Borderline Personality Disorder Treatment
Borderline personality disorder (BPD) is a complex condition characterized by instability in self-image, mood, and interpersonal relationships. Individuals with BPD tend to be impulsive and have intense episodes of anger, depression, and anxiety.
They struggle with suicidal thoughts and make suicidal attempts. Suicide rates are estimated to be between 8 percent and 10 percent, which is almost 50 percent higher than the general population. About 75 percent of individuals with BPD engage in self-mutilating behavior.
BPD frequently co-occurs with other conditions, including major depression, anxiety disorders, and post-traumatic stress disorder.
Even though BPD is a serious disorder, thankfully, it’s highly treatable, and individuals do recover. That is, people with BPD not only experience a reduction in suicidal thoughts and behavior and self-injurious acts, but they’re able to cultivate healthy relationships and lead fulfilling lives.
The primary treatment for BPD is psychotherapy. Medication’s role is less understood, and medication guidelines for individuals with BPD are mixed. However, medication may be helpful for some symptoms and/or co-occurring conditions.
Psychotherapy is the foundation of treatment for borderline personality disorder (BPD). Five treatments have been established as evidence-based treatment for BPD, which are explained below.
1. Dialectical behavior therapy (DBT)
Dialectical behavior therapy (DBT) is the most well-researched treatment for BPD. It focuses on these four critical skills:
- Mindfulness helps you become aware of your inner experience—your thoughts, feelings, sensations—and to focus on the here and now.
- Distress tolerance helps you to effectively tolerate difficult situations and overwhelming emotions. It uses techniques such as distraction, accepting reality, improving the moment, and soothing yourself with healthy strategies.
- Emotion regulation helps you understand your emotions, decrease the intensity of your emotions, and feel your emotions without acting on them. For example, one technique is opposite action, where you identify your feeling (e.g., sadness), and do the opposite (e.g., instead of isolating yourself at home, you have dinner with a friend).
- Interpersonal effectiveness helps you to cultivate healthy relationships, communicate effectively, express your needs in an assertive way, and learn to say no.
DBT consists of individual therapy; a 2-hour weekly skills training group; phone coaching for crises between sessions; and weekly consultation meetings for the therapist. Research published in 2015 in JAMA Psychiatry found that individual DBT (without the skills training group), and DBT skills training group without skills coaching, were as effective as traditional DBT in improving suicidality and reducing use of crisis services.
2. Schema-focused therapy (SFT)
Schema-focused therapy (SFT) combines cognitive behavioral therapy, psychodynamic psychotherapy, and emotion focused therapy. SFT focuses on helping individuals with BPD change their deeply entrenched, self-defeating patterns of thoughts, behavior, and emotions (known as “schemas”). It’s also based on the belief that individuals with BPD have four problematic modes: detached protector, punitive parent, abandoned/abused child, and angry/impulsive child. According to a 2018 article in PLOS One:
In the abandoned/abused “mode the patient’s feelings are in the rawest state, where they feel intensely worthless, unlovable, helpless, incompetent or abandoned. They frequently feel overwhelmed and look to others for solutions. According to the theory given the adversity of such a state, the patient will typically move from this to an alternative state. In BPD this might be an angry or an impulsive child mode. In angry mode the patient demands that others fix the situation or in impulsive child mode the patient tries to change the underlying pain through self gratification impulses with little or no regard to consequences.”
SFT uses a variety of techniques, including imagery rescripting. This involves recalling a certain situation and your thoughts and feelings about it, along with altering parts of the situation to revise your experience and meaning of it.
3. Mentalization-based therapy (MBT)
Mentalization-based therapy (MBT) proposes that individuals with BPD have a hard time “mentalizing,” or making sense of their own and others’ emotions and actions. These difficulties stem from disruptions in clients’ early attachment relationships. Because of these challenges, they often misunderstand others’ actions and words and overreact. MBT helps individuals identify and understand their own and others’ thoughts, feelings, and actions.
According to a 2017 article in Current Behavioral Neuroscience Reports, “MBT therapists adopt a stance of curiosity, and ‘not knowing’ in order to encourage patients to assess their emotional and interpersonal situation through a more grounded, flexible, and benevolent lens.”
