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Borderline Personality Disorder Dialectical Behavior Therapy – what to know

a person looks sad as they sit on a bench looking down

If you or someone you love one has recently been diagnosed with borderline personality disorder and/or a substance use disorder, it is common to feel uneasy, isolated, or overwhelmed. One of the best things that anyone can do after a recent diagnosis is to learn the facts about the mental health condition, as well as the available treatment options. Both borderline personality disorder and substance abuse can be treated through dialectical behavior therapy. Before beginning treatment, here are some things you need to know:

Borderline Personality Disorder


It is estimated that 1.6% of the adult U.S. population has Borderline Personality Disorder, a statistic that is representative of over four million people. However, that number may be as high as 5.9%. This may be due to the fact that over 40% of people with Borderline Personality Disorder have been previously misdiagnosed with more well-known or easily treated disorders, such as bipolar disorder or major depressive disorder. It’s also common for individuals to have other diagnoses in conjunction with BPD (such as substance abuse disorder). For example, a striking 20% of those diagnosed with Borderline Personality Disorder have been found to have a type of bipolar disorder, making treatment more complicated than treating one disease alone. Additionally, 75% of people that are diagnosed with Borderline Personality Disorder are women. However, it has been hypothesized that men may be more equally affected by BPD, but are commonly misdiagnosed with depression or post-traumatic stress disorder (PTSD). These numbers may also be a reflection of the fact that women are typically more likely than men to seek treatment for personality disorders.


According to the National Institution of Mental Health, Borderline Personality Disorder (BPD) can be defined as, “A mental illness marked by an ongoing pattern of varying moods, self-image, and behavior. These symptoms often result in impulsive actions and problems in relationships. People with BPD may experience intense episodes of anger, depression, and anxiety that can last from a few hours to days.” Overall, Borderline Personality Disorder is a condition that is characterized by difficulties in regulating emotion. Individuals may feel emotions (such as happiness, sadness, anger, regret) intensely and for extended periods of time. Additionally, it is very difficult for them to return to a stable baseline after an emotionally triggering event.


According to the Diagnostic and Statistical Manual (DSM-IV) diagnostic framework, the following are common signs and symptoms of Borderline Personality Disorder:

  • Separation anxiety
  • An intense and chronic fear of rejection. This may be evidenced by efforts to avoid real or imagined abandonment, such as rapidly initiating intimate relationships (either physically or emotionally). On the other hand, an individual may cut off communication or interactions with someone due to the anticipation or fear of being abandoned.
  • Interpersonal/relationship difficulties. People with Borderline Personality Disorder may long for intimacy with others, but struggle with navigating the emotions necessary to maintain healthy relationships. Individuals may frequently experience hostile, angry, or resentful feelings toward those they love, often without explanation. They may also become disproportionately angry in response to minor issues, or even alternate between idolizing and rejecting the people they love the most.
  • Identity struggles. Persons with BPD may frequently appear to modify or alter aspects of their identity, or have no sense of self at all. The frequent modifications often are a result of a desire to please others, in order to find love and acceptance. They may also have a low self-worth or a distorted self-image.
  • Impulsive behavior
  • Risky behavior
  • Self-Harm
  • Suicidal ideation or suicidal behaviors
  • Emotional instability, characterized by intense mood swings or extreme highs and lows. Many people with Borderline Personality Disorder have a “black and white” worldview, with viewpoints that frequently reflect people, places, things, and ideas as either “all good” or “all bad.”
  • Chronic and persistent feelings of boredom or emptiness. These feelings may relate to a person’s fear of abandonment or the lack of a clearly defined sense of self.
  • Inappropriate, intense or uncontrollable anger. This is typically followed by shame and guilt.
  • Dissociative feelings. This involves disconnecting from your thoughts or sense of identity, similar to an “out of body” experience, as well as stress-related paranoia. This may also lead to brief psychotic episodes.


As with any mental health disorder, it is often impossible to uncover the direct cause of a diagnosis. However, Borderline Personality Disorder is characterized by a few, specific risk factors. Firstly, environmental, cultural, and social factors play a role. Many people with BPD have reported report traumatic life events, particularly during childhood. Some estimates suggest as many as 75% of those with Borderline Personality Disorder have a history of sexual abuse. Other examples of childhood trauma include: physical abuse, emotional abuse, neglect, witnessing violence in the home, abandonment, or poverty. Others have reported traumatic events throughout their lifespan and into adulthood, such as chronic disease, exposure to unstable relationships, hostile conflicts, violence, and other adverse experiences. Secondly, family history is a viable risk factor in the development of Borderline Personality Disorder. Individuals who have a close family member (such as a parent or sibling) with the disorder may be at higher risk of developing it themselves. There is also some evidence that BPD is an intergenerational disease, and parents can pass down the condition to their children through environmental exposure, rather than genetics. For example, a caregiver’s instability may model harmful coping mechanisms to their children. Thirdly, some symptoms of Borderline Personality Disorder may be rooted in neurology. Structural and functional changes in the brain, particularly the areas that control impulses and emotional regulation, may contribute to the development and severity of BPD. However, it is difficult to determine whether these neurological changes are risk factors for the disorder, or rather are caused by the disorder themselves.


