Borderline personality disorder (BPD) is a mental health disorder characterized by a persistent pattern of unstable relationships, fear of abandonment, impulsive actions, and extreme emotional fluctuations. Treating BPD demands care specifically designed to address its complex manifestations and underlying causes.
Thankfully, clinical research has identified several effective therapies that can help people manage symptoms, build healthier relationships, and create more stable, fulfilling lives.
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Key takeaways
- Borderline personality disorder can involve emotional instability, impulsivity, abandonment fears, and unstable relationships or self-image.
- Specialized therapies such as dialectical behavior therapy, schema therapy, and mentalization-based therapy target different aspects of these difficulties.
- Integrated care, family involvement, and a suitable therapeutic approach can support recovery, while medication has a supporting role.
What is Borderline Personality Disorder?
BPD affects an estimated 1.4% to 2.7% of U.S. adults and tends to involve emotional storms and relationship problems that present unique therapeutic challenges. BPD often begins by early adulthood and occurs across various contexts in a person's life[1].
BPD symptoms can include[2]:
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- Unstable self-image: BPD can involve rapid shifts in goals, values, and perceptions of self. \n
- Intense fear of abandonment: These fears often spark extreme reactions to perceived or actual separation or rejection. \n
- Impulsive and risky behaviors: Behaviors include reckless spending, unsafe sex, substance misuse, and sabotaging positive situations. \n
- Suicidal threats or self-harm: These behaviors are often a response to fears of separation or rejection. \n
- Extreme mood swings: Emotional instability can involve intense happiness, irritability, anxiety, or shame that can last for hours or days. \n
- Chronic feelings of emptiness or intense anger: These feelings can manifest as frequent temper outbursts, sarcasm, bitterness, or physical aggression, alongside a persistent sense of emptiness. \n
Not surprisingly, BPD can impact relationships in intense ways. People may have difficulty with emotional attachment and dependence on specific people, as well as challenges with social cognition and empathy. Often, these symptoms result in turbulent relationships with extreme shifts between idealizing someone one minute and devaluing them the next[2].
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Personality disorders, anxiety, and depression
View profileTypes of Therapy Used to Treat BPD
Finding effective treatment for BPD is paramount for symptom management and improved quality of life. Without proper care, some people may grapple with self-harm, suicidal thoughts, and chronic feelings of emptiness. Therapeutic interventions and borderline personality disorder support can help people develop coping skills, improve emotional regulation, and promote healthier relationships.
Psychotherapy remains the cornerstone of care for persons with BPD. In fact, several therapies have been specifically designed to treat BPD. Various targeted therapy approaches help address the underlying causes of BPD while providing practical skills for emotional regulation and interpersonal effectiveness.
Several of these therapies work by enhancing social cognition and empathy, helping people better interpret the thoughts and feelings of others while gaining perspective on their own emotional responses. While treatments for BPD differ in their theoretical foundations and techniques, they all attempt to help patients develop more stable identities, healthier coping mechanisms, and more satisfying relationships.
Cognitive Behavioral Therapy
Effective for issues ranging from depression and anxiety to eating disorders and substance misuse, cognitive behavioral therapy (CBT) focuses on identifying and changing negative thought patterns and behaviors that contribute to emotional distress and relationship problems.
In BPD treatment, cognitive behavioral therapy can help a person identify and change unhelpful beliefs and behaviors that affect how they see themselves and relate to others. It can also help with mood symptoms and self-harming behaviors[3].
Dialectical Behavior Therapy
One of the most common types of therapies in BPD treatment, dialectical behavior therapy (DBT), combines CBT techniques with mindfulness practices. It helps people learn to regulate emotions, tolerate distress, improve interpersonal effectiveness, and develop mindfulness skills through personal therapy, group skills training, coaching, and more.
This comprehensive approach, which can be employed for multiple disorders and mental health issues, addresses the emotional dysregulation at the core of BPD. It teaches concrete skills for managing intense emotions and reducing self-destructive behaviors[4].
Schema Therapy
Schema therapy blends ideas from CBT with techniques from other therapeutic styles. Its main goal is to help people recognize and change harmful patterns of thinking and behavior, known as schemas, that often stem from early life experiences.
This form of therapy addresses four key patterns associated with BPD: detachment, anger and impulsivity, a critical inner voice, and abandonment and abuse. Schema therapy focuses on the relationship between the therapist and the patient, as well as the patient's daily life and any traumatic childhood events[5].
Mentalization-Based Therapy
Mentalization is the ability to understand one’s own and others' mental states, including thoughts, feelings, intentions, and desires. Thus, mentalization-based therapy (MBT) teaches people with BPD to understand their own thoughts and feelings, as well as those of others.
When someone stops mentalizing, they can misinterpret situations, feel upset, or act impulsively. MBT focuses on strengthening mentalization during stressful situations, with therapists helping patients reflect on their emotions and relationships realistically and with more flexibility[5].
Transference-Focused Therapy
Also known as psychodynamic psychotherapy, transference-focused psychotherapy (TFP) helps those with BPD learn about their emotions and issues as they relate to others. To do so, patients focus on creating and managing a relationship between themselves and their therapist[6].
As they explore their emotions, they can create a more balanced view of themselves and others, leading to healthier relationships, increased emotional stability, and overall greater well-being[5].
STEPPS Treatment
Systems training for emotional predictability and problem solving (STEPPS) is a CBT-based group-treatment program used to supplement ongoing personal therapy. STEPPS views BPD as both a mood disorder and a disorder of emotional and behavioral regulation.
Thus, the 20-week program is typically divided into two components: emotion-management skills training and behavior-management skills training. During STEPPS, participants learn to view their disorder as an emotional intensity disorder and develop specific skills to manage emotions and behaviors more effectively[7].
The Role of Medication in BPD Treatment
While psychotherapy remains the foundation of BPD treatment, medications may serve as supportive therapies for BPD in specific situations. Antidepressants, mood stabilizers, and antipsychotics may be prescribed to address symptoms such as mood instability, impulsivity, anxiety, or transient psychotic episodes[6].
That said, research on whether and how to use medications to treat BPD-related symptoms is inconclusive. This uncertainty is driven by the fact that minimal viable research exists on the effectiveness of medications in reducing symptoms. Nevertheless, medications are still widely used with BPD patients. Studies show that more than 18% of BPD patients take more than four psychotropic medications[5].
Bottom line: Medications typically aren’t a standalone solution to BPD and only function as potential aids to therapy. As such, patients should work closely with their doctors to monitor the effects of medications and avoid risks like overmedication.
Comorbid Disorders and Integrated Care
BPD rarely exists in isolation, with comorbid mental health and substance use disorders (SUDs) being the rule rather than the exception. 85% of those with BPD will experience a comorbid mental health condition in their lifetimes. When it comes to psychiatric disorders, anxiety, affective disorders, and post-traumatic stress disorder (PTSD) are the most common co-occurring conditions in people with BPD[8].
Unfortunately, SUD co-occurs at a similar rate. At some point in their lives, roughly 78% of adults with BPD develop substance use disorder[8]. Several factors contribute to this strong association. People with BPD often use substances to self-medicate intense emotions, cope with rejection sensitivity, or escape feelings of emptiness.
The impulsivity of BPD can also lead to risk-taking behaviors, including substance use. Additionally, both conditions share biological vulnerabilities and environmental risk factors, such as childhood trauma and disrupted attachment[8].
These high comorbidity concerns create complex treatment challenges that require a specialized approach. Integrated care represents the gold standard for treating co-occurring conditions. This approach addresses both disorders simultaneously rather than sequentially, as treating one condition while ignoring the other often leads to poor outcomes[9].
Family Involvement in BPD Therapies
A person's support network can significantly impact their treatment journey, either positively by reinforcing therapeutic goals or negatively if family dynamics unintentionally maintain problematic patterns. Thus, family education is often a fundamental component of comprehensive BPD care. When family members understand the nature of the disorder, its symptoms, and treatment approaches, they can often provide more effective support.
Several evidence-based therapies for BPD include family components. Three common BPD therapies with family involvement include[7]:
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- STEPPS: The STEPPS program incorporates a dedicated systems component that involves family members, significant others, and other support persons in the treatment process. In this approach, loved ones learn about BPD and receive guidance on reinforcing the skills that patients are developing in therapy. \n
- DBT: While DBT is offered via personal therapy, it can also include family skills-training sessions where relatives learn dialectical thinking and validation skills alongside their loved ones. This shared language and skill set can reduce household tensions and create a more supportive home environment. \n
- CBT: Family therapy and CBT can be combined to focus on how family members’ thoughts, behaviors, and emotions influence each other and how these dynamics can be changed to improve family functioning. \n
Embracing BPD Recovery
The treatment landscape for BPD continues to evolve, offering new pathways to healing and stability. With specialized psychotherapies addressing different aspects of the disorder, symptoms may become more manageable over time.
However, the journey toward recovery often requires patience, persistence, and the right therapeutic match. Finding qualified clinicians familiar with evidence-based treatments for BPD represents a critical first step.
For many, a combination of approaches, such as personal therapy alongside group skills training, provides the most comprehensive support. Through dedicated treatment, people can develop the emotional regulation skills, interpersonal effectiveness, and self-awareness needed to build more stable and fulfilling lives.
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