of distress tolerance techniques for those living with BPD that are learned in DBT include distraction, the TIPP skill, and radical acceptance, which involves accepting circumstances beyond your control. 

Emotional control

Those living with BPD are often prone to emotional instability and may find it challenging to maintain a positive mood when faced with difficult or inconvenient circumstances. Emotional control skills can help individuals with BPD better understand and manage their emotions. 

A dialectical behavior therapist may help a client learn various skills to aid in emotional control. These may include problem-solving, identifying and labeling emotions, and checking the facts to challenge emotional thinking. They may also help clients learn to change or widen their perspectives to understand situations more comprehensively.  

Interpersonal effectiveness

BPD can make it challenging to maintain relationships. Those with BPD may be prone to conflict with others or find it difficult to remain calm during a disagreement. DBT offers skills to help individuals manage and nurture relationships through interpersonal effectiveness. 

Interpersonal effectiveness skills include learning to communicate effectively with others, asserting one's needs and boundaries, and building healthy relationships. Through interpersonal effectiveness, a person may learn how to express their feelings respectfully, negotiate, set boundaries, and compromise. 

DBT's effectiveness

Since it was first developed in the 1990s, DBT has been considered one of the most effective behavioral tech treatments for BPD, due to its focus on emotion control and distress tolerance therapy skills, still recognized by the National Institute of Health. Several randomized clinical trials (RCT) and longitudinal studies have demonstrated the effectiveness of DBT, including the following: 

• In the Berlin Borderline Study, clients who underwent outpatient DBT showed significant symptom improvement. 
• A study of chronically parasuicidal women showed that the subjects who received DBT had fewer incidences of parasuicide and less medically severe parasuicides, were more likely to stay in individual therapy, and had fewer inpatient psychiatric days.
• One pilot study of 12 adolescents with borderline personality disorder found that self-injurious behavior declined significantly during and after treatment. 
• One randomized clinical trial found DBT effective in treating drug use in those living with BPD. 
• A comparative study found that individuals with BPD showed significant positive changes in depression, anxiety, global functioning, and social adjustment across one year of DBT treatment. 

Should you try dialectical behavioral therapy for BPD?

If you're living with borderline personality disorder, eating disorders, or another mental illness it may be worth considering treatment from a mental health professional. Through DBT and other forms of talk therapy, like cognitive-behavioral therapy (CBT), you can learn valuable skills to improve your emotional health and interpersonal relationships. Also, if you want to learn more about DBT therapy you can find a DBT skills training manual online.

You may begin your search online by looking for licensed DBT practitioners in your area or consider online therapy through a platform like BetterHelp. Research has found virtual DBT as effective as in-person treatment when delivered via videoconferencing technology. 

Online therapy may be preferable if you have mental health limitations like symptoms of BPD that make attending appointments challenging. You may fear having potentially embarrassing symptoms in public, for example. Or you may prefer to attend therapy from the comfort of your home. In addition to individual video sessions, online therapy may include added services like in-app messaging, online worksheets, and webinars.