The Role of Therapy in Managing Borderline Personality Disorder

Borderline personality disorder (BPD) is a type of personality disorder that affects approximately 1% of the population. BPD is a complex mental health disorder characterised by pervasive instability in mood, behaviour, self-image and interpersonal relationships. Therapy plays a pivotal role in the treatment of BPD as it offers individuals with this condition a pathway towards understanding and managing their symptoms effectively.

BPD is an effective treatment option for BPD because it provides tailored interventions that address the complex nature of the disorder. Unlike other mental health conditions, BPD often requires specialised treatment due to its unique combination of symptoms and challenges. Therapy is an essential component of BPD treatment as it provides individuals with a safe and supportive environment to explore their emotions, develop coping strategies and cultivate healthier patterns of thinking and behaviour.

About Borderline Personality Disorder (BPD)

Borderline personality disorder (BPD) is a complex and often misunderstood mental health condition characterised by persistent instability in mood, self-image, behaviour and interpersonal relationships. Individuals with BPD experience intense emotions that can fluctuate rapidly, which can cause difficulties in regulating their feelings and behaviours. This emotional instability can manifest as frequent mood swings, irritability, anxiety and feelings of emptiness.

Originally called borderline personality disorder because of the belief that BPD existed on the ‘border’ of two other mental health disorders, neurosis and psychosis, this belief no longer exists and BPD is now considered a completely separate mental health condition. Although borderline personality disorder is still the accepted term, some people now refer to the condition as emotionally unstable personality disorder (EUPD).

Although BPD affects everyone differently and can manifest in many different ways, people with BPD may experience:

• Emotional instability, including intense negative emotions such as anger, shame, panic, terror and sadness.
• Disturbed patterns of thinking, such as negative thoughts, distressing beliefs and hearing voices.
• A distorted sense of self, including uncertainty about their identity, values and goals.
• Impulsive or reckless behaviour, such as reckless driving, binge eating and excessive gambling.
• Feeling isolated.
• Feelings of abandonment or fears of being abandoned.
• Engaging in self-harm or having thoughts of suicide.
• Difficulties coping with stress.
• Intense emotions that are difficult to manage.
• Substance abuse, including misusing alcohol or drugs.
• Difficulties understanding other people’s points of view.
• Difficulties maintaining relationships.

The interpersonal relationships of individuals with BPD are marked by intense and unstable patterns. They may fluctuate between idealising and devaluing others, which can lead to tumultuous relationships characterised by extreme highs and lows. Because fear of abandonment is common among individuals with BPD, this can cause people to avoid real or perceived rejection, for example by cutting off or self-destructing relationships or avoiding getting close to people. For other people, fear of abandonment can manifest as the need for frequent reassurance or holding onto relationships, even when they are unhealthy.

The impact of BPD on individuals’ lives can be profound and far-reaching. It can impair their ability to maintain stable employment, form and maintain healthy relationships and pursue long-term goals. Additionally, individuals with BPD may experience co-occurring mental health conditions such as depression, anxiety disorders, substance use disorders and eating disorders, which can further complicate their treatment and recovery.

Given the complexity of BPD and its significant impact on individuals’ lives, specialised treatment is essential. Standard therapeutic approaches may not adequately address the unique needs and challenges faced by individuals with BPD. Therefore, a comprehensive treatment plan that incorporates evidence-based therapies tailored to the individual’s needs is necessary for effectively managing this disorder and promoting recovery.

The Importance of Therapy in BPD

Therapy is widely recognised as an essential component in managing borderline personality disorder. Unlike other mental health conditions, BPD presents a unique set of challenges, including intense emotional dysregulation, unstable self-image, impulsive behaviours and difficulties in forming and maintaining relationships. Therapy offers individuals with BPD a structured and supportive environment to address these symptoms and improve their overall quality of life in several ways:

