Cognitive Behavioral Therapy for Borderline Personality Disorder

What Is Cognitive Behavioral Therapy (CBT)?

Cognitive behavioral therapy (CBT) is one of the most common forms of therapy. In CBT, the therapist helps you identify thought patterns that negatively impact your behaviors and emotions. Getting to the root of these thoughts empowers you to reshape your experience. When used consistently for at least two months, CBT can help relieve feelings of stress and anxiety related to underlying negative emotion.¹

How Does CBT for BPD Work?

Cognitive behavioral therapy is particularly helpful in the treatment of borderline personality disorder (BPD) when combined with a focus on understanding thought distortions related to self and others.² Borderline personality disorder is characterized by symptoms that alter one’s thought patterns. CBT works to reframe these thoughts to help individuals better manage BPD symptoms. While BPD may not be completely curable, many find relief through CBT.

Shannon Sauer-Zavala, Ph.D. and Assistant Professor, Department of Psychology, University of Kentucky explains, “People with BPD struggle with negative schemas (i.e., core beliefs) about themselves and others, as well as problematic behaviors used to regulate strong emotions. CBT includes cognitive skills to help patients identify and challenge their core beliefs, along with behavioral skills that help patients learn to tolerate strong emotions.”

Components of cognitive behavioral therapy for borderline personality disorder include:

1. Setting SMART Goals

SMART stands for setting goals that are specific, measurable, achievable, relevant, and timely. These are great for those with BPD as it helps to give structure to their lives and keep them accountable to the goals they create in therapy.

2. Cognitive Restructuring

Cognitive restructuring is beneficial in offering individuals an understanding of how thoughts, feelings, and behaviors are all linked. This technique involves various strategies which help individuals recognize how their thought leads to action. Additionally, those with BPD learn how to stop or change the thought before it turns into a behavior.

3. Skills Training

Skills training helps individuals better manage unhelpful thoughts and social situations. By working with their therapist on breathing exercises and relaxation skills, individuals can learn to stop reinforcing negative patterns and change the way they think.

4. Mindfulness and Meditation

Mindfulness for BPD and meditation encourage one to pull their attention away from unhelpful thoughts and to be more present in the moment. These techniques also improve a person’s emotional regulation capabilities, and these skills are often integrated into therapy.

Examples of CBT for Borderline Personality Disorder

CBT for BPD is versatile and can be tailored to an individual’s unique situation. Given the variability of CBT techniques and the ways in which the modality can help, it can be used as a framework for adolescents and adults to manage relationship issues and serious thoughts of self-harm.

CBT for BPD Relationship Issues

CBT has been shown to be effective in improving BPD relationships, and one study revealed that those in CBT treatment for a year reported better relational outcomes. CBT helped these couples reduce feelings of hopelessness and impulsivity, which are big factors in BPD behavior.⁸

CBT for BPD & Suicide

Self-harm thoughts and behaviors are common symptoms for people struggling with BPD, and are often very discouraging for those dealing with them. CBT has been proven to help reduce suicidal thoughts by uncovering negative inner monologues, thus improving self-esteem and self-worth. Evidence shows that CBT has can result in decreased self-harm behaviors and beliefs within months of treatment.⁹

CBT for BPD in Adolescents

Parental involvement in family CBT can be helpful for the treatment of adolescents with BPD. This type of therapy also shows improved outcomes for parents and their ability to provide consistency and stability for the adolescent throughout treatment. ¹⁰

Other Types of CBT for BPD

There are many other types of CBT that may be beneficial in the treatment of BPD.

Other cognitive-behavioral therapy types that can be used to treat BPD include:^3,4,5

• Schema-focused therapy: Schema-focused therapy focuses on helping people with BPD identify their needs and understand how they have learned to meet these needs. Those with BPD who participated in schema-focused therapy reported better self-understanding and improved emotional regulation.
• Humanistic therapy approaches: Humanistic therapies can be helpful in facilitating good outcomes in those with BPD, particularly due to the focus on the client-therapist relationship. These can teach clients how to find meaning in their life, which has been shown to decrease BPD symptoms.
• Family therapy: Due to the social discord associated with BPD and the genetic/environmental causes, family therapy can be an important approach for the long-term success of those living with BPD. Researchers have encouraged better use of support systems in the client’s life, and attending therapy together is one way for loved ones to become more involved.
• Acceptance and commitment therapy (ACT): ACT can be helpful in distinguishing thoughts and behaviors from self and establishing parameters around identity. This allows those with BPD to establish new boundaries and make thoughtful decisions about their actions.

Is CBT Effective in Treating Borderline Personality Disorder?

CBT has been shown to be extremely effective at treating BPD. It manages symptoms and is also helpful for children, parents, and relationship partners impacted by an individual’s BPD diagnosis.

