homework assignments for borderline personality disorder

20 DBT Worksheets and Dialectical Behavior Therapy Skills

If you’re as lost as I was when I first heard the term, then you’ve come to the right place. In this piece, you will learn what DBT is, how it works, and some of the most useful and applicable components of treatment.

Whether you are someone who is thinking about participating in Dialectical Behavior Therapy, a therapist who is looking for DBT worksheets to use with clients, or just a curious individual, read on to learn more about it.

Mindfulness is critical to DBT. Before you read on, we thought you might like to download our three Mindfulness Exercises for free . These science-based, comprehensive exercises will not only help you cultivate a sense of inner peace throughout your daily life but will also give you the tools to enhance the mindfulness of your clients, students or employees.

This Article Contains:

• What is Dialectical Behavior Therapy? A Definition
• About the Founder by Marsha Linehan

DBT vs. CBT: How Do They Differ?

4 essential dbt skills & techniques to master.

• 4 DBT Worksheets, Handout and Manuals (PDF)

What Is The Diary Card All About?

The 4 best books on dbt, treatment methods based on dbt and emotion regulation, certification possibilities & courses.

• What is DBT’s Role in Mindfulness?

A Take-Home Message

What is dialectical behavior therapy a definition..

Dialectical Behavior Therapy (DBT) is a type of cognitive-behavioral therapy that focuses on the psychosocial aspects of therapy, emphasizing the importance of a collaborative relationship, support for the client, and the development of skills for dealing with highly emotional situations (Psych Central, 2016).

DBT was created for the treatment of individuals struggling with suicidal thoughts but has matured into a treatment for a range of other conditions that involve dysfunctional emotional regulation. It is currently considered the “gold standard” for borderline personality disorder and has even been applied to the treatment of substance abuse and eating disorders (Linehan Institute, n.d.).

DBT is generally characterized by its two main components:

• Individual weekly therapy sessions;
• Weekly group therapy sessions.

Individual Weekly Therapy Sessions

These individual sessions are an opportunity for the therapist and client to address the issues and solutions that came up over the last week, with special attention paid to self-destructive or potentially self-harmful behaviors. These behaviors are targeted not only because they are inherently worrisome, but also because they can seriously disrupt the treatment process and undermine treatment goals.

Clients and therapists work as a team in these individual sessions, with the focus on learning and improving social and coping skills . They may also discuss more general issues relevant to improving the client’s quality of life, or more specific issues like post-traumatic stress disorder .

Weekly Group Therapy Sessions

These sessions are usually scheduled for two and a half hours and generally focus on developing skills from one of four skill areas:

• Interpersonal effectiveness ;
• Distress tolerance/reality acceptance skills;
• Emotion regulation;
• Mindfulness skills.

Skill Modules

These four skill modules cover a wide range of useful skills that can be applied in daily life:

1. Interpersonal Effectiveness Module

The skills in this module are related to interacting with others, especially in difficult or potentially damaging situations.

These skills are intended to help clients function effectively when trying to change something (e.g., making a request) or in trying to resist changes (e.g., refusing a request). The intention is to aid the client in meeting their goals in each situation while avoiding any damage to the relationship or to the client’s self-respect (Psych Central, 2016).

2. Distress Tolerance Module

This module includes skills that are extremely important yet often overlooked: skills relating to accepting, tolerating, and learning from suffering.

Many other mental health treatment regimens focus on avoiding pain, changing difficult situations, or walking away from circumstances that cause suffering, but the distress tolerance skills taught through Dialectical Behavior Therapy focus on dealing with the pain and suffering that is inevitable to the human condition.

The distress tolerance module is split into four crisis survival strategies:

• Distracting;
• Self-soothing;
• Improving the moment;
• Thinking of pros and cons.

In addition, there are many skills that relate to accepting and tolerating the current situation, like radical acceptance and willingness vs. willfulness.

3. Emotion Regulation Module

Many clients who participate in DBT are struggling with personality or mood disorders and can benefit immensely from emotion regulation skills.

Some of these skills that can help clients deal with their  emotions include:

• Identifying and labeling emotions;
• Identifying obstacles to changing emotions;
• Reducing vulnerability to “emotion mind;”
• Increasing positive emotional events;
• Increasing mindfulness to current emotions;
• Taking the opposite action;
• Applying distress tolerance techniques (Psych Central, 2016).

4. Mindfulness Module

Readers of this blog are likely already aware of the numerous mindfulness-related skills that can benefit them in their daily life.

These skills include “what” skills or skills that answer the question “What do I do to practice core mindfulness skills?” like observing, describing, and participating. There are also “how” skills or skills that answer the question “How do I practice core mindfulness skills?”, like non-judgment and practicing “One-mindfully” effectively.

Many of these mindfulness skills feed into skills from the other modules; for example, the nonjudgment encouraged in mindfulness is also encouraged in distress tolerance, and the observing and describing skills can be helpful in identifying and labeling emotions.

About the Founder Marsha Linehan

Dialectical Behavior Therapy was developed by Dr. Marsha Linehan.

She is a Professor of Psychology and adjunct Professor of Psychiatry and Behavioral Sciences at the University of Washington and Director of the Behavioral Research and Therapy Clinics, a research consortium that explores treatments for severely disordered and suicidal individuals (The Linehan Institute, n.d.).

Dr. Linehan is dedicated to promoting effective and accessible resources for the treatment of individuals who are struggling.

Dr. Linehan founded Behavioral Tech LLC, an institute focused on developing and sharing treatment tools for DBT training, consultation, and treatment. Behavioral Tech Research, Inc., was also established by Dr. Linehan in an effort to incorporate online and mobile technology into the successful practice of DBT.

Dr. Linehan approaches her scientific research and development from a perspective that is relatively uncommon in the sciences: one based in spirituality. She has trained with a number of spiritual leaders and influential thinkers, including a Zen master.

This may help explain her affinity for mindfulness, which grew to prominence through a collaboration of traditional Buddhist philosophy and the modern scientific paradigm (The Linehan Institute, n.d.).

Of course, DBT is a type of CBT, so similarities are understandable. But DBT also has distinct features that set it apart from most CBT approaches.

DBT, like CBT, focuses on helping people address their dysfunctional thinking and behavior through modification of their thought patterns and, through changing their thoughts, their behavior as well. However, CBT is usually confined to a limited period of time and is often applied with one or two specific goals in mind.

On the other hand, DBT narrows the focus to psychosocial aspects of daily life. Many people have trouble with their thought and behavior patterns, but these issues are often at their most disruptive in the context of relationships with others. DBT was created to approach treatment from this angle, one that is often incorporated in general CBT but is not typically the main focus (Grohol, 2016).

This emphasis on relating to others is what explains the DBT-specific treatment component of group therapy sessions. The benefits of additional therapy to the treatment of severe emotion regulation dysfunction are clear, but it’s the group aspect that really helps explain its importance.

Adding group dynamics to the learning setting offers clients an opportunity to practice relational skills in a safe and supportive environment, a practice that has been shown to be extremely effective.

DBT also differs from general CBT in the use of clients’ history. Both incorporate the past in striving for a healthier future, but this discussion is not a focus of the therapy in DBT as it often is in CBT (Grohol, 2016). The perspective of DBT is that one can learn from their past, but that problems are inevitably rooted in current thoughts and behaviors, and the present is where these will be addressed.

We won’t go into all of them in detail, but these are the main skills and techniques applied in DBT.

Interpersonal Effective Skills

1) objectiveness effectiveness “dear man” skills.

• Appear confident;

2) Relationship Effectiveness “GIVE” Skills

• Interested;
• Easy manner.

3) Self-Respect Effectiveness “FAST” Skills

• Apologies / no apologies;
• Stick to value;

Distress Tolerance Skills

1) crisis survival “accepts” skills.

• Activities;
• Contributing;
• Comparisons;
• Pushing away;
• Sensations.

2) Self-Soothing Skills

3) improve the moment “improve” skills.

• Relaxation;
• One thing at a time;
• Encouragement.

4) Pros and Cons / Accepting Reality Skills

• Willingness;
• Turning your mind;
• Radical acceptance.

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Emotion Regulation Skills

1) reducing vulnerability skills.

• Treat physical illness;
• Altering drugs (only those prescribed by a doctor);

2) Build Mastery Skills

• Build positive experiences;
• Be mindful of current emotion;
• Opposite to emotion action.

Mindfulness Skills

1) “what” skills.

• Participate.

2) “How” skills

• Non-judgmentally;
• One-mindfully;
• Effectively (Dietz, 2012).

As you can see, acronyms are front and center in DBT treatment, in part because it makes remembering these skills in important moments easier.

You may also notice that many of these skills are generally considered effective skills , rather than specific skills for specific problems. While Dialectical Behavior Therapy focuses on the treatment of severely distressed individuals, the means of working towards these goals are not mystical or mysterious. The methods of furthering treatment are grounded in common sense and the straightforward practice of skills.

In fact, these skills are so generally applicable that many of them have practical applications for everyone.

Mindfulness

Mindfulness is such a simple and beneficial practice that it’s hard to sum up the potential positive impacts in one section, let alone one article (but we gave it a shot anyway – see our piece on the benefits of mindfulness ).

“Mindfulness can be described as simply living your life in the present instead of being stuck in the past or the future. Practicing mindfulness helps us become more aware of our thought patterns, our emotions, and how our thoughts and feelings affect our reactions to events” (Tartakovsky, 2015A).

If your mind has you jumping on the thought train (i.e., one thought leads to another, which often leads to a “should” thought, which can lead to judgment), try to detach yourself from the thought by telling yourself about the thought you are having (e.g., “There’s a thought about the errand I need to run after work”).

This can help you refocus on your current practice and remind yourself that you have thoughts, but you are not your thoughts (Tartakovsky, 2015A).

If you’re interested in learning more about how to practice mindfulness, check out our post on mindfulness exercises and techniques .

