How Effective Is DBT for BPD?
Borderline Personality Disorder (BPD) can be viewed as a diagnosis of hope. At its core, it is a condition that can occur when a neurological Super-Sensor experiences chronic invalidation for how they respond to the world around them. With effective treatment, there’s an opportunity for recovery—especially when patients are young and still developing their social and emotional skills. Dialectical behavior therapy (DBT) has proven to be particularly promising in these cases.
Randomized Controlled Trials (RCTs) are the gold standard in research. It takes two RCTs, preferably conducted by different researchers in different labs, to conclude that a treatment is effective for a diagnosis or population. Dialectical Behavior Therapy (DBT) has numerous RCTs for BPD and is recognized as a leading treatment in the US, Great Britain, the Netherlands, Australia, and Norway. To understand why results like this are possible and how effective DBT is for BPD, you have to examine the BPD origin, biosocial theory, and how DBT re-organizes the DSM criteria for BPD in a skills deficit framework.
Factors that Contribute to Positive Outcomes of DBT in BPD Treatment
DBT is a cognitive-behavioral therapy that combines two seemingly diametrically opposed concepts; change and acceptance. Patients can learn to both validate and change their emotions as they develop effective coping strategies and behavioral changes. This is based on the concept of dialectics that holds two opposing truths that can both be true at the same time, “I am trying my best and I need to try harder.”
There are three points to discuss when examining how effective DBT is for BPD. There’s the origin of the therapy itself, its biosocial theory foundation, and its alignment with the diagnostic criteria in the DSM.
The Origin of DBT
DBT was created by someone with lived experience: Dr. Marsha Linehan. Her story could be incredibly bleak if it wasn’t for the groundbreaking theory it motivated. She detailed her own struggles with BPD in a 2011 New York Times post, explaining how the treatment doctors initially tried was far from effective.
Dr. Linehan was only 17 when she was admitted to the Institute of Living in 1961. She would spend most of the next two years locked in a tiny room with bars on the windows. Initially misdiagnosed as schizophrenic, she was prescribed Thorazine and Librium and electroshock therapy.
This seemingly punitive treatment further cemented her idea that she had done something wrong, fueling the self-destructive urges that mark BPD.
It was a cycle of recurring trauma that Dr. Linehan would eventually learn could only be stopped through “radical self-acceptance.” This theory grew from a powerful but simple realization she had after visiting a church one night. “‘I love myself,” she proclaimed. While that wasn’t enough to cure her condition, it did trigger a behavioral change.
Dr. Linehan’s life didn’t get better overnight. She still endured emotional challenges, but the big difference was that she no longer self-harmed to cope. She learned to accept herself and validate her feelings. That laid the foundation for her healing and, subsequently, the foundation for DBT.
Over time, Dr. Linehan built on this theory for radical self-acceptance. She fleshed it out as she worked toward her Ph.D. at Loyola University, eventually moving on to work with patients at risk of suicide at a clinic in Buffalo. There, she gained first-hand experience in the most complex cases as she worked with patients who had no idea that her history mirrored their own.
She developed dialectical behavior therapy as an approach to BPD that focused on building practical coping skills while validating the patient’s feelings. She borrowed from different behavioral strategies to create a new way to relate to them—and it worked. A study done shortly after Dr. Linehan developed the therapy found that borderline patients undergoing DBT had fewer suicide attempts, hospitalizations, and improved treatment adherence compared to those receiving other treatments.
Dr. Linehan’s story is important because she experienced BPD. Her development of DBT wasn’t just built on science; it was built on how the treatment she received actually made her worse, and in retrospect, what needed to happen for her to get better. That’s one of the reasons that DBT is effective for BPD.
Understanding the Biosocial Theory
Biosocial is a combination of the biological and social factors that influence a person’s behavior. For obvious reasons, it’s heavily studied in therapeutic research. In DBT cases, there are both biological and social aspects that contribute to the complex trauma that they endure.
In the biological sense, you must look at how these patients deal with the world. They are super-sensors. It takes less for them to have an intense emotional reaction to something; when they do, it takes longer to return from it. That’s part of their biology.
And when it happens, they may hear, “You’re overreacting, you’re being dramatic, get over it.” Their biological response, their first instinct, is being invalidated. They are being invalidated. In the midst of that invalidation, they’re being traumatized.
Think of kids with BPD as grand pianos; neurotypical kids are synthesizers. A synthesizer is an easy instrument to learn. Anyone can master it because the instructions are clear, and they all follow the same standards. There’s no such thing as an out-of-tune synthesizer. They always play exactly as expected at the push of a button. While no major awards exist for mastering the synthesizer, it’s an easy entry-level instrument to learn.
Playing the grand piano is different. Every instrument has its own personality. The strings’ thickness, tension, and length influence the notes’ pitch and timbre. The hardness or density of the felt on the hammer can make them mellow or bright. To master the grand piano, you must first accept those differences. They’re not going away; in fact, they shouldn’t. It’s the ability to play those seeming imperfections that creates a virtuoso.
For a BPD kid, their biological baseline is like that grand piano. It requires special care and maintenance to stay in tune. If that doesn’t happen, the problem only compounds, and the trauma grows. When a grand piano is invalidated by its environment, it’s akin to reaching in and disattuning strings, making self-mastery even more out of reach.
