Dialectical behavioral therapy (DBT) is a long-term type of therapy that has been shown to effectively treat borderline personality disorder (BPD). It can last anywhere from six months to two years in inpatient or outpatient settings, and includes both individual therapy and group sessions. DBT therapists are highly trained to work with BPD symptoms like emotional dysregulation and relationship issues.
What Is DBT?
During dialectical behavioral therapy (DBT), the therapist models dialectical thinking and behaviors for their client. In every session, the DBT therapist validates their client’s emotions and holds them accountable for behavior using positive and negative reinforcement.
More than in other forms of therapy, DBT is a collaborative partnership, and therapists are encouraged to use self-disclosure to talk about their own personal experiences to strengthen the therapeutic alliance. Every session balances acceptance and change while nurturing and demanding certain behaviors. There is an online for DBT therapy online or in-person.
What to Expect From DBT
DBT therapy can be presented in both inpatient and outpatient settings. An inpatient setting provides more opportunity for positive attachment along with intensive therapy.2 Both settings, however, require attendance at one weekly individual session (sometimes two) and one weekly group session. Clients who miss group sessions can be removed from the group, although they can rejoin later.
DBT treatment is comprised of four stages:
- Reduce negative behaviors and improve behavioral skills
- Treat issues related to past trauma
- Develop of self‐esteem
- Find a higher purpose
Initially, the therapist and client will sign a contract for treatment outlining specific expectations. Clients will also be asked to complete weekly diary cards documenting their behaviors. At this point, the therapist begins the process of preparing the client to attend group sessions. When a client is placed in a group, they must continue to attend weekly individual therapy as well.
One-on-one therapy is the key to lasting change. During the first few sessions, the client and therapist will decide if they’re a good match. The client will be asked to state the change they want to make in themselves. The therapist will obtain further information through assessments, history-taking, and diagnosis.1 During this time, the therapist will also provide information about their interpersonal style, professional competence, and treatment goals.1
Once expectations are set, both sign a contract for the agreed upon treatment. The complete orientation and commitment may take upwards of four sessions, allowing for time to build a solid, positive therapeutic relationship.
Skills Training Group Sessions
Groups are a great way to learn to cope with extreme emotions and risky behaviors. Skills training groups have a goal of reducing self-destructive behaviors and finding better ways to manage anger and stress.
Group sessions introduce skill building in four areas:
- Interpersonal effectiveness
- Emotion regulation
- Distress tolerance
Clients graduate from the skills training group after completing all of the modules in roughly six months. Some clients with BPD require another round of training and additional individual therapy, or they may continue receiving assistance from a case manager and a DBT support group.
There may be some DBT therapists who offer phone/text consultation, especially for those who may have a hard time accessing traditional therapy. However, an initial phone consult is a standard practice for new clients looking to learn about DBT and if that therapist is right for them.
Therapist Consultation Team
The consultation team is generally composed of the client, therapist, the client’s family, friends, caregivers, neighbors, coworkers or any other significant person in that individual’s life. The team usually gathers during the initial few sessions and can be tapped to enter the conversation again at a later time depending on how the course of treatment is going.
How Does DBT For Borderline Personality Disorder Work?
DBT is typically made up of several different modules of areas of skill-building, including mindfulness, interpersonal effectiveness, distress tolerance, and emotional regulation. These modules would also be used to treat the signs and symptoms of borderline personality disorder.
Here is how the four modules would be applied to BPD:
Mindfulness Meditation Skills
Mindfulness meditation requires individuals to stay grounded in the here and now. It focuses on being very conscious about 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.10
Interpersonal Effectiveness Skills
Interpersonal skills are aimed at ensuring that needs are met, relationships flourish, and self worth is improved. These skills help those with BPD to draw boundaries that are appropriate for the situations and relationships they may be in.9
Distress Tolerance Skills
These are skills aimed at helping you cope in healthy ways when facing very strong feelings of anger or turmoil. The goal is to prevent engaging in risky behaviors by coming up with a toolbelt of coping mechanisms. Those with BPD tend to engage in a lot of risky behaviors, so distress tolerance skills help to mitigate reacting in the midst of extreme anger, also known as borderline rage.9
Emotion Regulation Skills
Emotional regulation skills involve controlling your own thoughts, feelings, and behaviors. For those with BPD, self regulating emotions is challenging, often due to a history of poor childhood experiences, trauma, or abuse. Using these skills for BPD can make a big difference in how they deal with the stressful emotions they may have as well as potential triggers.9
Is DBT Effective For Treating Borderline Personality Disorder?
In the early 1990’s, Marsha Linehan established DBT as an effective treatment for borderline personality disorder.1 It is considered the frontline treatment for BPD suicidality and self-harming behaviors.4 In the last 25 years, a substantial amount of empirical research, including random control trials, has provided evidence for DBT’s effectiveness.4
Recent work using MRI on women with BPD found significant changes in the brain’s gray matter after 12 weeks of DBT therapy.3 This important finding, and others like it, demonstrate the future possibility of using neurobiologically informed therapy to treat borderline personality disorder.3
What if DBT Doesn’t Help?
If you’re not experiencing the progress you want with DBT, there are plenty of other BPD treatment options, including cognitive behavioral therapy (CBT), schema-focused therapy, humanistic approaches, and family therapy.
Here are therapy types that can work to treat BPD symptoms:
- Cognitive behavioral therapy (CBT): cognitive behavioral therapy for borderline personality disorder is particularly helpful when combined with focus on understanding of thought distortions related to self and others.11 Other cognitive and behavioral approaches such as acceptance and commitment therapy (ACT) can be helpful at distinguishing thoughts and behaviors from self and establishing parameters around identity.