Reality Acceptance

Accepting reality is an effective antidote for a common problem in our society: struggling against the pain and suffering that is inherent to life as a human. DBT and Acceptance and Commitment Therapy (ACT) have this in common – both teach that accepting our reality, including the unpleasant aspects of it, is the only way to thrive.

This skill can be harder to practice and build than it seems since there are all sorts of sneaky ways we find to deny the reality of our situation.

These examples from Psych Central can shed some light on when we fight reality and how we can stop this tendency:

• You need to rush home, but you’re catching every red light. Instead of getting frustrated, you take a deep breath and tell yourself: “ It is what it is. I’ll get home when I get there .”
• You need to fill up your car, but gas prices have skyrocketed. Again, you breathe deeply, and say to yourself: “ There’s nothing I can do about it. I need gas. Getting angry isn’t going to help. ”
• You have to walk to work because your car is in the shop. It’s not far, but it’s pouring. You take a deep breath and say: “ It’s just rain. I’ll bring a towel, and I’ll dry off when I get to work ” (Tartakovsky, 2015A).

The part-humorous, part-helpful Tumblr blog “ Shit Borderlines Do ” provides some steps towards practicing this skill in the moment:

• Observe that you are fighting the reality of your situation. Acknowledge that you are reacting to something that you cannot change;
• Remind yourself what the reality is, even if it’s difficult or upsetting;
• Consider the causes of the current reality and incorporate the skill of non-judgment to remind yourself that this is a random occurrence set in motion by a million other factors that are outside of your control;
• Accept this reality with your whole being, or your mind, body, and spirit. Pay attention to the bodily signs of fighting reality (e.g., posture, “fight-or-flight” response) as well as the spiritual signs (you may “know” that this is real, but you don’t “feel” like it’s real).

These steps are by no means exhaustive or required to accept reality, but they can be helpful in the moment.

Radical Acceptance

Dialectical Behavior Therapy’s radical acceptance technique can help in these situations.

Radical acceptance is simply acknowledging the reality of your circumstances instead of fighting it by thinking “ This shouldn’t be happening ” or “ This isn’t fair. ”

It can be difficult to accept pain, but fighting the reality of your pain only creates more pain, and this pain is optional. Instead of fighting pain, radical acceptance offers a way to accept it and address it.

In the words of psychotherapist Sheri Van Dijk:

“If you don’t like something, you first have to accept that it is the way it is before you can try to [change] it. If you’re not accepting something, you’ll be so busy fighting that reality that you don’t have the energy to put towards trying to change it” (Tartakovsky, 2015).

This explanation shows us that not only can radical acceptance help us accept the reality of things that we cannot change, it can also help us to realize what can be changed.

Non-judgmental Stance

Being non-judgmental means that you avoid assigning value to events and feelings.

Instead of facing a difficult situation and thinking “ This is awful ,” practicing non-judgment allows us to take a step back and realize that the value judgments we make are based on facts (the facts of what is happening) and the emotions we are feeling in reaction (Tartakovsky, 2015B).

For example, you may be stuck in accident-related traffic and thinking “People are such idiots.” If you make an effort to be nonjudgmental, this may translate to “ I’m stuck at a standstill in traffic because of an accident up ahead. This makes me frustrated and upset. ”

When you break a judgment down into a fact and your emotional reaction, you not only reduce the emotion(s) you are feeling, you can also be empowered to think about ways to solve the problem and make healthy decisions.

Say you are thinking about how selfish your significant other is being right now. Instead of stopping at “ My partner is so selfish ,” practicing non-judgment may lead to articulating the issue (“ My partner is not helping me with this problem, and that makes me angry and disappointed ”) and finding a way to solve it (“ This is not a wise use of my time and energy. I will talk to my partner about how his/her unwillingness to help me with this problem makes me feel, and try to negotiate a solution with him/her ”).

Handling emotional situations in this manner can not only help you reduce your emotional reaction and find smart solutions to problems, it can also improve your self-esteem and self-respect when you handle the issue in a way that makes you proud of yourself (Tartakovsky, 2015B).

4 DBT Worksheets, Handout, and Manuals (PDF)

This is where Dialectical Behavior Therapy worksheets, handouts, and manuals can prove to be extremely effective tools in building your skills and improving your ability to accept your situation, deal with difficulty, and solve problems.

We’ll go over some of the most popular and effective ones below.

DBT Interpersonal Effectiveness Skills

This handout lists and describes the interpersonal effectiveness skills we outlined earlier, and also provides useful tips to put these skills into practice.

For example, the section on objective effectiveness (the DEAR MAN skills) lists the following tips:

• Use clear and concrete terms to describe what you want;
• Don’t say: “Could you please clean?”;
• Do say: “Could you do the dishes before going to bed?”
• Let others know how a situation makes you feel by clearly expressing your feelings;
• Don’t expect others to read your mind;
• Try using this line: “I feel ___ because ___.”
• Don’t beat around the bush—say what you need to say;
• Don’t say: “Oh, well, I don’t know if I can cook tonight or not;”
• Do say: “I won’t be able to cook because I’m working late.”
• Reward people who respond well, and reinforce why your desired outcome is positive;
• This can be as simple as a smile and a “thank you.”
• Don’t forget the objective of the interaction;
• It can be easy to get sidetracked into harmful arguments and lose focus.
• Consider your posture, tone, eye contact, and body language.
• No one can have everything they want out of an interaction all the time;
• Be open to negotiation;
• Do say: “If you wash the dishes, I’ll put them away.”

The Wise Mind

It is a balance between the two minds and is characterized by the ability to recognize and respect your feelings, but also respond to them in a rational manner .

The worksheet offers space to describe an experience that you have had with each of these three “minds” to further your understanding of the minds and how they have come into play in your life.

Function of Emotion Worksheet

The Function of Emotion Regulation  worksheet helps you to identify the function of an emotional reaction you have had over the last week.

The worksheet moves through the following questions and steps:

• What was the prompting event?
• What was your interpretation?
• What was the emotion and intensity (0-100)?

Use the following to identify the function(s) of the emotion:

• Did the emotion communicate something to others or influence their behavior? If so, describe;
• Did the emotion organize or motivate you to do something? If so, describe;
• Did the emotion give you information, color your perception, or lead you to any conclusions? If so, describe.

These questions aid the individual in making the connections between a galvanizing event and the reaction s/he had to the event, as well as understanding how the emotional reaction impacts the self and others.

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DBT Skills Training Manual: Second Edition

For a resource that can help you apply general DBT treatment, check out this manual from Dr. Linehan herself. It’s not free, but it is an extremely valuable resource for applying DBT with your clients.

This manual is separated into two parts: the first describes DBT and provides instructions on how to set up a treatment program and manage the problems that can arise, while the second gives detailed notes on teaching each DBT skill.

Check out the manual, buying options, and reviews from some very satisfied readers here .

According to dbtselfhelp.com :

“You use the card to track your urges, moods, how you did or did not use DBT Skills, your feelings, and whatever else is helpful to you. You bring these cards with you to your DBT therapist every week to help you look for behavior patterns and triggers that occur in your life. Such information is invaluable to help you to help yourself live a life worth living.”

There are many possible layouts for a diary card (see here , here , and here ), but they generally contain the same fields:

• Day/date of urge or behavior;
• Emotions felt;
• Actions taken or skills used (or not used);
• Triggers for the urges.

The diary card may also include space for a general rating for the day and any medications or substances used (legal or illegal).

The client is encouraged to fill out this card regularly and faithfully. While it is important that the client does so, they should know that no one is going to score them or judge them based on their diary card. It is not an assignment to be completed and graded, but a way for them to track their experience and evaluate their progression through DBT treatment and, hopefully, self-improvement.

Diary Card App

As with most problems or issues, technology is making an impact on how people keep diary cards.

If you hate to waste paper, don’t like getting ink on your hands, or just get tired of writing, there’s a diary card app that you can use instead.

Check out the app created by a licensed clinical psychologist here .

If you’re interested in learning more about Dialectical Behavior Therapy, as a client, therapist, or just a curious person, there are several books available.

Listed below are some of the most popular and highly reviewed books on DBT out there, and they’re all available for purchase on Amazon.com:

1. The Dialectical Behavior Therapy Skills Workbook – Matthew McKay, Jeffrey C. Wood, and Jeffrey Brantley

It walks the reader through descriptions of DBT and how it can help, introductory exercises, and more advanced skill chapters. This can be an excellent resource for any individual considering DBT or for therapists to recommend to their clients.

Available on Amazon .

2. DBT Made Simple: A Step-by-Step Guide to Dialectical Behavior Therapy – Sheri Van Dijk

It includes a section on the theory and research behind DBT and how it grew from traditional CBT approaches, as well as strategies for working with clients, an explanation of the four skill modules, and several handouts, case examples, and some sample therapy dialogue.

3. The Mindfulness Solution for Intense Emotions: Take Control of Borderline Personality Disorder with DBT – Cedar R. Koons and Marsha M. Linehan

It teaches readers about the seven powerful skills related to mindfulness and emotion regulation that can help people cope with a borderline personality disorder (BPD), post-traumatic stress disorder (PTSD), severe depression, and other emotion regulation problems.

4. Calming the Emotional Storm: Using Dialectical Behavior Therapy Skills to Manage Your Emotions and Balance Your Life – Sheri Van Dijk

With a rating of over 4.5 out of 5 stars from nearly 50 customers, it sounds like the description is accurate.

These books are an excellent start to learning about DBT and applying the skills in your clients’ lives, but if you’re looking for even more, visit this website to learn about other helpful books.

• Understanding one’s emotions;
• Reducing emotional vulnerability;
• Decreasing emotional suffering (Bray, 2013B).

There are several ways to work toward these goals.

One of the websites we mentioned earlier, dbtselfhelp.com , offers an outline of how to build emotion regulation skills:

Interpreting Emotions

We all have emotions, but there is a theory that there are only a few basic emotions while the rest is interpretation and evaluation.

