What is the most successful treatment approach for borderline personality disorder?

How Psychotherapy Is Used to Treat Borderline Personality Disorder

Psychotherapy, or talk therapy, is usually the first line of treatment for people with mental health issues, including BPD.

Therapy is usually conducted one-on-one with a therapist, but it may also be conducted in a group. It can help people with BPD better manage their emotions, reduce impulsiveness, and improve their relationships, among other things.

BPD can be treated with various types of therapies.

Dialectical Behavioral Therapy (DBT)

This therapy was developed specifically to treat BPD and is a form of cognitive behavioral therapy, or CBT (more on that below).

In DBT, patients are usually seen, individually and in groups, multiple times a week, making it a fairly intensive experience, Ochoa says. Sessions may focus on building skills like anger management, self-harm reduction, or avoiding substance use, or they may focus on interpersonal relations, like increasing awareness of oneself and others, she explains. Ultimately, Ochoa says the goal is to help people manage difficult feelings without engaging in self-destructive behaviors, and to manage their relationships effectively.

Using a skills-based approach, this type of psychotherapy can help people to:

• Better manage emotions
• Build tolerance to distress
• Improve interpersonal abilities
• Practice mindfulness, or being attentive to (and aware of) current situations and emotions

“DBT is unique in its focus on balancing acceptance and change,” Lazarus adds.

Cognitive Behavioral Therapy (CBT)

Another common type of therapy for BPD is general CBT, which is also used to treat numerous other mental health issues, including post-traumatic stress disorder (PTSD).

For people with BPD, CBT treatment can help them identify and change core beliefs about themselves, others, and the world, ultimately leading to a reduction in negative thoughts and behaviors.

CBT generally is anchored in the present, rather than focused on exploring the past, Ochoa says, noting that CBT focuses on examining links between thoughts, feelings, and behaviors.

“In general, CBT focuses on the development of new and more adaptive core beliefs about oneself, the world, and the future,” Lazarus says.

Still, Lazarus points out, “the research examining mechanisms of change in these treatments is far behind that which establishes their efficacy.” Some research has found key mechanisms behind that efficacy. Lazarus cites one review that looked at both DBT and CBT in the treatment of BPD. The review found that three themes were important drivers in changing symptoms: emotional regulation and self-control, skills use, and investment in treatment.

Other types of therapy for BPD include:

Schema-focused therapy (SFT) While not commonly used for BPD, this treatment combines aspects of various other types of psychotherapy to help people recognize and change maladaptive schemas, or negative patterns of thoughts, feelings, and behaviors toward themselves and others.

Typically, SFT involves two weekly individual therapy sessions, Lazarus says. It encourages an attachment between patient and therapist, a process called “limited reparenting,” she explains. Lazarus notes that the treatment aims to help patients alter negative patterns of thinking, feeling, and behaving to reduce the power of more dysfunctional patterns.

One March 2022 clinical trial, which included 495 adults with BPD from five countries, showed that a combination of individual and group schema therapy was significantly more effective than usual treatment (defined as the ideal psychological treatment available at each site) and predominantly group schema therapy in decreasing the severity of BPD. The researchers noted a need for future studies to assess the cost-effectiveness of schema therapy and compare this therapy head-to-head with other evidence-based treatments for BPD.

Mentalization-based therapy (MBT) Also less common than treatments like DBT, MBT aims to help patients with BPD stabilize their symptoms by increasing the patient’s capacity to imagine thoughts and feelings in their own and others’ minds — especially under stress, Lazarus says.

Outpatient MBT generally involves 50 minutes of individual weekly therapy, 75 minutes of group therapy, and a team meeting for therapists, Lazarus explains. She notes that the therapy aims to help improve mentalization abilities (the imagination of thoughts and feelings) under duress.

Transference-focused therapy (TFT) A type of psychodynamic psychotherapy, this treatment uses the developing relationship between the patient and therapist to help patients understand their emotions and interpersonal problems.