The opposite is also true. Validation can help bring these strings back in tune. Exciting research out of UCLA by Dr. Daniel Siegel actually shows, through PET imaging, that an adolescent brain becomes more myelinated and vagal nerve more “tuned” as parents are taught core validation skills. A quick formula to remember: Invalidation = dysregulation; validation = quickest path to regulation in parenting your Baby Grand.
DBT and the Biosocial Theory
DBT is effective for BPD because it embraces these biosocial components. Before treatment can start, you have to accept your teen’s baseline. It’s not wrong. It doesn’t need to be fixed; it’s how you respond to it that does. Specifically, DBT calls for three responses:
Essential Biosocial DBT Techniques
Parental Validation Skills Strengthening & Psychoeducation
|Teen Self-Validation||Emotion Regulation Skills Training|
|This involves coaching parents to lead first with validating their child’s emotional responses, while not validating the invalid. “I can see you’re in tremendous emotional pain, and the shame that comes from self-harm as a coping skill leaves you feeling actually worse in the long run.” It also means providing accurate and helpful information about BPD’s biological and psychological aspects to the patient and their support system.||The individual must recognize and acknowledge their emotions as valid and legitimate while growing in awareness around how their coping skills make a crisis worse in the long run.||The patient and the family learn to recognize their emotions, measure when they are becoming too overwhelming and use their DBT skills to return them to balance.|
These three integrated components collectively drive DBT’s efficacy in treating BPD. It’s not solely centered around the individual but extends its benefits to encompass everyone involved in the teenager’s life. Parents also learn DBT skills to address their teen’s challenges and provide an emotionally stable support network.
The BPD DSM Criteria
Dr. Linehan took the DSM criteria for BPD and reorganized it in a new framework that led to a non-judgmental and behaviorally specific way of looking at the criteria. It also created a roadmap of what to target in treatment.
The ABCs of BPD
|Affect Dysregulation: BPD teens have big emotions and low coping skills. They have to learn how to recognize and regulate those emotions. DBT’s Emotion Regulation module teaches them how to acknowledge, accept, and effectively manage their emotions.
Behavioral Dysregulation: The function of behavior is to regulate emotions. Self-harm is a good example. A teen uses it to bring down an intense emotion or overcome emotional numbness. Because the behavior helps them temporarily, they continue to do it. In DBT, the Distress Tolerance module teaches them how to survive a crisis without making things worse.
Cognitive Dysregulation: Individuals with BPD can be inflexible in their thinking and resistant to change. This leads to extreme thoughts and feelings. DBT seeks to establish a cognitive middle ground through its Middle Path Skills module, that promotes balanced thinking, helping teens recognize and challenge their extreme thoughts
|Self Dysregulation: Teenagers are well known for being highly influenceable by peers. In BPD teens, that influence is taken up a notch to contagious behaviors, often leading to identity dysregulation. The teen may have a poor or inconsistent sense of self, leading to impulsive behavior and challenges in interpersonal relationships. DBT can help these individuals develop greater self-awareness through its Mindfulness module, which helps them develop skills to be present and fully aware.||Others (Relationship Dysregulation): DBT teens also struggle to create and maintain relationships. The fear of abandonment and the desperate need for acceptance may lead them to initially exhibit clingy or idealizing behaviors, followed by sudden shifts to anger or devaluation if they perceive rejection. Through DBT’s Interpersonal Effectiveness module, these teens can learn healthier interpersonal skills, communication techniques, and how to ask for change from their environment using their words instead of behavior.|
Each of DBT’s five skills modules is laser-focused on a specific area of the DSM criteria that marks BPD. By addressing all aspects of these criteria through targeted skill development, DBT aims to comprehensively address the challenges individuals with BPD face.
Compass Behavioral Health: Gold-Standard Dialectical Behavior Therapy
BPD is a diagnosis of complex trauma, a lifetime of chronic invalidation leading to chronic dysregulation. DBT was developed, in part, from Dr. Linehan's own experience in recovery from profound skills deficits in living and the traumatic invalidation she received from her environment in response to her skills deficits. The answer to how effective is DBT for BPD will depend on the program you choose. Compass Behavioral Health provides a program led by DBT-Linehan Board-Certified™ experts in the delivery of the research-based protocols in the delivery of DBT Treatment.
Compass’ residential program is ideal for complex BPD adolescents, with individual treatment plans developed on a DBT curriculum that helps them learn to regulate their emotions and overcome self-destructive behaviors. Our program also includes family support through DBT Multi-family Skills group training, Parent Effectiveness Training, and intensive DBT Informed Family therapy.
If you would like to learn more about how effective DBT is for BPD, and how it can help your BPD teen, reach out for a free consultation.
Megan Plakos Szabo
Associate Director at Compass. Licensed Marriage & Family Therapist
Megan is a DBT-LBC certified clinicians who provides evidence-based treatment to adolescents and their families at Compass Behavioral Health. She shares her passion and expertise through clinical supervision to pre-licensed clinicians and practicum students. Currently, Megan is pursuing a doctoral degree at Loma Linda University where she studies the effectiveness of DBT and the role of family/caregiver involvement in successful treatment.