Dialectical Behavior Therapy for Borderline Personality Disorder: A Winning Combination?
It is estimated that one to two percent of the population is living with borderline personality disorder (BPD). Fortunately, dialectical behavior therapy (DBT) can be an effective therapy option.
Borderline Personality Disorder (BPD), one of 10 personality disorders currently identified by the DSM (the Diagnostic and Statistical Manual of Mental Disorders), can be described as a disorder of instability (in relationships, moods, behavior, and sense of self) combined with impulsivity.
People living with BPD often suffer from an extreme and chronic fear of abandonment. This abandonment can be a matter of perception; for example, someone turning up late for an appointment can trigger an outsize reaction from someone with BPD, because of their fear of abandonment.
BPD suffers often have a sense of identity that is in flux. That’s one reason abandonment is such a fear for them; it threatens their fragile sense of self, especially if their identity is wrapped up in their relationship with the other person.
The person with BPD might have such an unstable sense of who they are that they drastically alter their appearance or change their name, often more than once, in an effort to find themselves.
This naturally affects relationships, as others are unsure how to relate to the “new” person that shows up in their lives…which only confirms the belief that no one knows who they are, including themselves.
9 Traits of Borderline Personality Disorder
BPD differs from the other nine personality disorders identified in the DSM in its degree of emotional instability. People with BPD can run a gamut of very different emotions in a day or even an hour. (This contrasts with the mood disorders Bipolar I and Bipolar II, which are characterized by more prolonged episodes of mania or disinhibited behavior.)
Clinical psychologist Dr. Ramani Durvasula talks about nine traits of people with Borderline Personality Disorder.
A person does not have to have all nine of these traits to be diagnosed with BPD. If they have five or more, however, BPD may be in play.
1. Fear of Abandonment
As mentioned above, people with BPD may perceive ordinary behavior or mistakes, such as missed appointments, as evidence that they’re being abandoned. This can become a self-fulfilling prophecy as the person with BPD may become accusatory or confrontational to the point of pushing others away.
2. Unstable, Dramatic Interpersonal Relationships
People with BPD often have roller-coaster relationships with romantic partners, family members, and even work colleagues and personal friends. When all of a person’s relationships seem to follow this pattern of intense emotions that swing wildly and often between extremes, it can be a sign of BPD.
3. Identity Disturbance
As mentioned above, the person with BPD may have a sense that they don’t know who they are. When this is extreme, it can look like a multiple personality disorder (Dissociative Identity Disorder or DID), as the person repeatedly shows up in vastly different roles. For this reason, BPD is sometimes misdiagnosed and DID.
This propensity to act out without thinking goes beyond what we typically think of as spontaneity into more extreme dangerous or destructive behaviors such as gambling, substance abuse, overspending, or risky sexual behavior. The person with BPD often uses these actions to soothe themselves in the moment as a way of dealing with their intense emotions or the underlying issues causing them.
5. Recurrent Suicidal Behavior or Thoughts
This is a response to intense emotional pain. For a person with BPD, suicidal behavior or self-harm may also be a strategy to convince someone in their life not to abandon them. Even if the person doesn’t intend to kill themselves, this behavior can still be fatal, so it should always be taken very seriously.
6. Affective Instability
The characteristic of extreme and rapid mood shifts is an earmark of Borderline Personality Disorder. Unlike people living with bipolar disorder, where mood episodes last for days or weeks, those with BPD may transform from being cheerful to melancholy to enraged within a very short period of time. These people overreact emotionally to everything happening in their lives, which wreaks havoc on relationships.
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7. Feelings of Emptiness
This chronic feeling leads to the person living with BPD feeling compelled to fill the void with things outside themselves like food, shopping, sex, etc. Because the comfort these things bring isn’t lasting and doesn’t solve the underlying problem, the person with BPD will always be looking for the next “quick fix” in order to feel whole.
8. Inappropriate and Intense Shows of Anger
For someone living with BPD, seemingly minor things can set them off. This is another challenge for people in a relationship with someone with BPD. People with BPD express all their emotions strongly, but anger is the one that can have some of the most negative and even violent consequences for themselves and those around them, causing their family and friends to walk on eggshells.
9. Experiencing Paranoid Symptoms
In extreme cases, or when under intense stress, the person with BPD may feel people are out to get them, hear voices. They can also disassociate into another identity, such as that of a small child, similar to what we see in DID.
Dialectical Behavior Therapy – New Hope for BPD?
Dialectical Behavioral Therapy (DBT) has shown great promise for helping those struggling with the symptoms associated with BPD.
Originally developed for people showing suicidal behaviors, DBT is an evidence-based therapy that builds upon some of the elements of CBT (DBT is a subset of CBT) and combines them with other types of therapy, such as group therapy, to give more comprehensive support to BPD patients, as well as those with many other mental health challenges.
DBT incorporates eastern philosophies, such as mindfulness while emphasizing emotions and relationships as the core of what is essential to work through.
4 Areas of Focus
For such an effective therapy, DBT is surprisingly simple and user-friendly in its approach. It focuses on developing four essential skills to help people manage and cope with their symptoms on a daily basis, instead of feeling overwhelmed by them.
While a course of treatment may last six months, with DBT for BPD, people can start feeling better and noticing improvements in their lives and relationships almost immediately. Even people without BPD or another mental health issue can benefit from the skills taught in DBT.
1. Distress tolerance
One of the characteristics of Borderline Personality Disorder is a hyper reaction to stimuli, such as everyday stressors, interpersonal conflicts, and other problems.
The skill of distress tolerance empowers people with BPD to feel intense emotions like anger and handle them without reacting in an over-the-top way or resorting to negative behaviors such as violence against others or themselves.
