Dialectical Behaviour Therapy For Borderline Personality Disorder

  • Nikom Sonia PurohitaDoctor of Medicine - MD, Co-Assistant, Clinical clerkship of Medical School, Univerity of Lampung
  • Helen McLachlanMSc Molecular Biology & Pathology of Viruses, Imperial College London

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Dialectical Behaviour Therapy (DBT) is a type of therapy that is designed to treat people with mental health issues especially related to their emotions. While mainly used for people with Borderline Personality Disorder (BPD), other conditions may also use DBT, such as depression, eating disorders, post-traumatic stress disorder, and substance use disorder. 

What is borderline personality disorder?

Borderline Personality Disorder (BPD) is a mental health condition characterised by intense emotions, mood issues, and interpersonal relationship problems. People with BPD usually show symptoms that can be divided into 4 main groups:

  • Emotional instability: This includes rapid mood shifts and intense emotions. You will also be easily triggered by situations that others might find unremarkable. In psychology, this is called affective dysregulation 
  • Perception distortions: This involves seeing people as either all good or all bad (splitting), feeling disconnected from yourself or reality, and experiencing mistrust or suspicion towards others without evidence
  • Impulsive behaviour: This could be in the form of self-harm, reckless and impulsive spending, or substance abuse
  • Unstable relationships: There is fear of abandonment and intense emotions that make it difficult for people with BPDto maintain stable relationships.2

You might wonder what causes this mental disorder. While the exact cause remains unclear, there is evidence which suggests the role of genetic and environmental factors.2 People with a close family member diagnosed with BPD may be at higher risk of developing this condition. Research also shows brain structure changes in areas which regulate emotions and impulses among those with BPD. Moreover, many people with BPD have experienced some kind of childhood trauma or abandonment, and unstable and invalidating relationships.3

The importance of BPD treatment

If you have a borderline personality disorder and don’t receive appropriate treatment, you might be at risk for developing other mental conditions that will worsen your quality of life. Treatment options for BPD range from individual psychotherapy to group psychotherapy carried out by a licensed mental health professional, and may include medications. The duration of treatment varies, as many factors may affect the effectiveness of it, but typically lasts more than one year. While symptoms may reduce over time, there is a possibility that they will return.

Psychotherapy, also known as “talking therapy”, is used as a first-line treatment for people with BPD. The two most common psychotherapies for BPD are Cognitive Behavioural Therapy (CBT) and Dialectical Behaviour Therapy (DBT). Cognitive behavioural therapy focuses on identifying and changing your negative thoughts to improve mood swings and address dysfunctional behaviour. Whereas, DBT focuses on mindfulness, emotional regulation, acceptance, and encouraging change. Doing CBT will help you to cope with your intense emotions, build healthy relationships, decrease your impulsivity and self-destructive behaviours, enhance your self-esteem, and increase your daily life functionality. DBT is a way for you to find a healthy overall coping mechanism for your condition.2,3

What can you expect during DBT?

Dialectical Behaviour therapy (DBT) was developed by Dr Marsha Linehan to treat BPD. Traditionally, this therapy is divided into 4 components, including skills training group, individual psychotherapy, telephone consultation, and therapist consultation team.4

Basically, the DBT therapist will use these two concepts to try to bring positive changes in your behaviour:

  • Validation. You will learn to accept your emotions and validate them 
  • Dialectics. This embraces the idea that not everything is black or white. It recognises that most aspects of life are complex and interconnected5

DBT structure

Skills training group

This group work focuses on teaching psychological skills that include core mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. Typically, the sessions last for 2 hours every week with a total of 6 months to complete all modules.

  • Core mindfulness

In this skill, you will learn to observe, describe, and fully participate in the present moment. This skill targets your tendency towards impulsive and emotion-driven behaviour without awareness. Core mindfulness also teaches you to be present in the moment with a non-judgemental mindset and to learn to focus on one thing at a time. This skill will also target your tendency to idealise or devalue yourself or other people and the tendency to ruminate about the past and worry about the future 

  • Interpersonal effectiveness

This will teach you the social skills that are needed in building a stable and healthy relationship. Interpersonal strategies teach you how to ask for what you need, how to say no when there is an inappropriate request and the skills to cope with interpersonal conflicts. This strategy will help you to maintain relationships while also maintaining self-respect

  • Emotion regulation

Individuals with BPD can be very intense and unstable. Emotion regulation skills will help to identify and label emotions so that you can understand how these emotions can cause behaviour that affects your overall function as a human. You will learn about obstacles to changing your emotions and be taught to avoid vulnerable situations that usually lead to negative emotions

  • Distress tolerance

This teaches you that pain and conflict is always part of life, it is inevitable. Accepting your current situation does not mean that you have approved your situation. It will teach you techniques to distract and adjust your thoughts in the moment. This skill will transform your intolerable suffering into a tolerable pain4

Individual DBT

Individual DBT usually last for 40 to 60 minutes per session weekly. There are 6 goals to be achieved that focus on: 