You can work on your skills related to interpreting emotions by completing a writing challenge described here .

Describing Emotions

Emotions involve action urges, prompts to perform certain behaviors. These urges are not part of the emotion but can feel like they are. There is often a prompting event, followed by interpretation, body changes in response to the emotions, and action urges.

This can lead to an effective or dysfunctional expression of emotions, which can have a wide range of consequences. To work on describing emotions, try to describe the qualities of your emotions and pay attention to things that may interfere, like secondary emotions that spring from the original emotion.

Follow this link for more information on describing emotions.

Function of Emotions

Emotions have three major functions in DBT:

• They communicate to and influence others;
• They organize and motivate action, and;
• They can be self-validating.

You can learn about the function of emotions by answering questions like “What are some examples of situations where your expressions of emotion were misread?” and “Can you think of some times when you misread the emotions of someone else?”

See this page for more information.

Reducing Vulnerability

We are all vulnerable to negative emotions, but we can build our skills related to reducing vulnerability. You can keep track of the factors that affect your physical and mental wellbeing, like your diet, any mood-altering drugs, sleep, and exercise.

Refer to these skills in the emotion regulation module for more information.

Paying Attention to Positives

Increasing positive emotions can be an effective method for dealing with difficult emotions. To build this skill, focus on the positive experiences you have throughout the day (short-term experiences) and the bigger, more impactful ones (long-term experiences).

Focus on building and maintaining positive relationships, and give mindfulness a try to savor positive experiences.

Letting Go of Painful Emotions

On the flipside of savoring the positive, letting go of the negative also has a place in emotion regulation. While accepting that pain happens is healthy, dwelling on negative emotions is dysfunctional.

Practice observing your emotions, describing and accepting them but not allowing yourself to be overwhelmed by them.

See this page for more information on letting go.

Opposite to Emotion Action

This technique is used to change painful emotions that are harmful rather than helpful. It is not about suppressing our emotions, but accepting the emotion and using it to take a different action.

To practice this technique, list some examples of when you have acted opposite to your current emotion. Describe a situation in which it is not appropriate to act opposite to your emotion to help you learn about the difference between each situation.

Check out this link for more information.

What is Dialectical Behavior Therapy for adolescents (DBT)? – UC San Francisco

Dialectical Behavior Therapy is a recognized treatment that is well supported by the evidence. There are many ways to learn about applying DBT, but getting certified is a great option. There are courses and online DBT training for both individuals interested in practicing DBT and for therapists and other mental health professionals who wish to apply DBT in their work.

For Therapists and Other Mental Health Professionals

Dr. Linehan’s Behavioral Tech Research Institute provides information on Dialectical Behavior Therapy certification for therapists. The certification is available through the DBT-Linehan Board of Certification and requires the following:

• A graduate degree in a mental health-related field from a regionally accredited institution of higher education;
• A mental health practitioner license;
• A minimum of 40 didactic training hours specific to DBT Clinical experience with DBT (at least three clients);
• DBT team experiences (at least 12 months of preparation and current participation on a DBT team);
• DBT skills knowledge/experience;
• You must have read the Skills Training Manual for Treating Borderline Personality Disorder by Marsha Linehan, completed all the homework assignments in the manual, and taught or participated in all modules of skill training;
• Successful pass of exam based on the Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha Linehan;
• Letter of recommendation from your team leader;
• Work product demonstration (videotapes of three consecutive live therapy sessions);
• Mindfulness experience (at least one of the following: a mindfulness retreat, formal practice community participation, formally a student of a recognized Zen/contemplative teacher, or at least one formal training in mindfulness).

You can also become certified through the Dialectical Behavior Therapy National Certification and Accreditation Association (DBTNCAA). This allows you to list a specialized certification in DBT when you apply to Health Care Providers and HMO networks.

What is DBT’s Role in Mindfulness?

While DBT and mindfulness are not synonymous, they are certainly linked.

DBT is a therapy based on identifying, describing, and modifying thoughts and feelings. Mindfulness has clear applicability in this therapy, through its ability to help practitioners to become more aware of their feelings, thoughts, impulses, and behaviors (Bray, 2013A).

One description of the benefit of mindfulness in Dialectical Behavior Therapy is that it provides the individual with the ability to take control of the mind instead of having the mind control the individual.

Practicing mindfulness helps the individual in DBT to direct their attention to observing, describing, and participating in a nonjudgmental way, which enhances the individual’s skills and leads to improved ability to focus on the positive, let go of the negative, and regulate emotions.

As we’ve said before, mindfulness is an extremely useful skill for individuals dealing with difficult emotions or situations, but it can be an even more effective tool for people struggling with a diagnosis.

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The intention of this piece was to provide an overview of Dialectical Behavior Therapy and outline the skills and tools that can help you or your clients to address emotion regulation issues. I hope it has met this goal, and that you know much more about Dialectical Behavior Therapy than you did when you started!

I hope you also keep in mind that the skills involved in DBT are applicable for those that are not suffering from a diagnosed mental health issue as well. Skills like mindfulness, focusing on the positive, letting go of the negative, and accepting the reality of your situation have clear benefits for everyone, not just those who are in the midst of suffering.

Have you tried DBT? Have you applied DBT with your clients? As always, please let us know about your experiences in the comments.

Thanks for reading!

We hope you enjoyed reading this article. Don’t forget to download our three Mindfulness Exercises for free .

• Bray, S. (2013A). Core mindfulness in Dialectical Behavior Therapy. GoodTherapy. Retrieved from http://www.goodtherapy.org/blog/core-mindfulness-dialectical-behavior-therapy-0215134
• Bray, S. (2013B). Emotion regulation in Dialectical Behavior Therapy. GoodTherapy. Retrieved from www.goodtherapy.org/blog/emotion-regulation-dialectical-behavior-therapy-dbt-0318135
• Dietz, L. (2012). DBT skills list. DBT Self Help. Retrieved from www.dbtselfhelp.com/html/dbt_skills_list.html
• Grohol, J. (2016). What’s the difference Between CBT and DBT?  Psych Central. Retrieved from https://psychcentral.com/lib/whats-the-difference-between-cbt-and-dbt/ Linehan Institute
• Psych Central. (2016). An overview of Dialectical Behavior Therapy. Psych Central. Retrieved from https://psychcentral.com/lib/an-overview-of-dialectical-behavior-therapy/
• Tartakovsky, M. (2015A). 3 DBT skills everyone can benefit from. Psych Central. Retrieved from https://psychcentral.com/blog/archives/2015/08/28/3-dbt-skills-everyone-can-benefit-from/
• Tartakovsky, M. (2015B). What it really means to practice radical acceptance. Psych Central. Retrieved from https://psychcentral.com/blog/archives/2015/10/04/what-it-really-means-to-practice-radical-acceptance/
• The Linehan Institute. (n.d.).  Linehan Institute. Retrieved from http://www.linehaninstitute.org/about-Linehan.php

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What our readers think.

I appreciate you giving this information. In our online treatment, dialectical behavioral therapy is used. It works incredibly well for depression, substance abuse, and borderline personality disorder. Even the most serious cases respond very well to DBT, and we treat a wide range of clients.

I’ve been looking for this info!!! DBT saved my life and I believe EVERYONE could benefit from it. The reason I’ve been searching is for my boys. I never meant to pass that part of me to any of my children but I see it in them. I’m trying for them to avoid the wrong roads I took. I barely escaped the darkness. I couldn’t bare to see them in that place. So ty!! I can’t say it enough.

I have recently completed a DBT group therapy course which I found extremely helpful in managing my BPD and PTSD.

I would love to teach these skills to others worldwide, is it a requirement that you have a certain level of certification to teach cbt/dbt and if so what qualifications are required to go on to teach these skills to others online?

I believe I have enough personal experience, understanding and now knowledge of the skills and mental illness, but am confused on the law of teaching these skills without official certification, or even if that’s a must?

Please help

That’s great your experience was so helpful for you! To teach CBT and DBT skills to support people with mental illnesses, you need to become a licensed therapist or psychologist. This requires that you complete a master’s qualification. You can learn more about the process in our dedicated blog post: https://positivepsychology.com/how-to-become-a-therapist/

Hope this helps!

– Nicole | Community Manager

I have the same question. I work in mental health as a life coach and yoga instructior. I do not want to teach the program. My intention is to use the “My life Vision” worksheet and the wise mind model. What is the legal implications? I would sight the source while being clear on my role and title. The client would be provided resources for a licensed therapist.

This is outstanding!!!!!!

Just curious, you mention in the section – Working with Primary and Secondary Emotions While – “this webpage” but then there is no link to the webpage the article is referencing. I am wondering if you would direct me to the webpage please for further reference. As well, in the following paragraph on Emotion Regulation, again you mention “this worksheet” but don’t link a worksheet. Are you able to reference these for follow-up, please and thank you?

Hi Heather,

Thank you so much for being so observant and bringing this to our attention.

These links went to other websites, which may have restructured their content and caused dead links on our side. I have unfortunately not been able to trace the original worksheets discussed, but have amended our copy to prevent any further confusion.

Apologies for not being able to help you further.

Regards, Annelé

I wish DBT was more available in standard mental health services. In the UK, it’s thin on the ground.

BPD is prolific and causes so much suffering. Yet still much ignorance and stigma remains.

I hate the way so many blame and shame such lonely and fragile people.

We want love, but are terrified of our vulnerability being abused. I wish I could’ve got this treatment. My partners would not have had to put up with so much, maybe.

Damaged people damage people.

Thank you for sharing your thoughts on the availability of Dialectical Behavior Therapy (DBT) and the challenges faced by individuals with Borderline Personality Disorder (BPD). It is indeed disheartening to hear that access to this valuable treatment is limited in the UK and that stigma continues to surround BPD.