MBT can be conducted in groups or in individual therapy.
4. Transference-focused therapy (TFT)
Transference-focused therapy (TFT) is built on the belief that individuals with BPD perceive themselves and others in unrealistic extremes (i.e., as either good or bad). This split shift is expressed through BPD symptoms. These symptoms affect the client’s relationships—and they affect the relationship with the clinician (individuals view their therapist, for instance, in the same way they view others outside of therapy).
TFT focuses on improving BDP symptoms through the relationship between client and clinician. Individuals see their therapist twice a week, and there’s no group therapy.
5. Systems training for emotional predictability and problem-solving (STEPPS)
STEPPS includes cognitive-behavioral components and skills training. Two trainers lead 2-hour seminar-like group sessions for 20 weeks. STEPSS consists of three parts: psychoeducation, emotional regulation skills, and behavioral skills. Specifically:
- In the first part, individuals learn that BPD is an “emotional intensity disorder.” They learn that they aren’t fatally flawed, and can learn skills to manage and reduce their symptoms. They also learn the cognitive “filters” or beliefs that drive their behavior.
- In the second part, individuals learn techniques to manage the cognitive and emotional effects of BPD. They’re able to anticipate the course of an episode and when symptoms will be intensified, along with cultivating the confidence to manage BPD.
- In the third part, individuals focus on goal setting, self-care (e.g., sleep, exercise), self-harm avoidance, and effective relationship behaviors.
Individuals with BPD also identify a “reinforcement team,” which consists of loved ones and professionals who learn to support and reinforce these effective skills.
Good psychiatric management (GPM) is a newer evidence-based treatment that is easier for clinicians to learn. This is important because most of the above treatments, while highly effective, require extensive training and clinical resources. Which means they aren’t widely available. Previously known as general psychiatric management, GPM features three parts: case management; psychodynamically informed psychotherapy; and medication management.
GPM is based on the interpersonal hypersensitivity model of BPD, which surmises that an interpersonal stressor (e.g., criticism) sparks symptoms. According to the 2017 article in Current Behavioral Neuroscience Reports, “The therapist actively hypothesizes that any emotion dysregulation, impulsive or self-harming behavior, or hospitalization has resulted from an interpersonal problem, and works with the patient to better understand his or her sensitivities and responses.”
Individuals participating in GPM typically meet their therapist once a week.
It’s important for treatment to address co-occurring disorders, as well. For example, researchers have adapted DBT to treat individuals with both BPD and PTSD. In one study, exposure techniques were added to standard DBT to treat complex and severe forms of trauma. In another study, standard DBT was modified to treat severe PSTD symptoms from the start.
There’s no medication that targets symptoms of borderline personality disorder (BPD), and the research on medication overall is limited. However, individuals with BPD are still regularly prescribed a variety of medication.
In 2001, the American Psychiatric Association published guidelines for prescribing medication for BPD. For example, they suggested prescribing selective serotonin reuptake inhibitors (SSRIs) as a first-line treatment for mood dysregulation symptoms and impulsivity. For “cognitive-perceptual symptoms” (described as “suspiciousness, referential thinking, paranoid ideation, illusions, derealization, depersonalization, or hallucination-like symptoms), the APA suggested starting with a low-dose antipsychotic, such as olanzapine (Zyprexa) or risperidone (Risperdal).
A 2010 Cochrane review meta-analysis found improvement in affective dysregulation with a variety of medications: haloperidol (Haldol), aripiprazole (Abilify), olanzapine (Zyprexa), lamotrigine (Lamictal), divalproex (Depakote), and topiramate (Topamax). Aripiprazole and olanzapine improved cognitive-perceptual symptoms.
According to an article in Current Behavioral Neuroscience Reports, in the Cochrane review, “no SSRIs were found to improve any domain of symptoms and no medications alleviated certain core BPD symptoms, including avoidance of abandonment, chronic feelings of emptiness, identity disturbance, and dissociation.”
In 2015, the National Institute for Clinical Excellence (NICE) in UK concluded that there isn’t enough good evidence to develop prescribing practices. They advised against prescribing medication for specific symptoms and instead recommended medication for true co-occurring conditions.