CBT is effective in treating BPD in ways such as:^8,9,10,11,12

• Helping couples with a partner who has BPD work through relationship issues by reducing hopelessness and impulse behaviors.
• Helping individuals reduce suicidal thoughts and behaviors by working to unlearn negative thought processes and relearn positive ways of managing difficult emotions.
• Helping children with BPD symptoms by providing psychoeducation about how thoughts become actions, and helping parents by integrating their support in sessions to improve overall family functioning and cohesion.
• Helping those with BPD who are severely struggling with overall functioning. CBT for this population showed improvement in psychosocial functioning.
• Helping those dealing with a co-occurring eating disorder by decreasing dysfunctional behavior around emotions, feelings of depression, and dysfunctional eating behaviors.

CBT Vs. DBT for Borderline Personality Disorder

Similarly to CBT, those with BPD have responded well to dialectical behavioral therapy (DBT). DBT for BPD is emerging as a new frontline approach and includes both group and individual psychotherapy. In DBT, there is a specific approach aimed at helping those with BPD learn how to navigate and handle their feelings, teaching them how to better relate to others and face challenges.

“DBT is a specific form of cognitive behavioral therapy,” Sauer-Zavala says. “DBT is long-term; usually one year of  intensive, weekly individual therapy and skills group sessions are recommended.”

DBT skills used to treat BPD include:^6,7

• Mindfulness meditation skills: Mindfulness meditation requires individuals to stay grounded in the here and now. It focuses on being conscious of the present and not focusing on the past or future. Those with BPD tend to have extreme emotions and can feel trapped in those emotions. Mindfulness meditation can help to manage BPD symptoms and find new ways to cope.
• Interpersonal effectiveness skills: These skills are aimed at ensuring that one’s needs are met, relationships flourish, and self-worth is improved. These skills help individuals with BPD to draw boundaries that are appropriate for the situations and relationships they may be in.
• Distress tolerance skills: These are skills aimed at helping one cope in healthy ways when facing strong feelings of anger. The goal is to prevent engaging in risky behaviors by developing a toolbelt of coping mechanisms. Those with BPD tend to frequently engage in risky behaviors so distress tolerance skills help to mitigate reacting in the midst of extreme anger, or BPD rage.
• Emotion regulation skills: Emotional regulation skills involve controlling your own thoughts, feelings, and behaviors, especially negative ones. For those with BPD, self-regulating emotions is challenging, often due to poor childhood experiences, trauma, or abuse. Using these skills for BPD can make a big difference in how they deal with stressful emotions as well as potential triggers.

Deciding the Best Approach to Treatment for BPD

It’s important to work with your therapist to understand the causes and severity of your symptoms before determining the best individual treatment plan together. Taking an active role in formulating your treatment plan is essential, so it can be helpful to think about and discuss your goals and what you’d like to achieve in therapy with your counselor.

These goals can be determined by examining areas of your life that you are trying to improve. Some of the common areas of focus include one’s relationships, fears, substance use, self-harm behaviors, anger, impulsivity, and general well-being.

Sauer-Zavala further notes that, “BPD presentations are varied; for some patients, more intensive treatment is warranted. Others may see improvement with weekly outpatient therapy in a few months. I think the biggest consideration patients with BPD should take into account is how disruptive their symptoms are and whether they need intensive care.”

How to Find a Cognitive Behavioral Therapist for BPD

One great way to find the right therapist is by searching an online therapist directory. All licensed therapists are equipped to help people struggling with mental health issues such as BPD and may have formal training in CBT as it is a leading therapeutic modality. Reading reviews and looking at clinician bios to understand the scope of their practice can give you an idea of whether their experience suits your situation. Many CBT therapists offer a free phone consultation to help you know if they will be a good fit.

Another way to locate a therapist is by referral, which can come from a trusted loved one or physician. Healthcare providers often have access to a network of other providers who can be helpful. Going through your physician or specialist is also a great way to keep them in the loop about any treatment options or trauma experienced.

“CBT involves learning new skills to apply to negative thoughts and problematic behavioral urges. Learning any new skill requires practice,” says Sauer-Zavala. “CBT therapists will help you apply these skills to the situations their patients bring to session – and patients need to practice if they want to see improvement outside of their 50 minute sessions.”

In some cases, when BPD is diagnosed by a licensed professional,  CBT can be covered by mental health insurance. There is usually a copay for mental health services which can range from $40 to upwards of $100. Looking at “in-network” providers might be able to help with the out-of-pocket costs. In situations where health insurance does not cover CBT, sessions can range from $60-$200 per hour per session. It’s important to consider therapists and practices that offer sliding scale prices for sessions.

Final Thoughts

What you’re struggling with may be challenging, but remember that you’re not alone. If you are dealing with BPD, the first step is to give yourself some compassion and reach out to a therapist. Talking to a therapist who specializes in this issue can make a big difference in how you feel, how you’re able to cope, and what you’re able to do long-term to manage and heal. Together, you and your therapist can develop a plan to get you through this tough time and grow into a more fulfilled version of yourself.