The importance of raising awareness about mental health conditions and advocating for better access to evidence-based treatments, such as DBT, cannot be overstated. It is essential to create a more understanding and compassionate society that supports individuals with mental health challenges instead of perpetuating shame and blame.

I encourage you to check out Psychology Today! It has a great directory you can use to find therapists in your local area. Usually, the therapists provide a summary in their profile with their areas of expertise and types of issues they are used to working with.

Please know that your voice matters and your experiences can contribute to raising awareness, challenging stigmas, and ultimately improving mental health care for those who need it most.

Warm regards, Julia | Community Manager

I have been waiting a very long time for DBT therapy for diagnosed Borderline Personality Disorder, being unable to work for 20 months now. I have finally been assigned a place but am unable to purchase DBT Skills Training Handouts and Worksheets Second Edition. Seeking help from so many places, I can’t even find a Microsoft Word version of the worksheets that I can complete online in order to participate in the group therapy. As a result, I cannot have the therapy I desperately need. I know this is a long shot, but does anyone have a version in Word (or Open.Office) that they can send to me?? Otherwise, I will continue to suffer as the NHS has taken so long to help me with a condition I have had for decades, together with my depression and anxiety. Thanking you in advance.

I’m sorry to hear you’ve had so much trouble receiving support. Please let me know which specific worksheet(s) you are trying to open, and I will let you know the best way to do so with free software.

Thank you for providing this information.

This sums up the group therapy session I have just graduated from! Modalities were based from Marsha’s core theories; it is alot of skills to practice.

Courtney, everything you wrote on this page IS TRUE, well written for any level audience. Well done.

Radical Acceptance, and Emotional identification is THE HARDEST part of BPD and DBT. I find it hard now to identify why I am in an “emotional crisis”, since I want to “Name it, to Tame it”. I really can’t identify why I become so deeply emotional (rage, crying, worthless…) but the emotions are EXTREME. I can’t identify what I was so emotional about, why I became so emotional in the first place ONCE I GET CAUGHT IN “THE DARK HOLE” as my husband refers to my “emotional crises”.

Just thought I would share my own personal experience; FYI I am an ongoing work in progress. Still have many ups and downs; however I can reflect on these events (usually AFTER the fact, but LIVE AND LEARN).

Super frustrting that it says “We hope you enjoyed reading this article. Don’t forget to download our 3 Mindfulness Exercises for free.” but you enter your information and then it tells you it cost $27.00. Why the false advertising…why say free just to get another person email to spam?

My apologies! Please try visiting this link to access the free downloads. The three exercises are definitely free! But if there’s a link in the text that tries to point you toward a paid resources, please let us know where it is so we can correct this 🙂

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3 Mindfulness Exercises Pack (PDF)

Clinical psychology

Psychotherapy, personality, borderline personality disorder self help worksheets (5).

As a BetterHelp affiliate, we may receive compensation from BetterHelp if you purchase products or services through the links provided.

Some of these worksheets have been created by us while some of them have been curated from reputable third party websites, after reviewing relevant content in bulk.

It teaches them deep thinking techniques to help them manage their intense mood shifts.

Narcisim and paranoia are few of the different types of personality disorders.

Borderline Personality Disorder Self Help Worksheet- Mood Buttons

A borderline personality disorder is referred to as a dysfunctional emotional state.

The most common triggers of these individuals include problems in one’s relationships and distress resulting from those relations.

Borderline Personality Disorder Self Help Worksheet- Justifying Mood Shifts

Though emotion regulation seems difficult for individuals with borderline personality disorder it is not impossible.

Borderline Personality Disorder Self Help Worksheet- Pre-Planned Coping 

Dealing with uncomfortable feelings resulting from intense emotions like anger and fear is a challenging but achievable task.

Individuals with borderline personality disorder experience emotions with greater intensity and thus struggle to regulate their emotions.

When such individuals are aware of their triggers they can successfully work on their triggers and adopt pre-planned coping strategies to deal with uncomfortable emotions emerging in the future with efficiency.

Borderline Personality Disorder Self Help Worksheet- Anger Diary

Writing down feelings on a paper can help an individual prevent their negative outcomes. 

The individuals are directed to write down the anger causing the incident and their feelings.

Writing down the whole incident and their feelings can help an individual review the whole situation and figure out where the real problem is.

Anger diary not only helps an individual calm down but also aids in identifying the problem.

This worksheet is an effective source of managing anger . You can download it from here . 

Borderline Personality Disorder Self Help Worksheet- Triggers and Coping Skills

Borderline personality disorder can be treated by managing the triggers that give rise to intense emotions in an individual.

Acknowledging the triggers and working on them can help deal with the negative outcomes produced by the triggers.

The worksheet, triggers and coping skills, by a reputable website, aims to help individuals identify the things that trigger intense emotions in them and thinking of the skills and strategies that can help deal with them.

This worksheet is an effective source of identifying and managing emotions.

Borderline Personality Disorder Self Help Worksheet- Emotion Regulation Handout 10

This worksheet is easily available on the internet and can also be printed.

Borderline Personality Disorder Self Help Worksheet- Rank Order of BDP Intrusion

Rand order of BDP intrusion worksheet is a good resource for identifying one’s triggers and work on them.

Borderline Personality Disorder Self Help Worksheet- Six Steps of the Self-Mutilation Sequence

The six steps of the mutilation sequence worksheet is an effective worksheet for helping the individuals identify their self-harm patterns and enable them to control their behavior efficiently.

This page provides you with some of the best borderline personality disorder self-help worksheets .

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10 of the Best Sites for DBT Worksheets and Resources

The best dialectical behavior therapy resources, activities and assignments all in one place.

Hi, it’s Rosie here, Content Manager at Uncommon Knowledge. Continuing our series of ‘Top 10s’, which started with ‘ Top Ten CBT Worksheets ‘, we’ve put together this piece on DBT. I hope it’s useful!

Edit: We recently added our own therapy worksheets section. Take a look here .

Dialectical behavior therapy (DBT) is one of the most effective therapeutic treatment approaches for issues related to emotional dysregulation 1 . Focusing on the psychosocial aspects of therapy, DBT emphasizes a collaborative approach, with support for the client and development of skills for dealing with highly charged emotional situations.

DBT was originally created for treating clients diagnosed with borderline personality disorder and struggling with chronic suicidal ideation. But over time, DBT has shown efficacy in the treatment of a range of issues involving dysfunction of emotional regulation and has become the gold standard for treating borderline personality disorder.

Navigating the ocean of resources

As a practitioner, you are probably always on the lookout for clinically sound, cost-effective, easily accessible resources and tools. But Google “DBT worksheets” and you’ll get almost a million hits. (I’m not exaggerating!) How do you know what’s legit and what is just an attempt to sell you something that may not be clinically sound? And, more importantly, who has time to sift through that many links?

Here’s the article you’ve been waiting for! We’ve done the searches, sifted through the results, and gathered ten of the best DBT resources out there for information and worksheets. You’re sure to find something (probably many things!) you can use to help your clients.

1. The Linehan Institute

Now known as Behavioral Tech, you can’t talk about DBT without mentioning Dr Marsha Linehan and the Linehan Institute. At the institute’s website you will find a number of informative articles and resources for clients, families, and clinicians.

One of the highlights of the site is a free two-hour video that addresses how using the principles of DBT can help teens manage intense feelings. It is a great resource for clinicians and parents to learn how they can help.

2. PsychPoint

PsychPoint is a great mental health resource that offers a large selection of free DBT worksheets for therapists in PDF format. At the time of writing, 29 worksheets are available for download. Topics include:

• Distress Tolerance Skills: Radical Acceptance Worksheet
• DBT Interpersonal Effectiveness Skills: FAST Worksheet
• DBT Interpersonal Effectiveness Skills DEARMAN Worksheet
• Emotion Regulation Skills: Opposite Action Worksheet
• Emotion Regulation Skills: PLEASE Worksheet.

3. Therapist Aid

This website has long been a favorite of therapists, providing a large selection of free, simple-to-use worksheets that are easy to understand and jargon-free. Search for “DBT” and you’ll find a range of great worksheets on a variety of topics, including:

• DBT Distress Tolerance Skills
• DBT Emotion Regulation Skills
• The Wise Mind
• DBT Mindfulness Skills.

You will also find articles and some very reasonably priced resources for purchase.

4. Positive Psychology Program

You’ve probably seen this awesome website mentioned in other articles, and for good reason! This site has compiled some of the best resources available for a variety of clinical needs, including, of course, DBT . You may find some overlap with other sites, but the Positive Psychology Program website is one of the most comprehensive resources for tools and information related to the positive, person-centred approach.

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5. DBT Self Help

This interesting website was built by and for people who have experience with or are interested in DBT. Here you will find a variety of tools, such as:

• Diary cards
• DBT skills information
• Flash cards
• And so much more.

There are also links to a number of other resources that clients may find helpful. This is a great site for your more self-motivated clients to learn more about DBT and how it can be useful in their lives.

6. GetSelfHelp

This is another website that you’ve probably seen mentioned before for its plethora of CBT-focused resources. Now they’ve added a DBT-specific section that offers a good overview of DBT and the Wise Mind theory. Here you’ll also find a number of free worksheets and educational handouts, such as:

• Wise Mind Worksheet
• Dealing With Distress Worksheets
• Mindfulness
• Emotional Regulation.

7. Pinterest

Pinterest might not be the first place you think of when you’re looking for DBT worksheets. But believe it or not, this site is becoming one of the go-to places for therapists to find all kinds of helpful resources.

When you search for “DBT Worksheets” on Pinterest, you’ll find a myriad of pins and some great resources. You may even want to join some Pinterest Groups focused specifically on the types of tools you’re looking for. Some groups are more self-help based, while others are aimed at clinicians.

On Pinterest, you’re bound to find something that will help your client. And the best part? It’s free to use!