2. Emotion regulation
DBT helps people living with Borderline Personality Disorder address emotions and conditions like anger or intense sadness without shame. When we can identify and name our emotions, we gain greater control over them. The skill of emotional regulation gives people with BPD the tools to recognize, label, and manage their emotions.
By contrast, Cognitive Behavioral Therapy (CBT) gives some tools for managing thoughts and actions, which then leads to more productive emotions, but directly managing feelings themselves is one of the four pillars of DBT.
Best known as an element of meditation, mindfulness allows people with BPD to remain in the present moment and become more aware of themselves. Being the outside observer to one’s experience in the moment brings perspective to intense emotions.
Mindfulness does not have to look like traditional meditation, however. It’s beneficial to practice mindfulness while doing everyday activities, such as waiting in line at the store or doing the dishes.
Also, mindfulness to one’s physical environment noticing and engaging with what’s around you – can help when people find their minds wandering or brooding during traditional meditation practices.
4. Interpersonal effectiveness
While mindfulness concerns mostly the person themself, this skill is focused on how they interact with others. Interpersonal effectiveness means the person with BPD being able to navigate conflict and be assertive – not overly aggressive or passive – in expressing what they want.
4 Treatment Components Come Together in DBT for BPD
One of the things that makes DBT unique is its combination of modalities. Rather than just having a patient see a therapist one-on-one, or just engage in group therapy, for example, DBT brings four practices together to give comprehensive support to the person living with BPD.
1. Skills Training Group
This component of DBT for BPD has patients meet weekly as a group for two hours, led by a therapist.
In their group, they work together on developing the four skills cited above.
Being in a group allows them to practice their skills with others in a safe place, and observe the skills in action as they see others practice. The curriculum takes about six months to complete.
2. Individual Psychotherapy
Each BPD patient also has their own therapist they meet with one-on-one. This therapy is meant to build on the work being done in the group, as well as address the BPD patient’s individual and current needs.
While each person is different, the individual psychotherapy in DBT for BPD focuses on six main areas: parasuicidal behaviors, therapy-interfering behaviors, behaviors that interfere with the quality of life, behavioral skills acquisition, post-traumatic stress behaviors, and self-respect behaviors.
Parasuicidal behavior is defined as any non‐fatal, severe, and deliberate self‐harm with or without suicide intent. If the person with BPD is harming themselves in any way, this therapy makes a point of addressing it specifically.
Therapy-interfering behaviors are things like not taking one’s medication, skipping or being chronically late to therapy appointments, inattentiveness, not working on skills, or any other resistance to treatment. Focusing on these reduces both therapy burnout and drop-out rates for people with BPD.
Behaviors that interfere with the quality of life include substance abuse, high-risk sexual behaviors, behaving irresponsibly financially, and any behavior, action, or habit that puts the person at risk or threatens a stable, healthy life. These are addressed specifically in individual psychotherapy to help stop the behavior, regardless of the cause.
Behavioral skills acquisition refers to the skills mentioned above and practiced in the group component of DBT: distress tolerance, emotional regulation, mindfulness, and interpersonal effectiveness. Individual psychotherapy allows the BPD patient to explore their own feelings and challenges around any of these, in both the group and in their daily life.
Post-traumatic stress behaviors typically take a back seat to any parasuicidal behaviors, but in many cases, it is still significant. Reducing any feelings of fear or shame around past trauma and the tendency to remember and relive it are objectives of this part of therapy. Learn more about post-traumatic stress disorder (PTSD) here.
Self-respect behaviors includes the belief that you are good, worthwhile, and deserving of the respect of others. This helps the person with BPD build a stronger sense of self as the therapist reinforces self-respect behaviors throughout the therapy process.
3. Phone Consultation
A key part of DBT is the ability of the person living with BPD to have phone access to their therapist between one-on-one visits. These calls are there to help in moments of crisis, and they also give the person another chance to practice their interpersonal skills and apply them to their everyday life. Just knowing that their therapist is as close as the phone and feeling safe making the call may be enough for some BPD patients to choose talking to self-harm.
4. Therapist Consultation Team
A unique part of DBT is this fourth prong, which helps the therapists themselves by allowing them to gain support from each other, share best practices and help them manage their own stress as they help patients. The therapist consultation team is made of both one-on-one and group therapists and meets once a week.
The amount and scope of support offered by dialectical behavioral therapy to both the patient and the practitioner have proven effective in many ways. For example, while many treatments for both personality disorders like BPD and mood disorders like bipolar disorder still combine the use of medication with therapy, DBT has been shown in some cases to reduce the need for medication.
How to Help Someone with Borderline Personality Disorder
If you think a person close to you has BPD, the best thing is to try to get them into therapy.
Rather than confronting them head-on about a personality disorder like BPD, you might instead focus on a problem that BPD is causing in their lives, such as financial problems from overspending, or health issues from binge eating.
This can be a less threatening strategy that can lead them into the right diagnosis and therapy.
At the same time, there are ways you can support them and yourself in daily life outside of therapy.
Because it’s common for people with BPD to react intensely and impulsively, they may say hurtful things. Recognize that it’s not about you and try to have patience and compassion for them when this happens.
Also, realize that their mood right now will probably not last. If you can wait it out, you can avoid escalating an outburst into something more damaging to the relationship.
You might even consider cognitive behavioral therapy or other therapies for yourself if you have been experiencing stress from living with someone with BPD.
While BPD is typically a lifelong condition, it can be managed very well with the appropriate therapy. DBT for BPD is an evidence-based and relatable approach that is improving many people’s quality of life and their relationships, one moment at a time.