How is borderline personality disorder treated?

In another article on borderline personality disorder (BPD), I described the main dysfunctional areas in people who have this disorder (I recommend you take a look at it here to get your bearings, so this one makes more sense). Today I’d like to pick up where I left off and talk about how those areas are treated. Dialectical behaviour therapy (DBT) is currently recognised as the most effective approach for reducing the manifestations of BPD. To begin with, BPD is understood as a disorder whose origin is the sum of:

Biological vulnerability + invalidating environment = self-invalidation (no tolerance for frustration, self-hatred, completely unrealistic expectations)

What does this mean? That the causes of the disorder are both biological (dysfunction in certain brain structures involved in managing emotions) and environmental or learned (an invalidating environment is one that persistently denies or dismisses certain behaviours regardless of whether they are valid; for example, recognising and expressing one’s own emotions).

With that in mind, the goals of dialectical behaviour therapy are:

1. Validation/acceptance of one’s own emotions and ways of behaving.
2. Changing how they are managed: learning to regulate those emotions and increasing interpersonal effectiveness (that is, the relationships I have with the world). In short: teaching the patient to solve and manage problems efficiently and healthily. That excludes avoidance, self-harm and running away, which are the main weapons people with BPD use to resolve conflicts.

Throughout therapy, the aim is to reduce the patient’s mental rigidity, so they let go of such a black-and-white view (no shades of grey: if it goes wrong, it’s a failure; if I try hard and don’t succeed, I’ll never succeed…). This highly polarised view leads them to very extreme negative emotions, to hopelessness and therefore to very dysfunctional behaviour. Validate/accept and change, validate/accept and change… that’s the heart of it all.

Note: you can accept something while also trying to improve it.

To get there, therapy goes through several stages. The goals of the first stage would be:

• Reducing suicidal behaviour and self-harm: people with BPD often see these behaviours as a solution to their problems. Therapy sets out “rules” for handling attempts and, if there are any, they are analysed in depth.
• Reducing therapy-interfering behaviours (not turning up to sessions, arriving late, not doing what’s asked… sabotaging it, basically). These sabotaging behaviours are defined in advance and, if they happen, their causes are explored in depth to find alternative solutions that reduce them.
• Reducing behaviours that interfere with the patient’s quality of life (substance misuse, illegal activities, dysfunctional behaviour at work, serious eating problems…).

To do this, we use the DBT diary card. It’s a sheet the patient fills in and brings to every session. A weekly diary that tells the therapist about different things, such as: whether or not there has been drug or alcohol use; whether there have been impulsive behaviours and which ones; inappropriate sexual behaviour; emotions and their intensity… This weekly diary gives the therapy session relevant information about the patient’s most frequent problem behaviours and shows us where to start.

With the information the diary gives us, we carry out a behavioural chain analysis (you can refresh what that is here); in other words, we analyse the sequence of steps that led the patient to the problem behaviour to see where we can step in and start reducing the chances of that behaviour happening, that is, apply problem-solving.

If avoiding value judgements is important in therapy (it’s actually a basic), it’s even more so with people with BPD, precisely because of how sensitive they are. Validate without judging. You don’t need to give an opinion to help someone change.

In these cases, special attention needs to be paid to feelings of emptiness and boredom, as they often trigger problem behaviours. That’s why it’s important to teach the patient to distract themselves with activities they find motivating. Or to look for a job (if they’re currently in a position to do so), as this will also boost their sense of self-efficacy (feeling useful).

Another time I’ll tell you about social skills training, another stage of therapy that deserves close attention, because people with BPD often interact with others in a very dysfunctional way, which leads to more distress and reinforces all their irrational ideas. Learning to relate to the world will be a core part of treatment.