8. Psychology Tools

This website offers so many useful resources for both clinicians and self-motivated clients. There are plenty of free self-help tools and information available here, including:

• A Guide to Emotions
• Thought Records
• Symptom Monitoring
• Behavioral Activation
• And much more.

The site also offers a wide assortment of more clinically focused materials, including assessments and worksheets, workbooks, e-books, techniques, and more. Some of these materials are free to use, while others are available to subscribers only. The subscription fee is very reasonable, but if you’re not sure just opt for a free trial to see what’s available.

9. The Centre for Clinical Interventions (CCI)

This Australian mental health organization has developed a number of DBT-related resources. Free resources available on the website include programs and educational materials on topics such as:

• Distress Tolerance/Emotional Regulation
• Assertiveness
• Interpersonal Effectiveness.

The site also offers a number of workbooks and manuals for clinicians. Some of these are free to download; others are available for a reasonable fee. To start with, it’s worth checking out the Distress Tolerance workbook .

The resources on this site are some of the best out there, and not just for DBT. This is one site you’ll want to bookmark, as you will return again and again.

10. Mark Purcell, PsyD

This is a gem of a website. Dr. Purcell is a clinician experienced in the practice of DBT with youth. His website offers an entire section of resources available for professionals. Here you will find an excellent DBT Workbook and sample Diary Card.

What makes this site a standout are the many PowerPoint presentations available for use by clinicians. You’ll find a number of training presentations, including a great overview of the principles and therapeutic strategies of working with youth using DBT. What a great tool for your DBT toolbox!

So, DBT practitioners, there you have it: some of the very best DBT-related resources the internet has to offer. I hope you find this list useful in your practice and helpful for your clients. Of course, you probably have a few of your own little gems that you go to again and again, but if there’s one thing I know, it’s that you can never have too many great tools in that toolbox!

Check these out and find the ones that work for you. Be well!

For more articles on therapy worksheets and more, subscribe to our co-founder Mark Tyrrell’s therapy tips newsletter .

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Cognitive Behavioral Therapy (CBT) and Borderline Personality Disorder (BPD)

• December 13, 2023

Cognitive Behavioral Therapy (CBT) is a type of therapy that focuses on the connection between thoughts, feelings, and behaviors. It is based on the premise that our thoughts influence our emotions and behaviors, and by identifying and changing negative thought patterns, individuals can experience improvements in their emotional make-up and behavior.

CBT can be used to treat Borderline Personality Disorder as well as other mental health conditions such as depression, anxiety, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, and more. Cognitive Behavioral Therapy is also the basis for  other types of psychotherapy such  as  Dialectical Behavioral Therapy  and  Schema Therapy  – both of which are popular methods of treatment for Borderline Personality Disorder.

The  key  principles of Cognitive Behavioral Therapy include:

Cognitive Restructuring : Cognitive Restructuring involves recognizing and challenging negative patterns of thought, and replacing them with healthier ways of thinking.   By changing irrational or negative thinking,  individuals can often change their emotional responses.

Behavioral Techniques:  CBT emphasizes the importance of understanding and modifying behaviors that may contribute to psychological distress.  This  can involve goal-setting, problem-solving, and developing new coping strategies.

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Exposure Therapy:  This technique  is commonly used to treat anxiety disorders. It involves slowly exposing individuals to feared or anxiety-inducing stimuli in a controlled and systematic way, helping them to build tolerance and reduce anxiety.

Homework Assignments:  CBT often includes  homework assignments  that individuals complete between therapy sessions. These assignments may involve  keeping a journal , tracking thoughts and behaviors, or practicing new coping skills.

Collaborative and Time-Limited: CBT is typically a short-term, goal-oriented therapy that involves active collaboration between the therapist and the individual. The focus is on addressing particular issues and developing practical skills for managing them .

How Does CBT Work?

The theory behind CBT is that the way  we think about situations strongly affects  the way  we feel and behave.  Our thoughts become feelings  which  become actions.  Negative  actions can  then  lead to further negative  feelings  and actions and become a cycle that’s hard to escape  from .

A CBT therapist aims to help you change  the way  you think about yourself, those around you, and the situations you get  yourself  into.  By learning to think about things in a more balanced way, you can reduce the black-and-white thinking that pervades the minds of those of us with Borderline Personality Disorder.

CBT programs typically involve one-on-one sessions with your therapist, some group therapy, and exercises for you to practice as a form of homework.

Because Cognitive Behavioral Therapy tends to be a short-term form of treatment, it’s not always ideal for people with Borderline Personality Disorder as there can be problems too complex to work through in a short amount of time.

It can also be difficult for people who struggle to talk about their emotions – although this is true of most forms of therapy.

The ABC Model

A  common  exercise performed while undergoing Cognitive Behavioral Therapy is the ABC Model, which helps people examine the connection between events and their thoughts, feelings, and behaviors regarding the event.

A – Activating Event 

Start by identifying a particular event that caused a strong emotional reaction. People with BPD are highly sensitive   so  you will likely have a lot to draw on. It could be as simple as someone not texting you back after you sent them a message.

B – Beliefs

Explore the beliefs that went through your mind about the activating event. What did you tell yourself about the situation? Were there any automatic negative thoughts or associations?

C – Consequences

Examine the emotional and behavioral responses to those thoughts and beliefs. How did those thoughts make you feel  and  how did you act on them? Did these thoughts and behaviors make the situation better or worse?

D – Disputation

Challenge and dispute your  own  beliefs about the event that triggered your emotional response. Is there a more balanced way to view the event? What evidence supports or contradicts your initial thoughts?

Consider how disputing and changing your initial beliefs about the event could lead to a different emotional response and behavioral outcome. What would be a healthier way of reacting to the event?

Now  let’s  look at an example of the ABC Model in action using the activating event of a friend not responding to a text message. Your belief might be that your friend has fallen out with you and never wants to talk to you again  but  your beliefs  are assuming  that you know  exactly  what is going through your friend’s mind. No matter how close you are to someone,  you should never assume  to know what they’re thinking.

A  common  BPD emotional response to this sort of event is to split and engage in black-and-white thinking.  This  could mean turning yourself or your friend into a villain in your mind. And the behavioral response could be an increase in impulsive behavior or lashing out at your friend.

Take a moment to dispute your initial beliefs.  Has your friend abandoned you  or  is it  far,  far more likely that they’re busy or tired and haven’t had time to see or respond to your message?  They may be struggling to juggle their responsibilities right now.

When you take a moment to dispute your beliefs and humanize the people concerned  in the event , you’re likely to come to a more rational and healthy outcome.

What’s the Success Rate for Treating Borderline Personality Disorder with Cognitive Behavioral Therapy?

A study by the National Center for Biotech Information found that  people using traditional CBT to treat BPD experienced a 50% decrease  in their symptoms compared to a control group. However, more research needs to  be done  in this area. Lack of funds and the selection of patients always make mental health research difficult.

It should be noted that Dialectical Behavioral Therapy is a spin-off of Cognitive Behavioral Therapy, and was created specifically  to treat Borderline Personality Disorder. As such, DBT typically enjoys a higher success rate in treating people with BPD, with one study reporting a success rate as high as 77%.

So  it  may be a better idea to try DBT to treat BPD rather than traditional CBT.

Finding The Right Therapist

Working on your mental health is a job  and  – like with any job – it’s  important  to select the right tool. Therapy takes time, effort, and money  so  finding the right therapist is  tantamount  to achieving the desired results.

Fortunately, it’s never been easier to find the right therapist for you as the internet makes it simple to find reviews of any therapists in your area. You can also arrange short consultations with therapists to discuss your problems and your hopes for what therapy will provide – this gives you the perfect opportunity to assess whether you think you gel well with the therapist.

You may wish to ask them questions about how experienced they are, their experiences in treating Borderline Personality Disorder, how they  were trained , what their therapy sessions typically look like, how to contact them during a mental health emergency, and how much they charge.

If you’re struggling to find a therapist in your  area   then you  may also consider online therapy  as  there are several options.  Some people  find they  feel more comfortable being in their own home, talking to someone over their computer or phone. Others  do  still prefer that personal touch  though  so it’s all down to what you’d feel most comfortable with.

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• February 26, 2024

Mentalization-Based Therapy and Borderline Personality Disorder

Mentalization-Based Therapy (MBT) is a type of therapy designed to help people understand and interpret their thoughts and feelings and those of others. It is based on the concept of mentalization, which refers to the ability to understand mental states, such as…

• February 14, 2024

Why You Should Seek Therapy

In the tapestry of mental health, Borderline Personality Disorder (BPD) stands out as a particularly complex and challenging condition. BPD not only affects the lives of those who bear its weight but also ripples out to touch the lives of friends, family,…

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Borderline personality disorder (BPD): Signs and treatment

Reviewed by Brooks Baer, LCPC, CMHP

Last updated: 06/26/2024

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What is borderline personality disorder (BPD)?

Types of borderline personality disorder.

• Impulsive BPD: Characterized by impulsive behaviors.
• Discouraged BPD: A person may exhibit clingy or codependent behavior, often feeling unworthy or insecure.
• Petulant BPD: Marked by unpredictability and anger , coupled with stubbornness and a compulsion to have control.
• Self-destructive BPD: Where a person may engage in self-harming behaviors and act out in a self-destructive way.

Signs of borderline personality disorder

• Having strong feelings and moods that change abruptly
• Worrying about being abandoned by loved ones
• Having intense, “rocky” relationships
• Acting impulsively or taking risks
• Feeling uncertain about your identity, or like it’s constantly changing
• Feeling paranoid when you’re stressed out
• Feeling empty or disconnected from reality
• Frequently getting angry  or starting fights
• Self-destructive behavior or self-harm
• Thinking about or threatening suicide

Borderline personality disorder vs. bipolar disorder

Bpd splitting, causes of borderline personality disorder.

• Genetics: Having a family member with borderline personality disorder.
• Brain differences: Certain differences in your brain’s functioning or structure.
• Childhood trauma or stress: Traumatic childhood events including abuse , separation from a parent or caregiver, or unstable family relationships .