TFT generally involves two weekly individual therapy sessions but no group therapy, and allows clinicians to work individually (though supervision is encouraged), Lazarus says. She notes that TFT aims to help patients by having them develop a more balanced and coherent view of themselves and others.

Systems training for emotional predictability and problem solving (STEPPS) This 20-week, group-based treatment aims to involve family members, caregivers, friends, or significant others.

Lazarus emphasizes that STEPPS is designed to supplement other treatments, and that some of its benefits include its cost-effectiveness and its relative brevity.

Dialectical behavior therapy family skills training This form of DBT treatment incorporates family members into DBT sessions.

DBT generally includes things like one hour of weekly individual therapy, two hours of group skills training, and a consultation team for the therapist, Lazarus says. She notes that the full DBT model can be resource-intensive, given its intensity and structure.

DBT aims to treat patients by helping them develop skills that improve emotional regulation, mindfulness, and effectiveness within interpersonal relationships, Lazarus says.

General psychiatric management This is a structured treatment that includes case management, symptom-targeted medication, and psychodynamic psychotherapy to target mood instability, impulsivity, and aggressiveness.

This treatment is designed to be less intensive, and it is more easily accessible to the generalist clinician, Lazarus says. General psychiatric management focuses on the patient’s life outside of therapy and typically involves one session per week, along with group and family therapy and medication management, she explains. Lazarus notes that this treatment aims to help patients by facilitating the natural course of BPD’s improvement.

Understanding the Pros and Cons of Psychotherapy for BPD

For all the above treatments, people with BPD can benefit from having a person to go to when they feel hopeless or desperate, building strong relationships with their therapist and treatment team, and educating themselves about their condition, Ochoa says.

But cons include the length of treatment, sometimes requiring multiple visits a week, the cost of these longer-term treatments, and the demanding nature of therapy, especially if it requires the patient to face uncomfortable feelings, Ochoa notes.

Other Ways to Treat Borderline Personality Disorder

As with other forms of mental illness, proper self-care may help reduce some symptoms of BPD, such as severe mood changes, irritability, and impulsivity.

“There are times we are all more vulnerable to negative emotions. Taking care of ourselves can help us feel more balanced in the face of life’s challenges,” Lazarus says. “Tending to physical illness, getting enough exercise, eating right, taking medication correctly, and avoiding mood-altering substances can help us regulate our emotions more effectively.”

People with BPD should aim to:

Get regular exercise. Exercise can promote a sense of well-being and accomplishment, and can help with mood regulation, Ochoa says.

Maintain good sleep habits. Sleep can reduce irritability and cloudy cognition, and can improve attention and concentration, Ochoa says. The amount of sleep you will need varies: most adults need somewhere between seven and nine hours per night.

Practice stress-management techniques, such as yoga or meditation. It’s important to be proactive about managing stress, Lazarus says, such as by planning ahead for difficult situations and incorporating relaxation techniques, like breathing, mindfulness, and mindful movement, into your routine.

Follow a healthy diet. A January 2018 systematic review noted two studies that found that omega-3 supplementation could help stabilize moods and control impulsivity, Lazarus says.

But no specific foods have been shown to help with BPD, says Amy Swift, MD, an attending psychiatrist at Mount Sinai Beth Israel in New York City.

Improve their education about BPD. “There are lots of resources to learn more about BPD and get support,” Lazarus says, noting one resource is the National Education Alliance for BPD, which caters to people with BPD and their families, and has resources on the disorder, treatment, and opportunities to connect with others dealing with the disorder.

By getting educated about BPD, patients can also find explanations for some of their long-standing difficulties and learn about treatment options. “It is often comforting to have a diagnosis that captures their experiences that other people may not understand or empathize with,” Ochoa says.

Set realistic goals for themselves. By setting realistic goals, patients can develop hope for the future, and come to believe that change can happen over time, Ochoa says.