Because individuals with Borderline Personality Disorder have difficulties regulating their emotions, this can lead to a variety of harmful consequences. These may include but are not limited to, impulsivity, poor self-image, tenuous or tumultuous relationships, intense responses to everyday stressors, and even dangerous behaviors such as self-harm or suicidal ideations. In fact, approximately 70% of people with Borderline Personality Disorder attempt suicide at least once. Furthermore, between 8 and 10 percent of those individuals will complete suicide. Overall, the suicide rate among individuals with BPD is over 50 times higher than the general population as a whole. The consequences of Borderline Personality Disorder have to the potential to become much more severe when individuals do not seek adequate treatment after receiving a diagnosis. However, among those receiving seek appropriate treatment, the prognosis for BPD is very good. In fact, almost half of those who are diagnosed with Borderline Personality Disorder will not meet the criteria for a diagnosis just two years later. Additionally, after ten years, a striking 88 percent of individuals who were once diagnosed with BPD no longer meet criteria for a diagnosis.

Dialectical Behavior Therapy and Borderline Personality Disorder

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that is widely used to treat Borderline Personality Disorder. DBT is a modification of Cognitive Behavioral Therapy, combined from the basic principles of both behavioral and cognitive psychology. These theories contend that our thoughts and beliefs influence our all of our behaviors, emotions, and physiology. Dialectical Behavior Therapy is based on the perspective that some individuals develop pervasive problems in social functioning due to a lack of interpersonal and self-regulation skills. As a result, their potential to develop appropriate, adaptive behaviors is inhibited by both personal and environmental factors. Using a variety of tools and assessments, Dialectical behavior therapy first targets a client’s immediate, life-threatening behaviors. The intervention then moves on to address problem behaviors that may intervene with the client’s ability to participate in therapy, as well as their overall quality of life. The end goal of DBT is to help people learn and use new skills and strategies to develop a “life worth living.” Dialectical Behavior Therapy utilizes Individual Therapy, a Skills-Training Group, Coaching, and Consultation, in order to achieve the treatment targets through the various stages of intervention. After the client has expressed a commitment to therapy, they are able to begin with the first stage. The goal of Stage 1 is to achieve behavioral control. The goal of Stage 2 is for the client to learn skills that enable them to experience and process a full range of emotions, as well as reduce post-traumatic stress symptoms. Both the third and fourth stages of Dialectical behavior therapy focus on the development of self-respect and autonomy, as well as issues surrounding an individual’s own meaning and purpose. During Stage 3, the client is challenged to set life goals, and work toward living a life of healthy emotional regulation, being able to experience appropriate levels of happiness and unhappiness. Finally, in Stage 4, the overall goal of treatment is for the client to move from a sense of incompleteness or emptiness towards a spiritually fulfilling life. Over 30 years of research have demonstrated the effectiveness of Dialectical Behavior Therapy (DBT) for people diagnosed with borderline personality disorder (BPD). DBT has been evaluated and found to be effective among individuals from diverse backgrounds in terms of age, gender, sexual orientation, and race/ethnicity, while being implemented within a wide variety of practice settings around the world. For example, Dr. Marsha Linehan (the founder of DBT) and her colleagues found that DBT resulted in significant improvements for chronically suicidal and self-injuring women who had been diagnosed with Borderline Personality Disorder (Linehan et al., 1991).

Borderline Personality Disorder and Substance Use Disorder

According to a 2014 National Survey on Drug Use and Health, 7.9 million people in the U.S. experience both a mental disorder and substance use disorder simultaneously. Individuals who are experiencing a mental health condition such as Borderline Personality Disorder may turn to alcohol or other drugs as a form of self-medication, in order to mask the mental health symptoms they are experiencing. In actuality, alcohol and drug use worsens the symptoms of mental illnesses. As a result, those with a mental disorder as well as a substance use disorder have a more severe clinical profile than those with just one diagnosis. Therefore, it is important to seek a treatment method that will be effective in addressing both conditions simultaneously.

Dialectical Behavior Therapy and Substance Abuse

Fortunately, Dialectical Behavior Therapy for Substance Use Disorders (DBT-SUD) was developed for individuals with both substance use disorder and Borderline Personality Disorder. DBT-SUD is effective in treating substance use problems while simultaneously addressing other complex problems related to emotion dysregulation. The following addictions and mental health concerns associated with Borderline Personality Disorder and Substance Abuse can be addressed using DBT-SUD:

  • Alcohol
  • Tobacco or nicotine
  • Prescription pain medication
  • Opiates
  • Stimulants (e.g., methamphetamine, ecstasy)
  • Depressants
  • Antidepressants
  • Hallucinogens (e.g., LSD)
  • Illegal drug addiction (e.g., cocaine, heroin)
  • Recreational drug addiction (e.g., marijuana)
  • Eating disorders
  • Depression
  • Impulsivity
  • Anxiety
  • Post-traumatic stress disorder (PTSD)

Dialectical Behavior Therapy for Substance Use Disorders utilizes the same treatment strategies and protocols as standard DBT, while incorporating specific skills and targets relating to substance use behaviors. The four components of standard Dialectical behavior therapy (skills training, individual therapy, phone coaching and therapist consultations) are conducted with a particular emphasis on decreasing the abuse of different types of substances. This is accomplished through reducing painful withdrawal symptoms, regulating emotions, diminishing cravings and urges to use, avoiding tempting situations, increasing community support by developing relational skills, and encouraging recreational or vocational activities that support abstinence. Overall, Dialectical behavior therapy has been proven to dramatically improve outcomes for clients who were suffering from co-occurring disorders, such as Borderline Personality Disorder and substance abuse. The implementation of behavioral skills such as effective mindfulness, interpersonal effectiveness, distress tolerance, and emotional regulation through DBT has helped countless individuals truly develop a “life worth living.”

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