Getting a borderline personality disorder diagnosis

Borderline personality disorder treatment.

• Cognitive behavioral therapy (CBT)
• Dialectical behavior therapy (DBT)

Borderline personality disorder and relationships

How to support a loved one with bpd.

1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8874928/#B8-medicina-58-00162/ 2 https://pubmed.ncbi.nlm.nih.gov/36853245/ 3 https://pubmed.ncbi.nlm.nih.gov/36853245/ 4 https://www.ncbi.nlm.nih.gov/books/NBK430883/ 5 https://www.ncbi.nlm.nih.gov/books/NBK430883/ 6 https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2007.07071125/

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The editorial team at therapist.com works with the world’s leading clinical experts to bring you accessible, insightful information about mental health topics and trends.

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• Borderline personality disorder

Borderline personality disorder is a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life. It includes a pattern of unstable, intense relationships, as well as impulsiveness and an unhealthy way of seeing themselves. Impulsiveness involves having extreme emotions and acting or doing things without thinking about them first.

People with borderline personality disorder have a strong fear of abandonment or being left alone. Even though they want to have loving and lasting relationships, the fear of being abandoned often leads to mood swings and anger. It also leads to impulsiveness and self-injury that may push others away.

Borderline personality disorder usually begins by early adulthood. The condition is most serious in young adulthood. Mood swings, anger and impulsiveness often get better with age. But the main issues of self-image and fear of being abandoned, as well as relationship issues, go on.

If you have borderline personality disorder, know that many people with this condition get better with treatment. They can learn to live stabler, more-fulfilling lives.

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Borderline personality disorder affects how you feel about yourself, relate to others and behave.

Symptoms may include:

• A strong fear of abandonment. This includes going to extreme measures so you're not separated or rejected, even if these fears are made up.
• A pattern of unstable, intense relationships, such as believing someone is perfect one moment and then suddenly believing the person doesn't care enough or is cruel.
• Quick changes in how you see yourself. This includes shifting goals and values, as well as seeing yourself as bad or as if you don't exist.
• Periods of stress-related paranoia and loss of contact with reality. These periods can last from a few minutes to a few hours.
• Impulsive and risky behavior, such as gambling, dangerous driving, unsafe sex, spending sprees, binge eating, drug misuse, or sabotaging success by suddenly quitting a good job or ending a positive relationship.
• Threats of suicide or self-injury, often in response to fears of separation or rejection.
• Wide mood swings that last from a few hours to a few days. These mood swings can include periods of being very happy, irritable or anxious, or feeling shame.
• Ongoing feelings of emptiness.
• Inappropriate, strong anger, such as losing your temper often, being sarcastic or bitter, or physically fighting.

When to see a doctor

If you're aware that you have any of the symptoms above, talk to your doctor or other regular healthcare professional or see a mental health professional.

If you have thoughts about suicide

If you have fantasies or mental images about hurting yourself, or you have thoughts about suicide, get help right away by taking one of these actions:

• Call 911 or your local emergency number right away.
• Contact a suicide hotline. In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline, available 24 hours a day, seven days a week. Or use the Lifeline Chat . Services are free and confidential.
• U.S. veterans or service members who are in crisis can call 988 and then press "1" for the Veterans Crisis Line . Or text 838255. Or chat online.
• The Suicide & Crisis Lifeline in the U.S. has a Spanish language phone line at 1-888-628-9454 (toll-free).
• Call your mental health professional, doctor or another member of your healthcare team.
• Reach out to a loved one, close friend, trusted peer or co-worker.
• Contact someone from your faith community.

If you notice symptoms in a family member or friend, talk to that person about seeing a doctor or mental health professional. But you can't force someone to change. If the relationship causes you a lot of stress, you may find it helpful to see a therapist.

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As with other mental health conditions, the causes of borderline personality disorder aren't fully known. In addition to environmental factors — such as a history of child abuse or neglect — borderline personality disorder may be linked to:

• Genetics. Some studies of twins and families suggest that personality disorders may be inherited or strongly related to other mental health conditions among family members.
• Changes in the brain. Some research has shown that changes in certain areas of the brain affect emotions, impulsiveness and aggression.

Risk factors

Factors related to personality development that can raise the risk of getting borderline personality disorder include:

• Hereditary predisposition. You may be at a higher risk if a blood relative — your mother, father, brother or sister — has the same or a like condition.
• Stressful childhood. Many people with the condition report being sexually or physically abused or neglected during childhood. Some people have lost or were separated from a parent or close caregiver when they were young or had parents or caregivers with substance misuse or other mental health issues. Others have been exposed to hostile conflict and unstable family relationships.

Complications

Borderline personality disorder can damage many areas of your life. It can negatively affect close relationships, jobs, school, social activities and how you see yourself.

This can result in:

• Repeated job changes or losses.
• Not finishing an education.
• Multiple legal issues, such as jail time.
• Conflict-filled relationships, marital stress or divorce.
• Injuring yourself, such as by cutting or burning, and frequent stays in the hospital.
• Abusive relationships.
• Unplanned pregnancies, sexually transmitted infections, motor vehicle accidents, and physical fights due to impulsive and risky behavior.
• Attempted suicide or death due to suicide.

Also, you may have other mental health conditions, such as:

• Depression.
• Alcohol or other substance misuse.
• Anxiety disorders.
• Eating disorders.
• Bipolar disorder.
• Post-traumatic stress disorder (PTSD).
• Attention-deficit/hyperactivity disorder (ADHD).
• Other personality disorders.
• Personality disorders. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5-TR. 5th ed. American Psychiatric Association; 2022. https://dsm.psychiatryonline.org. Accessed April 28, 2023.
• Borderline personality disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/. Accessed April 28, 2023.
• Skodol A. Borderline personality disorder: Epidemiology, pathogenesis, clinical features, course, assessment and diagnosis. https://www.uptodate.com/contents/search. Accessed April 28, 2023.
• Skodol A. Approach to treating patients with borderline personality disorder. https://www.uptodate.com/contents/search. Accessed April 28, 2023.
• The lifeline and 988. 988 Suicide & Crisis Lifeline. https://988lifeline.org/current-events/the-lifeline-and-988/. Accessed April 28, 2023.
• Borderline personality disorder. National Alliance on Mental Illness. https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Borderline-Personality-Disorder. Accessed April 28, 2023.
• Starcevic V, et al. Pharmacotherapy of borderline personality disorder: Replacing confusion with prudent pragmatism. Current Opinion in Psychiatry. 2018; doi:10.1097/YCO.0000000000000373.
• Veterans Crisis Line. U.S. Department of Veteran Affairs. https://www.veteranscrisisline.net/. Accessed April 28, 2023.
• Allen ND (expert opinion). Mayo Clinic. June 21, 2023.
• Ekiz E, et al. Systems Training for Emotional Predictability and Problem-Ssolving for borderline personality disorder: A systematic review. Personal Mental Health. 2023; doi:10.1002/pmh.1558.
• Mendez-Miller M, et al. Borderline personality disorder. American Family Physician. 2022. https://www.clinicalkey.com. Accessed April 28, 2023.
• Lebow J. Overview of psychotherapies. https://www.uptodate.com/contents/search. Accessed April 28, 2023.
• Elsevier Point of Care. Borderline personality disorder. https://www.clinicalkey.com. Accessed April 28, 2023.

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“Skills for pills”: The dialectical‐behavioural therapy skills training reduces polypharmacy in borderline personality disorder

Joaquim soler.

1 Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Barcelona Spain

2 Universitat Autònoma de Barcelona (UAB), Barcelona Spain

3 Institut d’Investigació Biomèdica‐ Sant Pau (IIB‐SANT PAU), Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Barcelona Spain

Elisabet Casellas‐Pujol

Isabel fernández‐felipe.

4 Labpsitec, Laboratorio de Psicología y Tecnología. Dpto. Psicología Básica, Clínica y Psicobiología, Universitat Jaume I, Castelló Spain

Ana Martín‐Blanco

David almenta, juan c. pascual, associated data.

The data that support the present study are available from the corresponding author upon reasonable request.

Polypharmacy and overprescription of off‐label medications are common in patients with borderline personality disorder (BPD). The aim of the present naturalistic study was to explore whether the skills training module of dialectical‐behavioural therapy (DBT) can reduce polypharmacy in these patients in routine clinical practice.

Retrospective, observational study of 377 patients with a primary diagnosis of BPD consecutively admitted to the BPD outpatient unit from 2010 through 2020. All patients were invited to participate in the DBT skills training module (DBT‐ST). DBT‐ST participants ( n  = 182) were compared with a control group who did not participate in DBT‐ST ( n  = 195). Pre‐post intervention changes in medication load and use of antidepressants, benzodiazepines, mood stabilizers, and antipsychotics were evaluated.

At baseline, most patients (84.4%) were taking at least one medication and 46.9% were on polypharmacy. Compared to controls, patients in the DBT‐ST group presented a significant reduction in the number of medications (2.67–1.95 vs. 2.16–2.19; p  < 0.001), medication load (4.25–3.05 vs. 3.45–3.48; p  < 0.001), use of benzodiazepines (54.4%–27.5% vs. 40%–40.5%; p  < 0.001), mood stabilizers (43.4%–33% vs. 36.4%–39.5%; p  < 0.001), and antipsychotics (36.3%–29.1% vs. 34.4%–36.9%; p  < 0.001).

Conclusions

These findings suggest that patients with BPD can benefit from the DBT‐ST module, which may reduce the medication load, particularly of sedatives. The results suggest that DBT‐ST may be useful to treat overmedication in patients with BPD and could help to promote “deprescription” in clinical practice.