- Schema-focused therapy: Schema-focused therapy helps people with BPD identify their needs and understand how they have learned to get those needs met. Those with BPD who participated in schema-focused therapy reported better self-understanding and improved emotional regulation.12
- Humanistic approaches: humanistic therapies can be helpful in facilitating good outcomes in those with BPD, particularly due to the focus on the client-therapist relationship. Humanistic approaches can be useful in helping the client find meaning in their life, which has been shown to decrease BPD symptoms.13
- Family therapy: Due to the social discord present in this disorder and the genetic/environmental causes, family therapy can be an important approach for 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.14
How to Find a DBT Therapist
To find a therapist in your area, you can ask for a referral from your primary care physician, or you can use an online therapist directory. You can search based on specialty (like DBT), price, experience, and more. Do not be afraid to ask a therapist about their education, training, certifications, experience, and personal treatment philosophy. It is important to have the right fit so that treatment goals can be accomplished within a safe, honest, and trustworthy environment.
How Hard Is it to Find a DBT Therapist For BPD?
Many therapists have online bios that include their areas of focus as well as specializations. It’s important to consider these when choosing a therapist. Looking for training around DBT for BPD may take some time, but there are many therapists who are increasingly practicing DBT in treatment.
How Much Does DBT Typically Cost?
With a BPD diagnosis from a licensed professional, DBT may be covered by health insurance. There is usually a copay for mental health services with most insurance providers that can range from $20 and upwards of $100.
Looking at “in-network” providers might help with the out-of-pocket costs with copays. In situations where health insurance does not cover DBT, sessions can range from $60-$200 per hour per session. It’s important to consider therapists and practices which may offer sliding scale prices for sessions.
7 Questions to Ask a DBT Therapist
Before starting treatment with a new therapist, it’s a good idea to get to know them in an initial phone consultation. This will help you gauge how much experience they have with BPD, as well as figure out if they’re a good personality fit for you.
Here are seven questions to ask a new therapist before starting DBT for BPD:
- How long have you been practicing DBT?
- How often do you meet with individuals and how long are appointments scheduled for?
- Do you have a crisis line or resources available? Do you offer contact between sessions? Phone sessions?
- What specialized DBT training do you have in treating BPD?
- On average, how long do you see individuals with BPD before they report improvements?
- Do you give therapy homework and what might that look like?
- What struggles do people run into when receiving this form of treatment, and what do you encourage them to do when they happen?
Examples of DBT For Borderline Personality Disorder
While those with BPD experience many similar symptoms, it can present differently depending on someone’s unique background and relationships.
Here are examples of DBT for BPD:
Young Adult Woman With Skin Picking Issues
Joan had not originally been diagnosed with BPD, but she had traits of impulsivity, self-harm, chaotic relationships, fear of abandonment, emotional dysregulation, and an unstable self-image. At age 39, she became overwhelmed when her husband of 20 years divorced her.
At her first meeting, Joan said she couldn’t stop crying and picking her face. She had severely scarred her face and arms and was embarrassed by her appearance. She rarely left home and had not been able to work for the last six months although she had held jobs successfully in the past.
With this information and her intake assessment, she met seven out of nine criteria for BPD. The evaluation lasted a few sessions and found that Joan had been experiencing extreme symptoms for a period of time, which was concerning to her family and friends. The subsequent sessions included a treatment plan.
Joan went home with diary cards and relevant handouts about BPD and DBT therapy. The primary behavior targeted was skin picking. Mindfulness techniques and coping skills were used to reduce it over time.
After four weeks of preparation, Joan joined a group. Each week in therapy, problem situations, ineffective behavior, and skills that worked or didn’t work were discussed. After four months when her first level of DBT therapy was complete, Joan resumed individual therapy and began unpacking childhood trauma.
With therapy, Joan became stable, aware of her emotions, and used mindfulness skills enough to engage in eye movement desensitization reprocessing (EMDR therapy for anxiety). Over the next three months, Joan’s treatment was focused on trauma treatment while she worked in a group. After a year, she was able to graduate from the group, resolve her trauma, and engage in a purposeful life with a positive sense of self.
Substance Use & Anger Problems
30-year-old Jeannie was working through a court ordered drug diversion program and attending college courses. She had a long history of cutting, skin picking, suicide attempts, severe trauma, heroin addiction, selling drugs, and prison time. She had also lost her four children to Child Protective Services (CPS). Regardless, she was intelligent, curious, and motivated.
When Jeannie had terrible fits of rage and stormed out of DBT sessions, her therapist would take her calls but limited to two minutes, and say something irreverent like, “That was a hurricane that achieved nothing.” Her therapist would tell her they missed having more time with her. Then, when she asked to see the therapist that same week, the therapist said they would have to wait until next week’s session.
This is an example of behavioral shaping: Positive reinforcement of wanted behaviors and negative reinforcement of unhealthy behaviors. This is also a practice of modeling emotional regulation skills as well as distress tolerance.
Jeannie learned she couldn’t throw a tantrum and get what she wanted. She had to learn to identify her feelings, tolerate them, know why they were there, and ask the therapist for what she needed. The therapist was able to provide positive reinforcement and guide Jeannie to find better ways of handling situations.
Jeannie joined a group after four individual sessions. Initially, she completed her homework and read the materials. She came to weekly appointments in crisis and her therapist coached her through the extreme emotions and engaged her so she could better ground herself. Mindfulness meditation was used, too.
She was progressing, but slipped back into drug use. When Jeannie relapsed, the same approach to treatment was used, as well as engaging the group. The treatment plan included a contract where Jeannie would commit to consistency in treatment and the newly added support system of the group helped to keep her on track and stay accountable to herself.
Final Thoughts on DBT for BPD
If you or a loved one are dealing with unwanted symptoms of BPD, DBT could be a great option for feeling better. The sooner you seek treatment, the better.