  • Developing safety skills and regulating intense emotions in order to prevent suicidal intention or self-harming behaviour
  • Reducing therapy-interfering behaviours such as non-adherence, breaking agreements, etc. By doing this, the drop-out rate can be reduced significantly
  • Addressing behaviours that interfere with quality of life, for example substance abuse, high-risk sexual behaviour, or any behaviours with potential legal/interpersonal/health issues 
  • Learning and acquiring behavioural skills to improve your ability to cope with challenging situations and build healthy relationships These skills include mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness skills 
  • Address trauma history when the patient is ready. This includes remembering the abuse, reducing self-blame or stigmatisation, ending denial, and reducing dialectical view (an extreme black-or-white view) of the self and the abuser 
  • Learn about self-respect including valuing yourself and setting healthy boundaries. It aims to empower you to make choices that align with your value and self-worth4,6

Telephone consultation

This consultation will allow you to talk to your therapist for guidance when you need it. Phone calls with the therapist are designed for the patient to ask for help effectively and to apply any skills that have been learned, especially during a crisis. The availability of the therapist, and the length and frequency of phone calls might vary for different therapists and patients.4

Therapist consultation team

Regular meetings are not only for you as the patient, but also for all the therapists that provide DBT, usually weekly. These sessions will help them to maintain the motivation and commitment to provide optimal treatment. Even if a group setting is not available, DBT therapists are encouraged to engage in consultation or supervision relationships.4

FAQs

Is dialectical behaviour therapy effective for borderline personality disorder?

Yes, evidence shows that DBT is effective in treating and managing BPD and other mental disorders.  Studies suggest that DBT has demonstrated reductions in self-harm, suicidal behaviours, and hospital admission among BPD patients. It is also recommended by leading health organisations in the UK and the US as the first-line treatment for BPD.7

Which exercises are good for borderline personality disorder?

Many physical exercises will help your mental well-being while dealing with BPD, such as walking, running, yoga, gym, exercise at home, and gardening.

Other exercises that may also be beneficial include: 

  • Grounding that helps you realign and reconnect to the earth
  • Breathing exercises to help you relax and manage emotional dysregulation
  • Meditation can help you to have a greater awareness and body acceptance

Is CBT or DBT better for BPD?

For BPD, dialectical behavioural therapy is more effective and helpful compared to CBT. Also, CBT is not the first-line therapy recommended for individuals diagnosed with BPD. Cognitive behavioural therapy has shown good results for patients with other conditions, e.g. depression and anxiety disorder.8

Does BPD get worse with age?

It is commonly believed that BPD symptoms will lessen as you age. The majority of people with BPD achieve greater relationship stability and vocational functioning in their 30s and 40s. However, a study shows that age has only a small influence on symptom improvement of BPD. They found no connections between age and psychological functioning in patients with BPD.9

What is the gold standard treatment for borderline personality disorder?

The most effective treatment for people with BPD is dialectical behavioural therapy.

What is a BPD meltdown?

A BPD meltdown is an episode in patients with BPD where they feel an intense emotional reaction which can be triggered by various factors such as stress, abandonment, and rejection. During this episode, they may experience difficulty calming down, extreme mood swings, and impulsivity.10

Summary

Dialectical Behavioural Therapy (DBT) is a psychotherapy used to treat Borderline Personality Disorder (BPD). It focuses on mindfulness, emotional regulation, acceptance, and encouraging change. 

In DBT, you learn about “dialectical” strategy which means “the existence of opposites”. The goal is to accept and validate your current emotions and behaviour while also trying to make changes to yourself, so as to experience more positive emotions and behaviour. This therapy consists of a skills training group and individual DBT sessions. When needed, you will have the option to make a phone call to your therapist, especially during a time of crisis. It is important to note that DBT plays a crucial role in managing your BPD and will improve your quality of life.  

References

  1. Chapman AL. Dialectical behavior therapy. Psychiatry (Edgmont) [Internet]. 2006 Sep [cited 2024 Jan 16];3(9):62–8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2963469/ 
  2. May JM, Richardi TM, Barth KS. Dialectical behavior therapy as treatment for borderline personality disorder. Ment Health Clin [Internet]. 2016 Mar 8 [cited 2024 Jan 17];6(2):62–7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6007584/ 
  3. Gillespie C, Murphy M, Kells M, Flynn D. Individuals who report having benefitted from dialectical behaviour therapy (Dbt): a qualitative exploration of processes and experiences at long-term follow-up. Borderline Personal Disord Emot Dysregul [Internet]. 2022 Mar 1 [cited 2024 Jan 17];9:8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8885141/ 
  4. Shea MT, Edelen MO, Pinto A, Yen S, Gunderson JG, Skodol AE, et al. Improvement in borderline personality disorder in relationship to age. Acta Psychiatr Scand [Internet]. 2009 Feb [cited 2024 Jan 17];119(2):143–8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2629076/

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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Nikom Sonia Purohita

Doctor of Medicine - MD, Co-Assistant, Clinical clerkship of Medical School, Univerity of Lampung

Nikom is a medical doctor with clinical experience working in primary health care and hospital across rural and urban areas in Indonesia. Following her medical practice, she expanded her career into medical writing and communications. Her interest extends from precision medicine, mental health, and global health, with particular focus on advancing health equity.

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