Significant outcomes

• Most patients were on pharmacotherapy and polypharmacy was common.
• Patients who participated in the skills training module of dialectical‐behavioural therapy presented a significant reduction in the number of medications, medication load, and use of sedatives.
• Dialectical‐behavioural therapy skills training may be an effective strategy in helping to reduce polypharmacy and could promote deprescription in patients with BPD.

Limitations

• Because of the non‐randomized, retrospective study design, there is a risk of selection bias.
• The observed decrease in the medication load after skills training does not necessarily imply better clinical and/or functional outcomes.

1. INTRODUCTION

Borderline personality disorder (BPD) is a mental disorder characterized by a persistent pattern of emotional dysregulation, self‐image and interpersonal relationship instability, and marked impulsivity. It is a severe but common disorder, with an estimated prevalence ranging from 1.6% in the general population to 20% in psychiatric inpatient populations. 1 , 2 BPD is associated with severe psychosocial and occupational dysfunction, intensive use of mental health resources, and carries a substantial economic burden. 3 , 4

All of the main clinical guidelines support psychotherapy as the treatment of choice for BPD (for an overview see 5 , 6 , 7 ). Although various psychological treatments have proven to be efficacious treatments for BPD, dialectical behavioural therapy (DBT) is the most frequently studied treatment, supported by robust empirical evidence from Cochrane reviews and meta‐analyses. 6 , 7 However, access to psychological therapies such as DBT is frequently limited, which is why most individuals with BPD only receive pharmacological treatment, even though no drugs have been specifically approved for the treatment of BPD and some clinical guidelines specifically recommend avoiding psychotropic drugs to treat BPD. 8 , 9 , 10 While psychotropic drugs are commonly used to treat Axis I comorbidity disorders, they are also used to reduce the characteristic symptoms in patients with BPD such as intense mood instability, anger, and/or impulsive behaviour. 7 , 11 , 12 , 13 However, the optimal therapeutic drug for BPD‐specific symptoms is controversial, in part because of the scant research on pharmacological management in patients with BPD but also to the lack of consensus pharmacological recommendations in clinical guidelines for BPD. 5 , 7 , 12

Several studies have shown that more than 80% of patients with BPD in western countries receive psychotropic drugs and more than 50% of patients receive polypharmacy. 11 , 12 , 13 , 14 , 15 In a study conducted by our group, nearly three quarters of patients with BPD were taking antidepressants, 55% benzodiazepines, 40% mood stabilizers, and 35% antipsychotics. 15 Some authors have described the risks of medication use in BPD, which include interactions with substances of abuse, addiction potential, increased risk of suicidal tendencies and disinhibition, serious side effects, a high risk for self‐injury with pills, and psychological risks such as diverting attention and energy from psychotherapeutic aims, thus altering the effectiveness of psychotherapy. 16 The reasons for overprescription of psychotropic drugs in this population include: lack of perceived clinical alternatives; the prescription of drugs to address a temporary crisis that are never withdrawn (thus becoming chronic); attempts to treat all symptoms with medications; and treatment of comorbid disorders. 12 , 16 , 17 Several strategies have been developed to reduce polypharmacy and promote quality pharmacological treatment, including efforts to familiarize physicians with the concept of "deprescribing" (defined as the process of reducing medications toward the minimum helpful treatment), to emphasize the need to prescribe drugs only on an "as needed" basis, and to establish a support group for physicians to avoid case overload. 16

One approach that could be useful in deprescribing drugs in patients with BPD is psychotherapy. One of the most effective psychotherapeutic treatments for BPD is DBT to develop cognitive‐behavioural principles to replace maladaptive behaviours with healthier coping skills. 18 DBT is an outpatient treatment supported by empirical evidence in BPD populations with other comorbid disorders such as post‐traumatic stress disorder, eating disorders, and substance abuse disorders (DBT‐S). 19 Given that DBT is a multicomponent therapy, that is both expensive and time consuming, several studies have sought to identify the most relevant components of this therapy to reduce costs and treatment time. For example, the DBT skills training module (DBT‐ST) alone has proven to be effective in BPD. 20 , 21 DBT skills training comprises four modules focused on mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation. 18 , 20 Importantly, offering DBT to patients with BPD does not rule out the concurrent use of medications, which should be considered potential adjuncts to psychological therapy. 18 , 19 Nonetheless, DBT has been shown to promote the "skills for pills" effect, whose aim is to reduce the use of problematic drugs such as benzodiazepines, especially DBT‐S in patients with substance abuse disorders. 19 The main idea is to taper the medication while simultaneously increasing the use and proficiency of the trained skills. In this way, physicians can encourage patients to learn and practice these skills, thus allowing them to reduce their use of prescription medications, when appropriate. Consequently, to ensure that pharmacological and psychological treatment are tightly coordinated, the clinician prescriber should ideally work closely with the psychology treatment team, which would also improve continuity of care.

1.1. Aims of the study

The aim of the present naturalistic study was to explore, in a naturalistic clinical setting, whether DBT‐ST reduces the use of medications and/or polypharmacy in patients with BPD. We hypothesized that providing patients with training in specific skills such as mindfulness, emotion regulation, and distress tolerance would reduce or eliminate the need for problematic drugs such as benzodiazepines.

2. MATERIAL AND METHODS

2.1. participants.

Data were retrospectively collected from 377 patients diagnosed with BPD and admitted to the outpatient BPD unit at the Department of Psychiatry at the Hospital de la Santa Creu i Sant Pau, between January 2010 and December 2020. This outpatient program is part of Spain's Public National Mental Health Service and provides specialized care for people with BPD referred from other psychiatric clinical units (eg, psychiatric emergency units, acute hospitalization units, general mental health outpatient services, private mental health centers, among others). A high percentage of these patients had previously received pharmacological and psychological treatment in other clinical units. Because of the lack of human and economic resources, general mental health public services in Spain have some limitations of offering a complete assistance to individuals with BPD. Compared with general mental health center, the BPD Unit offers: reliable confirmation of BPD diagnosis with validated instruments, greater accessibility to the unit, emergency attention in crisis, higher frequency and duration of visits, therapeutic team with specific experience and sensitivity for BPD, family care, psychoeducation of disorder, general management and non‐harmful strategies, and, finally, supervision of pharmacological treatment avoiding the excessive use of medication. Moreover, our BPD unit offers, as specific psychotherapeutic intervention for all individuals, groupal DBT skills training.

2.2. Study design

This was a naturalistic, retrospective cohort study. All participants underwent a clinical interview, and two semistructured diagnostic interviews were conducted by an experienced psychiatrist and a clinical psychologist. Admission to the BPD unit required a confirmed BPD diagnosis with the validated Spanish language versions of the Structured Clinical Interview for DSM‐IV Axis II Disorder (SCID‐II) 22 , 23 and the Diagnostic Interview Revised for Borderlines (DIB‐R). 24 , 25 Inclusion criteria were as follows: (a) age between 18 and 55 years; (b) primary diagnosis of BPD (DSM‐IV criteria) confirmed by structured interviews (SCID‐II and DIB‐R); (c) absence of comorbid psychotic or bipolar disorders; and (d) no neurological disease, intellectual disability, or any severe physical condition that could affect the psychotherapeutic intervention.

All study data were obtained from patient medical records, which included data relative to admission to the BPD unit (time 1) and after completion of the psychotherapeutic intervention and follow‐up in the BPD program (time 2). All patients included in this historical cohort in the BPD program were invited to participate in the DBT‐ST intervention. The cohort was divided into two groups: those who agreed to participate in the DBT‐ST intervention (DBT‐ST group; n  = 182) and a control group consisting of those who did not participate in the intervention (control group; n  = 195). Therefore, this was a non‐randomized, observational study.

In parallel with the psychotherapeutic intervention, all patients received periodic psychiatric evaluation and follow‐up visits, including supervision of pharmacological treatment to prevent excessive use of medications. Patients did not receive any other psychotherapeutic interventions. The psychiatrists who performed these periodic evaluations were not affiliated with DBT psychotherapy. The follow‐up period in the BPD program was variable and depended on the following factors: duration of therapy, whether or not the patient repeated the psychological intervention (DBT‐ST), and whether the patient dropped out during follow‐up.

The following sociodemographic and clinical data were collected: age; sex; follow‐up period (months); presence of lifetime comorbid axis I disorders (yes/no) classified into four groups: affective, anxiety, substance use, and eating disorders; DIB‐R total and subscale scores (affect [DIB‐aff]; cognition [DIB‐cog]; impulsive action patterns [DIB‐imp]; and interpersonal relationships [DIB‐per]).

Data on pharmacological treatment were obtained and classified as follows: antidepressants, including selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants and dual‐acting agents; benzodiazepines; mood stabilizers; and first and second generation antipsychotics (FGA and SGA, respectively). For these drugs, we determined whether the participant was taking a given medication (yes/no) and the total number of medications (all categories) per patient.

The study adhered to the principles outlined in the Declaration of Helsinki and was approved by the Clinical Research Ethics Committee at the Hospital de la Santa Creu i Sant Pau . Written consent to participate in the study was not considered necessary as all data were collected retrospectively from routine admission data and subsequently anonymized. We checked the medical records of all patients to verify that no written objection to the use of this information was included in the record.

2.3. Instruments

The following instruments were administered to all participants.