• Emotional regulation – One of the main symptoms of BPD is emotional dysregulation, where individuals experience intense and rapidly shifting emotions. Therapy helps individuals learn strategies to identify, tolerate and regulate their emotions more effectively. Through techniques such as mindfulness, distress tolerance and emotion regulation skills training, therapy equips individuals with BPD with the skills to manage their emotional reactivity and reduce the frequency and intensity of mood swings.
• Improving self-image – Individuals with BPD often struggle with a fragmented or unstable sense of self which can lead to feelings of emptiness and identity disturbance. Therapy provides a space for individuals to explore and develop a more coherent and positive self-image. By examining past experiences, challenging negative beliefs and encouraging self-compassion, therapy helps individuals create a stronger sense of identity and self-worth.
• Addressing impulsive behaviours Impulsive behaviours such as self-harm, substance abuse, reckless driving or binge eating are common among individuals with BPD and can have detrimental consequences. Therapy, particularly approaches like Cognitive Behavioural Therapy (CBT) or Schema Therapy, helps individuals understand the underlying triggers and motivations behind their impulsive behaviours. By identifying healthier coping mechanisms and developing alternative strategies for managing distress, therapy empowers individuals to make more positive choices and reduce the frequency of impulsive actions.
• Building healthy relationships – Interpersonal difficulties are a significant challenge for individuals with BPD, characterised by intense and unstable relationships that often include fear of abandonment, idealisation and devaluation. Therapy focuses on improving interpersonal skills, communication and boundaries, enabling individuals to form and maintain healthier relationships. By learning effective communication techniques, practising empathy and understanding relationship patterns, therapy helps individuals develop more stable and fulfilling connections with others.
• Enhancing coping skills – BPD often co-occurs with other mental health conditions such as depression, anxiety or post-traumatic stress disorder (PTSD), which can further complicate the treatment process. Therapy equips individuals with a toolbox of coping skills to manage symptoms associated with these co-occurring disorders. By addressing underlying trauma, challenging maladaptive thought patterns and developing adaptive coping strategies, therapy improves individuals’ overall resilience and ability to navigate life’s challenges.

Types of Therapy for BPD

Several therapeutic approaches have been developed specifically to address the unique challenges faced by individuals with borderline personality disorder. 

The main types of therapy used in the treatment of BPD are:

• Dialectical behavioural therapy (DBT).
• Cognitive behavioural therapy (CBT).
• Schema therapy.

Overall, these therapeutic approaches offer comprehensive strategies for managing borderline personality disorder by addressing core symptoms, enhancing coping skills and promoting emotional regulation and interpersonal effectiveness. The choice of therapy may depend on individual preferences, treatment availability and the specific symptoms and needs of the individual with BPD.

Dialectical Behavioural Therapy (DBT)

Dialectical behaviour therapy (DBT) is a comprehensive and evidence-based therapy originally developed for the treatment of borderline personality disorder. DBT is now widely recognised as an effective therapeutic approach for individuals with BPD and other complex mental health conditions that are characterised by emotional dysregulation, impulsivity and interpersonal difficulties. DBT integrates principles of cognitive behavioural therapy (CBT) with elements of mindfulness, acceptance and dialectics. 

The core components of DBT are:

• Emotional regulation – DBT teaches individuals skills to identify, understand and manage their emotions effectively. This includes learning to recognise and label emotions, understanding the function of emotions and developing healthy ways to regulate emotional intensity. An individual with BPD may struggle with intense mood swings and difficulty regulating their emotions. Through DBT, they learn techniques such as emotion labelling, opposite action (acting opposite to the emotion) and self-soothing activities (e.g. deep breathing and progressive muscle relaxation). With consistent practice, they become better equipped to manage emotional ups and downs, which leads to improved emotional stability and resilience.
• Distress tolerance – DBT equips individuals with skills to tolerate and cope with distressing situations without resorting to maladaptive behaviours such as self-harm or substance abuse. Distress tolerance skills help individuals navigate crises and intense emotions without making impulsive decisions. For example, if an individual with BPD encounters a triggering situation, such as a conflict with a loved one or a setback at work, instead of reacting impulsively or engaging in self-destructive behaviours, they can apply distress tolerance skills learned in DBT. This might involve using distraction techniques (e.g. engaging in a hobby or going for a walk) or self-soothing strategies (e.g. having a warm bath or listening to calming music) to ride out the intense emotions without escalating the situation.
• Interpersonal effectiveness – DBT focuses on improving communication skills, setting boundaries and building healthy relationships. Individuals learn strategies to assert their needs and navigate interpersonal conflicts effectively while maintaining self-respect and respect for others. In a therapy session, an individual with BPD may role-play assertiveness techniques taught in DBT to address a conflict with a friend or family member. They will learn to express their needs, set boundaries and negotiate compromises effectively while respecting the other person’s perspective. Over time, these skills translate into healthier and more satisfying relationships outside of therapy.
• Mindfulness – Mindfulness is a central component of DBT. It emphasises the importance of present-moment awareness and non-judgemental acceptance of thoughts, emotions and sensations. Mindfulness practices help individuals develop a greater sense of self-awareness, reduce emotional reactivity and improve inner peace. A person with BPD may initially struggle with the concept of mindfulness, finding it challenging to stay present and non-judgemental amidst their racing thoughts and turbulent emotions. Through guided mindfulness exercises and daily practice, they gradually learn to observe their thoughts and feelings without getting caught up in them. This newfound mindfulness helps them break free from automatic patterns of reaction and make more conscious choices in their daily lives.

Cognitive Behavioural Therapy (CBT)

Cognitive behavioural therapy (CBT) is a widely used therapeutic approach that focuses on identifying and modifying dysfunctional thought patterns and behaviours to promote emotional well-being and symptom reduction. While originally developed for conditions like depression and anxiety, CBT has also been adapted for individuals with BPD. 

Some ways that CBT can be adapted for the treatment of BPD include:

• Focus on emotion regulation – Emotion dysregulation is a core feature of BPD. In CBT for BPD, therapists help individuals identify triggers for intense emotions and develop strategies to regulate them effectively. This may involve teaching skills such as identifying and challenging cognitive distortions related to emotions, using relaxation techniques and practising emotion-focused coping strategies.
• Addressing maladaptive behaviours – Individuals with BPD often engage in impulsive and self-destructive behaviours as a way of coping with distress. CBT helps individuals recognise the negative consequences of these behaviours and identify alternative coping strategies. This may involve implementing behavioural experiments to test the validity of beliefs about the effectiveness of certain behaviours and developing more adaptive coping skills.
• Challenging core beliefs – Like other forms of CBT, therapy for BPD involves identifying and challenging negative beliefs and assumptions about yourself, others and the world. Individuals with BPD may hold negative beliefs about themselves, e.g. that they are unlovable, or have rigid expectations about relationships, e.g. that people will always abandon them. By examining the evidence for and against these beliefs, individuals can develop more balanced and realistic perspectives.
• Identifying negative thought patterns – In CBT for BPD, individuals learn to recognise and challenge negative thought patterns that contribute to their emotional distress and maladaptive behaviours. This may involve keeping thought records to identify automatic thoughts associated with specific situations or emotions.

Schema Therapy

Schema therapy is an integrative therapeutic approach that draws from cognitive behavioural, psychodynamic and attachment theories. It is specifically designed to address long-standing, deep-rooted beliefs and patterns, known as schemas, that underlie psychological difficulties, including BPD. 

The key principles of schema therapy are:

• Schema identification – The first step in schema therapy involves identifying negative schemas or core beliefs that contribute to emotional distress and dysfunctional behaviour. These schemas often develop early in life as a result of unmet emotional needs or traumatic experiences.
• Schema exploration – Once identified, schemas are explored in depth to understand their origins, triggers and effects on thoughts, feelings and behaviours. Therapists help individuals with BPD recognise how these schemas shape their perceptions of themselves, others and the world.
• Schema change – Schema therapy aims to modify negative schemas through a combination of cognitive, experiential and behavioural techniques. This may involve challenging negative beliefs, developing alternative coping strategies and reprocessing past experiences to promote healing and resolution.
• Limited reparenting – A key aspect of schema therapy involves providing individuals with BPD with corrective emotional experiences to meet unmet emotional needs from childhood. Therapists offer empathetic and nurturing responses to help individuals develop healthier attachments and self-concepts.

Schema therapy has been shown to be effective in treating BPD and addressing a range of issues commonly associated with the disorder, including:

• Identity disturbance – Individuals with BPD often struggle with a fragmented or unstable sense of self. Schema therapy helps individuals develop a more cohesive and positive self-concept by addressing underlying schemas related to defectiveness, shame and inadequacy.
• Emotional dysregulation – Schema therapy teaches individuals with BPD skills to regulate their emotions more effectively by targeting schemas related to emotional deprivation, emotional inhibition and vulnerability to harm. By addressing these core emotional needs, individuals learn healthier ways to cope with intense feelings.
• Interpersonal difficulties – Individuals with BPD often experience difficulties in forming and maintaining stable relationships. Schema therapy helps individuals recognise and modify maladaptive relationship patterns by addressing schemas such as abandonment, mistrust and unrelenting standards.
• Impulsivity and self-destructive behaviours – Schema therapy provides individuals with BPD with alternative coping strategies to manage impulsivity and reduce self-destructive behaviours. By addressing schemas related to impulsivity, entitlement and self-harm, individuals learn to make more healthy choices and resist impulsive urges.

