Introduction

Mental health conditions can be debilitating, impacting the way we see ourselves, how we interact with others, and even how we perform daily tasks.¹ So, finding the right treatment option can be life-changing. Borderline personality disorder (BPD) is a complex mental health condition that is primarily treated with therapy.² However, with several therapy options available for BPD, it can be hard to know which is best for you.

In this article, we will cover what BPD is, explore several therapy strategies for BPD, and finally, highlight how people with BPD can access this support.

Understanding borderline personality disorder (BPD)

What is BPD?

BPD is a mental health condition characterised by instability. For example, people with BPD often have difficulties with emotional regulation, meaning they experience sudden shifts between intense emotional states.³ They may also have an unstable sense of identity (not knowing their true beliefs and interests), leading to feelings of emptiness and attempts to change their personality to mimic or fit in with others.^3,4 This can make it hard to maintain stable, healthy relationships.³

Other symptoms of BPD include³:

• Fear of abandonment
• Impulsivity and risk-taking behaviours like overspending, sexual promiscuity, or using substances
• Depression
• Anxiety
• Stress-induced paranoia and dissociation
• Inappropriate anger and aggression
• Self-harm or suicidal behaviour

If you are experiencing any of these symptoms, it is important to talk to a GP or mental health professional so that you can access the right treatment. If you are experiencing a mental health crisis, immediate help is available.

How common is BPD?

BPD affects 1–5% of the general population, and between 10–20% of patients receiving mental health care.^5,6 It was originally thought to be more common in women, though newer research suggests that it affects all genders equally.⁵

What causes BPD?

BPD does not have a single cause. Scientists and clinicians currently think that it arises from a combination of genetics and stressful or traumatic experiences during childhood.⁷

How is BPD treated?

There are currently no medications approved for treating BPD.⁷ Specific medications can be prescribed to BPD patients for severe depressive or psychotic symptoms in acute mental health crises or for comorbid conditions; however, they should NOT be taken for long periods of time.⁷ Therapy remains the safest and most effective BPD treatment, of which there are many different types.⁷

Therapy approaches for BPD

The approach to therapy for BPD is not one-size-fits-all. While treatment usually lasts at least three months, the duration and type of therapy that works best will depend on each patient's needs, preferences, and recovery stage.⁸ Some practitioners may even combine different types of therapy to approach symptoms from different angles.⁹ In the next section, we will look at some of the therapeutic strategies used to treat BPD in more detail.

Dialectical behaviour therapy (DBT)

What is DBT?

DBT is the most established therapy for BPD.² It is “dialectical” because it teaches that two seemingly opposite things can be true at the same time. Namely, patients can both accept their current reality and feelings, and work to change unhelpful thoughts and behaviours.¹⁰

What does DBT involve?

Traditionally, DBT is conducted through weekly individual therapy sessions, group skills coaching, and telephone consultations.⁷ However, the format can be modified to suit the needs of the patient.¹⁰

In individual therapy sessions, a DBT-trained therapist helps the patient to¹⁰:

• Manage self-harming thoughts and behaviours
• Tackle therapy-interfering behaviours
• Process trauma, validating the patient's feelings and experiences
• Address high-risk, impulsive behaviours that impact quality of life
• Learn skills to help manage everyday challenges
• Build greater self-respect

Group sessions coach patients in four core skills to help them manage everyday challenges¹⁰:

• Distress tolerance: strategies like distraction and self-soothing can make stressful situations more bearable
• Mindfulness: staying present and taking one thing at a time
• Emotional regulation: learning how to identify, understand, and manage emotions
• Interpersonal effectiveness: improving relationships with others by learning how to communicate clearly, set boundaries, and navigate conflict

Patients learn and practise these skills through discussion, worksheets, and reflection (often by keeping a therapy diary).¹⁰ They may also contact their therapist by telephone (within specific boundaries) to ask for in-the-moment guidance.⁷

How effective is DBT?

DBT is moderately effective at treating key symptoms of BPD, such as self-injurious behaviours, suicidal ideation, impulsivity, depression, and mood instability.¹¹ Additionally, it can improve symptoms of comorbid conditions like substance use disorders and eating disorders.² However, the high drop-out rates (over 25%) suggest that DBT may not work for everyone.¹²

Mentalisation-based therapy (MBT)

What is MBT?