Swedish guidelines on personality disorders from 2017 noted that medication also shouldn’t be the primary treatment but may be prescribed for co-occurring disorders. Guidelines from Switzerland from 2018 noted that medication should be restricted to crisis situations. Finnish guidelines from 2015 noted that antipsychotics might relieve symptoms and mood stabilizers can help with reducing impulsivity and aggression.
Several guidelines noted that benzodiazepines should be avoided because of their potential for abuse and dependence.
Good psychiatric management (GPM) includes an algorithm for prescribers. If individuals with BPD don’t request medication and aren’t in distress, medication should not be prescribed. For individuals with a co-occurring major depressive episode or who are experiencing mild distress and request medication, SSRIs can be prescribed. A mood stabilizer or antipsychotic can be prescribed for impulsivity and anger. And a low-dose antipsychotic can be prescribed for cognitive-perceptual symptoms.
Overall, medication should not be the main treatment, and it’s critical to discuss risks and side effects with the prescribing physician.
When individuals with borderline personality disorder (BPD) are a danger to themselves or others, hospitalization may be necessary. Hospitalization is typically brief (about a week) to help the person get stabilized.
However, some hospitals that specialize in treating mental illness, including BPD, offer longer stays. For example, individuals stay at the Hope Program for Adults at the Menninger Clinic in Houston, Texas for an average of 6 weeks.
After hospitalization, individuals with BPD may transition to a day-long program. Typically, this includes attending various skill-based groups (e.g., individuals learn skills from dialectical behavior therapy). The length of these programs also varies. Some programs last several weeks, while others last several months. It really depends on the specific hospital or treatment center. For instance, here’s information about the partial hospital program at McLean Hospital, which helps individuals with BPD.
It’s critical to work with a therapist, but there are strategies you can practice on your own or in conjunction with therapy. These include:
Work through a workbook. There are various helpful workbooks for borderline personality disorder. Here are several to consider:
- The Borderline Personality Disorder Workbook: An Integrative Program to Understand and Manage Your BPD
- The Stronger Than BPD Journal: DBT Activities to Help Women Manage Emotions and Heal from Borderline Personality Disorder
- The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation and Distress Tolerance
- DBT Skills Training Handouts and Worksheets
- Borderline Personality Disorder Toolbox: A Practical Evidence-Based Guide to Regulating Intense Emotions
Journal. Carve out time every day to journal about your feelings. This is a healthy way to express yourself and make sense of your emotions—without letting them build up and bubble over.
Adopt healthy coping strategies. When big feelings surface, practice turning to healthy activities. Go for a walk. Listen to soothing music. Listen to a calming guided meditation. (For example, here’s a meditation specifically for individuals with BPD.) Try a yoga video. Try a mindfulness app. Try progressive muscle relaxation, where you tense and relax different parts of your body. Watch a funny film. Take deep breaths. Take a hot (or cold) shower. Even cleaning the house can be therapeutic.
Practice good self-care. Get enough sleep and rest. Stay hydrated, and add nutrient-rich foods to your daily diet. Engage in calming or energizing physical activities, such as walking, riding your bike, stretching, dancing, or running. Connect to your creativity through writing, painting, drawing, and other activities.
Check out reputable resources. For instance, the website EmotionallySensitive.com offers online classes on dialectical behavior therapy (DBT) taught by a therapist and DBT skills teacher who’s recovered from BPD. Another resource is My Dialectical Life (MDL), a daily email created by a DBT specialist that contains a DBT skill to use that day.
Know you’re not alone. Learn about individuals who’ve struggled with BPD and recovered. For instance, this video from New York Presbyterian Hospital (and the entire series) on YouTube is excellent. You also might check out the book Beyond Borderline: True Stories of Recovery from Borderline Personality Disorder.
Connecting with people who have BPD can be tremendously helpful. For example, Psych Central has a Borderline Personality Disorder support group and the BPD Beautiful Support Group on Facebook is open to individuals with BPD, as well as their loved ones. Also, this smaller Facebook group is for individuals recovering from BPD. Emotions Matter is a non-profit organization for individuals with BPD and offers an online support group.
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