Overall, schema therapy offers a comprehensive and integrative approach to treating borderline personality disorder by addressing long-term negative beliefs and patterns that contribute to psychological difficulties. Through schema change, individuals with BPD can experience significant improvements in their symptoms, relationships and overall well-being.

The Therapeutic Relationship

The therapeutic relationship between the client and therapist plays an important role in the treatment of borderline personality disorder. This relationship serves as the foundation for therapy and can significantly impact the effectiveness of treatment. Individuals with BPD often have a history of interpersonal difficulties, including experiences of abandonment, betrayal or invalidation. In therapy, establishing trust and creating a safe space is essential for individuals to feel comfortable sharing their thoughts, feelings and experiences without fear of judgement or rejection.

Many individuals with BPD experience intense emotional pain and struggle with feelings of invalidation and rejection. A supportive and validating therapist acknowledges and validates the individual’s experiences, emotions and struggles and helps them feel understood and accepted. This validation creates a sense of connection and builds rapport between the client and therapist.

The therapeutic relationship provides individuals with BPD an opportunity to learn and practise emotion regulation skills in a supportive environment. Through the therapist’s empathetic responses and validation of their emotions, individuals can learn to regulate intense feelings more effectively and develop healthier coping strategies.

For many individuals with BPD, therapy offers a unique opportunity to address past traumas and unresolved issues in the context of a safe and supportive therapeutic relationship. A validating therapist can provide empathy, understanding and validation as individuals explore and process painful memories and experiences which help with healing and emotional growth.

A supportive and validating therapist gently challenges negative patterns of thinking and behaviour without invalidating the individual’s experiences. By providing constructive feedback and guidance, the therapist helps individuals gain insight into their patterns and develop more adaptive ways of coping with challenges.

Individuals with BPD often struggle with low self-esteem and self-doubt. A supportive therapist can help individuals recognise their strengths, talents and positive qualities, creating a sense of self-worth and self-confidence. This positive reinforcement contributes to the individual’s overall well-being and resilience.

The Role of Medication

Medication can play a supportive role in the treatment of BPD when used in conjunction with therapy. While medication alone is not considered a primary treatment for BPD and will not usually be prescribed as a treatment option, it may be prescribed to manage specific symptoms or co-occurring conditions that commonly accompany BPD.

Some medications that can be used to treat co-occurring mental health difficulties and symptoms include:

• Mood stabilisers – Mood stabilisers such as lithium or anticonvulsants may be prescribed to help stabilise mood fluctuations and reduce emotional dysregulation in individuals with BPD. These medications can help reduce symptoms of impulsivity, irritability and mood swings.
• Antidepressants – Antidepressant medications, particularly selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), may be prescribed to reduce symptoms of depression and anxiety often experienced by individuals with BPD. Antidepressants can help improve mood, reduce anxiety and enhance overall well-being.
• Antipsychotics – Atypical antipsychotic medications may be prescribed to manage symptoms such as severe mood swings, paranoia, dissociation or impulsivity in individuals with BPD. These medications can help stabilise emotions and reduce the severity of psychotic symptoms.
• Anxiolytics – Anxiolytic medications, such as benzodiazepines or buspirone, may be prescribed on a short-term basis to alleviate symptoms of anxiety or agitation in individuals with BPD. However, these medications are typically used cautiously due to the risk of tolerance, dependence and potential for misuse.
• Sleep aids – Sleep disturbances are common in individuals with BPD and can exacerbate emotional instability and cognitive impairments. Medications such as sedatives or low-dose antipsychotics may be prescribed to improve sleep quality and duration, which can help to improve overall mental health and well-being.

Conclusion

In conclusion, therapy plays an integral role in the management of borderline personality disorder. Through evidence-based therapeutic modalities such as dialectical behaviour therapy (DBT), cognitive behavioural therapy (CBT) and schema therapy, individuals with BPD can gain valuable insights, develop effective coping strategies and experience profound healing and growth.

Therapy offers individuals with BPD a safe and supportive environment to address the core symptoms of the disorder, including emotional dysregulation, identity disturbance, impulsivity and difficulties in forming and maintaining relationships. By working with a qualified therapist, individuals can learn essential skills such as emotional regulation, distress tolerance, how to build and maintain healthy relationships and mindfulness. This can empower them to lead more balanced, fulfilling and meaningful lives.