MBT is a therapy rooted in mentalisation, which is the ability to imagine and understand the thoughts and feelings of ourselves and others.² People with BPD struggle to mentalise under stress, leading to intense emotional reactions in social situations and difficulties navigating relationships.⁷ MBT seeks to alleviate BPD symptoms by improving mentalisation skills.²

What does MBT involve?

MBT also includes both individual and group therapy. The treatment consists of three stages⁷:

• Pre-treatment phase: where the patient’s history is discussed, specific issues are identified, and a patient-therapist relationship is built
• Treatment phase: where patients learn how to mentalise under stress, as well as how to regulate anxiety and stress to make mentalising easier
• Final phase: where the patient and therapist review the experience together and focus on how the patient can take these skills forward

How effective is MBT?

MBT can significantly improve BPD symptoms, including depression, suicidal behaviours, and interpersonal functioning, as well as overall quality of life.^13,14 However, it may be less effective than DBT at reducing self-harm and improving emotional regulation.¹⁵

Structured clinical management (SCM)

What is SCM?

SCM is a more general therapeutic approach designed to treat disorders like BPD.² It was developed in the UK to be carried out by general mental health professionals, as opposed to the specially-trained therapists that DBT and MBT require, minimising training costs.²

What does SCM involve?

SCM includes weekly individual and group therapy sessions. A short course of family therapy is also recommended. Patient-therapist contact is discouraged outside of sessions, except for emergencies.

SCM borrows many of its principles from DBT, MBT, and cognitive behavioural therapy (CBT).² This includes flexibility, pragmatism, openness, and curiosity rather than hostility towards feelings.² SCM also emphasises safety planning and creating an environment where the patient feels comfortable.

How effective is SCM?

SCM can help improve social functioning, relieve depressive symptoms, and reduce hospitalisations for BPD patients.² It may even be faster at reducing self-harm behaviours than therapies like MBT.² However, its flexible nature may lead to more varied outcomes between patients and practitioners.

Eye movement desensitisation and reprocessing (EMDR) therapy

What is EMDR therapy?

EMDR therapy involves reprocessing distressing memories and experiences.¹⁶ It was originally developed to treat post-traumatic stress disorder (PTSD), but it is increasingly being used with BPD patients, as childhood trauma is a major risk factor for BPD.¹⁶ In theory, resolving and reframing these improperly stored traumatic memories may reduce their ability to negatively impact current thoughts, emotions, and behaviours,¹⁷ improving symptoms of BPD.

What does EMDR therapy involve?

EMDR therapy is usually conducted through one-to-one sessions. It has eight distinct phases.¹⁸

The pre-treatment and closure phases are similar to other BPD therapies,¹⁸ but the treatment phases are where EMDR therapy stands out. While the patient recalls a traumatic memory, they engage in bilateral (left-to-right) activation of a single sense.¹⁷ This may involve moving the eyes back and forth, tapping on the knees, or even listening to sounds through headphones.¹⁸ This bilateral stimulation helps patients to relax and stay grounded while they work through these memories with the therapist, allowing them to be reprocessed and stored in a healthier way.¹⁹

How effective is EMDR therapy?

Individual case reports suggest EMDR therapy can help BPD patients, relieving depression, anxiety, and dissociation symptoms.²⁰ Larger, controlled studies appear to suggest the same thing, though there are few of them, and their high drop-out rate (over 75%) suggests the treatment may not agree with all patients.¹⁹

Recovery and support

If you are struggling with symptoms of BPD, know that you are not alone, and support is available to you.

To access therapy for BPD, it is important to talk to your GP. They will be able to refer you to specialist mental health services who can help you find the right type of therapy for you. For many people, going to the doctor can feel intimidating. Talking to a friend or family member first can be helpful, giving you the support and confidence you need to ask for professional help.

It is important to remember that therapy does not “cure” BPD in the traditional sense. What it can do is help people learn to manage their symptoms and live healthier lives. With time and effort, remission and recovery are much more achievable and sustainable than people realise.²¹

Summary

• BPD is a complex mental health condition characterised by difficulties with emotional regulation, navigating relationships, and maintaining a stable identity
• Therapy is the recommended treatment for BPD
• Therapies like DBT, MBT, SCM, and EMDR work in different ways, but are all effective at treating a range of BPD symptoms
• There is no single “best” therapy: the right approach depends on the individual
• With time, care, and the right support, many people with BPD learn to manage their condition in a safer, healthier way