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: