DBT Treatment for Borderline Personality Disorder – Dialectic Behavioral Therapy

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

DBT therapy – mindfulness.
Photo courtesy of pixabay.

Does treatment for Borderline Personality Disorder work?

Lots of treatments for Borderline Personality Disorder have been tried over the years. One treatment, Dialectic Behavioral Therapy (DBT) has lots of evidence that it works and is effective.

The problem in treating Borderline Personality Disorder.

Lots of clinicians (Counselors and Therapists) do not use DBT and don’t want to learn it. In fact, plenty of clinicians I know don’t even like seeing BPD clients. Some clients don’t like going for DBT either, despite the glowing testimonials we hear from clients who say DBT changed their life.

If DBT is so effective for treating BPD, why do so few clinicians want to use it and why aren’t their lines of clients waiting for treatment?

BPD is a painful disorder. Treating BPD is like treating a burn victim. They are in terrible pain. Just touching them (emotionally) may cause them to feel the pain. Helpers don’t like to hear their clients scream in pain. Clients in pain tend to lash out. Clients with BPD are more likely than other people to lash out at the therapist, walk out of session and even go out and try to hurt themselves.

Their pattern of unstable relationships is so pervasive that they have difficulty forming a healthy relationship with the clinician. Just when we think we are helping them they may quit treatment and blame the clinician for their increased pain. They are also more likely to file complaints with the licensing board or even a lawsuit because they feel therapy did not help them and now their pain is even worse.

Despite all these issues DBT does work and does help clients with BPD.

About Dialectic Behavioral Therapy (DBT.)

DBT was developed by Marsha Linehan (Ph.D.) at the University of Washington. Her book Cognitive-Behavioral Treatment of Borderline Personality Disorder is a classic in the field and her workbook has lots of useful exercises for clients to use. I have had the pleasure of hearing Marsha Linehan speak a number of times but can’t say I am fully trained on DBT. What follows is my horrifically oversimplified understanding of what DBT is and how it works.

DBT is a blend of Cognitive Behavioral Therapy, that change your thinking, to change your feelings, to change your behavior stuff that I like to use, and “stuff” Marsha Linehan calls mindfulness. The pain from BPD is so intense that the normal reaction would be to run away.

Mindfulness involves stress reduction, meditation and ways to be able to reduce and tolerate that pain. By reducing the need to run from pain the pain can be shrunk to a manageable size. This skill is called “distress tolerance.”

Since many clients with BPD (maybe all) came from non-affirming environments they struggle with issues of self-worth and self-acceptance. Clients with the full-blown disorder not just some small level of BPD traits have lots of self-harming and self-destructive behaviors which they use to get away from the negative feelings.

Treating DBT has been described as “like driving a car with one foot on the gas and one on the brake.”  It makes for a bumpy ride for both the clinician and the client.

The client needs to learn to accept and like themselves just the way they are. The clinician continually tells the client that they are a worthwhile human just the way they are.

The client needs to change. They need to stop doing those self-destructive, self-sabotaging behaviors, which are keeping them stuck in an unhappy life. Now comes the tricky part.

When the clinician says “I want you to change” the client hears “I am no good and need to change to be accepted.” The clinician then says “You are accepted just the way you are, but I still want you to change.”

The struggle here is to have clients accept that the goal is not for them to be a certain way to be acceptable, but that what we are looking for is “progress not perfection.”  Any good coach or teacher wants to see their student’s progress and do better, that does not mean there is anything wrong with them if they do not become the best at their discipline.

There is a second challenge for those with BPD and those who treat them which DBT seeks to address.

People who have BPD do not live in the meadow full of flowers in the springtime, they live in the hurricane. If they are ever in a calm place, they know this is the eye of the hurricane and the next blast of the storm is a moment away.

Because the volume on their emotions is turned up so loud, there is always the crisis of the day, hour or minute. When you are living in an emotional hurricane it is hard to think about disaster preparedness.

The clinician who does DBT has to limit the time they spend on today’s crisis so they can work on developing skills to prevent or cope with future crises. This “let’s not talk about your urges to cut on yourself or use drugs right now, let’s work on your skills” attitude is hard for clinicians and client who are used to that warm fuzzy empathetic listening stuff.

Clients can leave a skills-based session thinking that the counselor didn’t listen to them and doesn’t care. The counselor may worry “what if they do cut or self-harm? Will it be my fault because I wanted to work on stress reduction skills?” Sticking to the skills building curriculum can be difficult for both.

One ethical principle that clinicians have learned is that it is not helpful to keep the client dependent on their counselor to cope with life. Our goal should be to get the client to the place where they can function without the clinician. Sometimes that is uncomfortable for both client and counselor.

So DBT is very useful in treating BPD because it increases the client’s self-confidence and self-esteem while teaching them the skills to believe they can cope with life’s problems without having other people do it for them.

Other posts on Borderline Personality Disorder include:

What is Borderline Personality Disorder?

What causes Borderline Personality Disorder?

Levels or types of Borderline Personality Disorder

Treatment for Borderline Personality Disorder

If any of you have been to someone for Dialectic Behavioral Therapy or have had another treatment for Borderline Personality Disorder, would you be willing to leave a comment and tell us how it worked or didn’t work for you?

Staying connected with David Joel Miller

Three David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

SasquatchWandering through a hole in time, they encounter Sasquatch. Can they survive? The guests had come to Meditation Mountain to find themselves. Trapped in the Menhirs during a sudden desert storm, two guests move through a porthole in time and encounter long extinct monsters. They want to get back to their own time, but the Sasquatch intends to kill them.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Books are now available on Amazon, Kobo, iBooks, Barnes & Noble, and many other online stores.

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

Levels or types of Borderline Personality Disorder

By David Joel Miller MS, Licensed Therapist & Licensed Counselor.

Are there different types of Borderline Personality Disorder?

personality disorder

Are there types of Borderline Personality Disorder?
Photos courtesy of Pixabay.

People with Borderline Personality Disorder (BPD) differ so much there might be more than one type of BPD or that we may be placing several different mental illnesses together under one label. Gunderson in his book Borderline Personality Disorder describes three levels of functioning in people with BPD. Hotchkiss appears to enlarge this idea into three types of borderlines.

Diagnostic criteria for mental health disorders are largely normal characteristics which have grown so large that they begin to interfere with everyday life. Everyone has sadness sometimes and we all are or should be anxious occasionally. That same concept of degree rather than nature is applicable to BPD.

Masterson wrote about Narcissistic Personality Disorder and described this as coming in low, medium and high levels. I think the use of that same sort of yardstick for measuring BPD might be useful.

Low Borderline characteristics or traits.

People with low BPD or beginning Borderline traits have or are able to sustain a primary relationship. This relationship may be rocky but the low borderline trait individual is able to have satisfying interactions with a partner. They will perceive this partner as supportive.

What brings a low symptom Borderline into treatment will be feelings of emptiness, loneliness or depression despite having a supportive partner. They may also suffer from chronic boredom or masochism. They want both a close relationship and fear that relationship because needing someone exposes you to becoming dependent on them.

As a result of the presence of that supportive person in their life, a mild BPD individual may go undiagnosed. They may lack the intense anger and have fewer and milder mood swings than those that appear in more severe cases. Their self-destructive behaviors will be fewer and less frequent and may be ascribed to life experiences like layoffs or fights with their S. O. rather than being recognized as BPD traits.

What tips the clinician off to the BPD traits is not the current relationship but a history of previous unstable relationships and a pattern of over-rapid entry into and speedy exit from relationships, as well as a history of being the victim of abuse or neglect.

Medium BPD.

As the symptoms of BPD become more severe you may experience more anger, more worries about losing your partner and more frantic efforts to keep your partner in the relationship. People with medium BPD are described as having difficulty seeing things from others point of view and devaluing others. They may manipulate as a way to get their needs met. They have the belief that asking will not get them what they need and that they need to force others to stay with them.

This level of borderline functioning is full of break-ups and make-ups, drama from current and previous relationships and recurrent self-harm or suicide attempts to force the partner to stay. Someone with medium intensity BPD may plan suicide with the thought that this will punish the other for not loving them enough.

High Borderline Personality Symptoms.

When BPD reaches this level the person with Borderline Personality Disorder is unable to maintain a relationship with a significant other. They are without a functioning support system and become increasingly lonely and angry. They may develop distorted thinking, delusions and eventually hallucinations. They may have episodes of panic involving various anxiety-provoking possibilities.

At this level of BPD symptoms, the most likely coping mechanisms are efforts to distract the self by using drugs and alcohol, abusing food, and acting out behaviors. Fights, promiscuity, self-mutilation or suicide attempts will be common.

Are relationships a cause or the result of the level of BPD?

There is some question as to whether having a significant relationship reduces the level of borderline traits or if people low in traits can maintain better relationships than those who are high in BPD traits.

One thing that seems clear is that if you have a supportive other in your life, especially in your primary relationship, you are more likely to be able to cope with your mental illness. Learning life skills can improve you functioning and increase the likelihood of finding a supportive partner. Healthy people attract healthy partners.

Are you doing all you can to create good relationships with others and to become the kind of person who can have happy supportive relationships?

Other posts on Borderline Personality Disorder are:

What is Borderline Personality Disorder?

What causes Borderline Personality Disorder?

Levels or types of Borderline Personality Disorder

Treatment for Borderline Personality Disorder

Staying connected with David Joel Miller

Three David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

SasquatchWandering through a hole in time, they encounter Sasquatch. Can they survive? The guests had come to Meditation Mountain to find themselves. Trapped in the Menhirs during a sudden desert storm, two guests move through a porthole in time and encounter long extinct monsters. They want to get back to their own time, but the Sasquatch intends to kill them.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Books are now available on Amazon, Kobo, iBooks, Barnes & Noble, and many other online stores.

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

What Causes Borderline Personality Disorder?

By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.

personality disorder

What Causes Borderline Personality Disorder?
Photo courtesy of Pixabay.com

Suggested causes for Borderline Personality Disorder (BPD)

Since this is a condition that is diagnosed by the presence or absence of a group of symptoms rather than any one specific test our understanding continues to change. Some authors have suggested that there are several levels or types of Borderline Personality Disorder. People with milder BPD symptoms can be described as having Borderline traits. It is possible that various levels of BPD symptoms may have different causes.

Like most other mental illnesses, Borderline Personality Disorder (BPD) appears to have both a genetic risk factor and an environmental risk factor. Having a risk factor does not mean that you are going to develop the disorder but the more the risk factors the more the risk.

Genetics is a risk factor for mental illness.

NIMH (National Institute of Mental Health reported some time back (2008,) that there appears to be a genetic risk factor for BPD. This study found that a particular mutation on chromosome nine created an increased risk for BPD. At some point in the human past, the characteristics we think of Borderline traits may have been helpful in certain situations.

Experience has made any one research report linking a particular chromosome and a disorder highly suspect. It would be nice if this study were correct and we could do a simple test for BPD, but with other disorders, we find that it is not one gene or chromosome that creates mental illness. It is the influences of several or a combination of large numbers of the many possible genes that result in an increased risk.

In this study, the contribution of genetics was 40%. Meaning that environment contributed the other 60% or put another way, your relationships and experiences increase the risk of developing BPD 150% as much as your genetics.

Environment can increase the risk for Borderline Personality Disorder.

One factor seems to contribute a huge amount of this environmental risk.

Growing up in a non-affirming place with people who did not validate you, is a hugely important cause of many of the symptoms that make up BPD and Borderline Personality traits.

Many people with borderline traits report that their family was not supportive. Their caregivers were either absent or constantly frustrating.

Many people with BPD grew up in homes that did not create the feeling of being valued as a human being. People with BPD may have been neglected, abused or simply did not have their emotional needs met. They may have found that direct requests for things did not work and that the only way to get their needs met was to engage in behaviors that forced the family to notice them. In adult life, their behaviors will be described as manipulative.

A borderline can be both clingy and distant, wanting a close intimate relationship but also fearful that to let someone get in close to them invites another abandonment.

People with BPD may associate any accomplishment with an increased risk of abandonment. They often quit school a week before finals or fail to show up for a job on the first day.

People with Borderline characteristics may end up slipping into a relationship with someone who has difficulty being close. Just like the co-dependent person who keeps marrying the alcoholic trying to get it right, someone with BPD may continue to enter a relationship with a partner who is unable to provide any warmth and closeness.

The classic expression of this feeling becomes “If I become fully me, will you stop loving me?” The recurring fear is that the significant person in their life will abandon them and they will fall apart without someone to support them.

One issue people with BPD may need to tackle is the inability to have and enjoy happiness or other positive feelings. If you came from an environment that said it was not OK to have or display feelings, it can be terrifying to allow yourself to feel happiness of any sort.

The person with PBD may feel empty, numb or bored without someone else in their life that provides for their needs. The theory here is that the more the person was let down by their support system, the less able they have been at becoming an independent person, the more likely they will be to develop borderline traits.

Learning to act Borderline.

Those with BPD often come from homes where the caregivers themselves had poorly regulated emotional lives. Parents can and do frequently provide genetic risk factors, environmental factors and learned behavior that support the continuation of BPD.

Is seems likely that living with or around a caregiver with BPD is likely to alter the way in which someone handles emotion.

The takeaway from all this is that whatever the reason someone has BPD there are treatments available that can help manage, reduce or eliminate the symptoms of Borderline Personality Disorders.

Other posts on Borderline Personality Disorder include:

What is Borderline Personality Disorder?

What causes Borderline Personality Disorder?

Levels or types of Borderline Personality Disorder

Treatment for Borderline Personality Disorder

Staying connected with David Joel Miller

Three David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

SasquatchWandering through a hole in time, they encounter Sasquatch. Can they survive? The guests had come to Meditation Mountain to find themselves. Trapped in the Menhirs during a sudden desert storm, two guests move through a porthole in time and encounter long extinct monsters. They want to get back to their own time, but the Sasquatch intends to kill them.

For these and my upcoming books; please visit my Author Page – David Joel Miller

Books are now available on Amazon, Kobo, iBooks, Barnes & Noble, and many other online stores.

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.