2.3.1. Structured Clinical Interview for DSM‐IV Axis II Disorder (SCID‐II)

The SCID‐II is a semistructured interview designed to assess DSM‐IV personality disorders. The Spanish validation study showed that this instrument discriminates well between personality disorders and has good inter‐rater reliability. 22 , 23

2.3.2. Diagnostic interview revised for borderlines (DIB‐R)

The DIB‐R is an instrument designed to diagnose BPD and to assess the severity of the disorder within the last 2 years. The Spanish version has demonstrated good internal consistency (Cronbach's alpha, 0.89; sensitivity, 0.81; and specificity, 0.94). 24 , 25

2.3.3. Medication load index

This index measures the total medication load. Following the method proposed by Hassel et al., 26 the total medication load index was calculated by coding the dose of each antidepressant, mood stabilizer, antipsychotic, and anxiolytic medication as follows: absent = 0, low = 1, or high = 2. For antidepressants and mood stabilizers, the doses and types were coded according to the method proposed by Sackeim. 27 Antipsychotic doses were converted into chlorpromazine dose equivalents and coded using the mean effective daily dose as reference. 28 The lorazepam dose was also coded to the reference of the midpoint of the recommended daily dose range from the Physician's Desk Reference. 29 Scores for each of the individual medication were summed to create a total medication load index. The composite total medication load index seeks to reflect the dose and variety of the different medications taken. The index score is the sum of all individual medication codes in each medication category for each participant. We also calculated the sedative load index, which includes all medications that contribute to sedative load: benzodiazepines, antipsychotics, and drugs with a sedative component or side effect, including pregabalin, gabapentin, lamotrigine, oxcarbazepine, carbamazepine, topiramate, and mirtazapine. Only those medications that were regularly used by the patients were considered when comparing the indices at each time point.

2.4. Psychotherapeutic intervention

2.4.1. dialectical‐behavioural therapy skills training.

The DBT skills training intervention is an adaptation of the DBT format drawn from one of the four intervention modes of the standard version. 18 , 20 , 21 DBT‐ST consisted of weekly skills training sessions (120 min each) held over a 6‐month period. Upon completion of this 6‐month program, patients were invited to repeat the program to further reinforce the skills learned. All training sessions were conducted by two experienced psychotherapists, each with more than 10 years of clinical experience and specific training in DBT (Behavioral Tech Inc.). The treatment groups consisted of 9–12 participants. None of the participants received any other type of individual or group psychotherapy during the study period.

Dialectical‐behavioural therapy skills training aims to promote behavioural change, to help participants learn how to be interpersonally effective, and to learn how to better regulate emotions, and foster acceptance, mindfulness, and distress tolerance. The group sessions were all structured in a similar manner: teaching the content, in‐session practice of the strategies, and weekly homework assignments. The skills taught in a given week were reviewed at the following session.

The DBT skills training consists of four modules, as follows:

Mindfulness

This training module aims to help participants to develop non‐judgmental awareness, attentional control, and sense of self. Other aspects taught in this module include observing and describing thoughts, emotions, bodily sensations, and events; and fully engaging in experiences without judgment, focusing on one thing at a time, and being effective.

Distress tolerance

This module involves training participants to perceive the environment without demanding that it be different. Participants learn to experience and accept painful emotions without trying to change them. This module focuses on teaching strategies to help manage crises and skills to accept reality.

Emotion regulation

In this module, participants learn skills to help identify, label, and describe emotions, and to experience emotions from a mindful attitude to decrease vulnerability to unpleasant emotions, increase pleasant emotions. Participants learn to act in the opposite way when emotions are not justified.

Interpersonal effectiveness

This module contains strategies for solving problems at the interpersonal level. The focus is on teaching participants how to reach personal objectives while maintaining relationships and self‐respect. Participants also learn how to ask for what they need and on knowing how to say no when appropriate.

Control group

This group included all patients that did not participate in the DBT‐ST intervention for any reason, which included any of the following: scheduling conflicts ( n  = 48 [24.6%], mainly for academic reasons); work‐related issues ( n  = 53, 27.2%); preference for other types of therapy ( n  = 13, 6.7%); preference for individual therapy ( n  = 66, 33.8%); preference for private psychotherapy ( n  = 10, 5.1%); and others ( n  = 5, 2.6%).

Although these individuals did not receive any specific psychotherapeutic intervention for BPD, compared with general mental health services, they valued the higher frequency of psychiatric visits, attention in crisis, family care, and greater experience and sensitivity in the management of BPD. This follow‐up visits also include supervision of pharmacological treatment avoiding, if possible, the excessive use of medications, as recommended by all clinical guidelines. They also received non‐harmful strategies based on the Handbook of Good Psychiatric Management for Borderline Personality Disorder . 30

2.5. Statistical analysis

Data were analyzed with the IBM‐SPSS Statistics for Windows, v. 25.0. All data were screened for skewness and kurtosis to test assumptions of normality. All hypotheses were tested to a two‐sided significance level of 0.05.

First, patient demographic and clinical characteristics at baseline (time 1) were described using typical measures of frequency, central tendency, and dispersion. To compare these characteristics between groups (DBT‐ST vs. control group), chi‐square tests (or Fisher's exact test if expected frequencies were <5) were used for categorical variables, and t ‐tests for independent samples were used for continuous variables.

Second, to determine the impact of the group allocation on the use of medication, the percentage of withdrawal of each class of drug (antidepressants, benzodiazepines, mood stabilizers, and antipsychotics) at time 2 was compared between both groups (DBT‐ST vs. control group) using chi‐square tests (or Fisher's exact tests if expected frequencies were <5).

Finally, to evaluate the impact of treatment on pre‐post differences in the mean number of drugs taken per patient, and in the medication and sedative load indices, we conducted multivariate repeated‐measures ANOVAs. Treatment effects were assessed by entering each variable as dependent variables; time (pre‐ and post‐treatment) was entered as a within‐subjects factor, and group condition (DBT‐ST and control group) was entered as a between‐subjects factor.

Post hoc analyses were carried out when significant interactions were found. Effect sizes are reported by partial eta squared, with values up to 0.01, 0.06, and 0.14 considered small, moderate, and large, respectively. 31

3.1. Sample characteristics

The final sample consisted of 377 patients with a primary diagnosis of BPD. Table  1 summarizes the sociodemographic and clinical characteristics of the participants. The typical patient profile was a 30‐year‐old female with moderate clinical severity (based on DIB‐R total score). Most patients presented at least one lifetime comorbid Axis I disorder, most commonly substance use and eating disorders.

Baseline demographic and clinical characteristics of the sample with differences between groups

Abbreviations: DIB‐R, Revised Diagnostic Interview for Borderlines; n. s., not significant; SD, standard deviation.

At admission to the BPD program, 84.4% of the patients were taking at least one medication. The mean number of medications was 2.4 (range, 0–8), and nearly half of the patients were receiving polypharmacy (≥3 medications). Nearly three quarters of the sample (71.9%) were on antidepressants (mostly SSRIs), 47% on benzodiazepines, 40% on mood stabilizers, and 35% on antipsychotics (mostly SGAs).

3.2. Clinical and pharmacological differences between the DBT‐ST group and controls non‐DBT‐ST group

There were no significant between‐group differences in terms of sociodemographic characteristics or the prevalence of Axis I comorbidities. However, participants in the DBT‐ST group had higher mean DIB‐R total scores (7.46 vs. 7.05), indicating greater clinical severity (Table  1 ). There were also small but statistically significant differences between the groups at the timeframe (time in months between time 1 and time 2): DBT‐ST 11.1 (SD: 5) vs. Control group 9.77 (SD: 4.7; p  = 0.007). We re‐analyzed using this variable as a covariate, without finding any influence on the results.

Participants in the DBT‐ST group were taking, on average, more medications than controls, with a higher proportion receiving polypharmacy, as well as higher medication and sedation load indices (Table  1 ). In addition, in the DBT‐ST group, a higher percentage of patients were taking antidepressants and benzodiazepines.

3.3. Differences between groups in prescription changes pre‐post intervention

Changes in prescription patterns are shown in Table  2 and Figures  1 and ​ and2. 2 . Patients who participated in DBT‐ST intervention experienced a significant decrease in the number of medications prescribed [ F (1,375) = 69.74, p  < 0.001] and in the medication and sedation load indices [ F (1,375) =86.77, p  < 0.001; F (1,375) = 127.56, p  < 0.001, respectively] over the course of the psychotherapeutic intervention compared with control group. The effect of intervention for all variables was large. Participants in the DBT‐ST group also significantly reduced their use of benzodiazepines (from 54.4% to 27.5%), mood stabilizers (from 43.4% to 33%), and antipsychotics (from 36.3% to 29.1%).

Between‐group differences in changes in prescriptions pre‐post intervention

Abbreviations: DBT‐ST, dialectical‐behavioural therapy skills training; n.s., not significant; SD, standard deviation.

Differences between groups in prescription changes pre‐post intervention

Pre‐post intervention differences in the prescription of antidepressants, benzodiazepines, mood stabilizers, and antipsychotics

In the control group, no decrease in medication use was observed in any class of drugs. Moreover, for some medications, small increases were observed. The most notable finding was a significant decrease in the prescription of benzodiazepines, mood stabilizers, and antipsychotics in the DBT‐ST group versus controls.

4. DISCUSSION

The findings of the present study confirm previous reports that a high proportion of patients with BPD treated in clinical settings receive pharmacotherapy and polypharmacy. However, patients who received DBT skills training achieved a significant pre‐post reduction in the mean number of medications and in the medication and sedation load indices. These results confirm our main hypothesis that DBT skills training would help to reduce the medication burden. Compared to controls, patients who received DBT‐ST also significantly reduced their use of sedatives (benzodiazepines and antipsychotics).

In line with previous studies, we found that most patients with BPD were taking at least one medication, with nearly half of those patients receiving polypharmacy. This prescription practice in the public mental health system in Spain is consistent with clinical practice in other western countries 13 , 14 and higher than recommended in some clinical guidelines (eg, United Kingdom and Australian guidelines), which do not recommend prescribing pharmacological agents to treat BPD symptoms, but only to treat comorbid disorders or for short term use during periods of crisis. 7 , 8 , 9 , 10 Although clinical guidelines in other countries (Netherlands, Germany, and the United States) differ and have a more symptom‐oriented approach, all guidelines seem to agree that pharmacotherapy should not be used as a first‐line strategy because of the risks associated with these drugs. 32

Interestingly, the patients who agreed to participate in the DBT‐ST intervention had higher DIB‐R total scores (indicating greater severity) and also took more prescription drugs than controls. Given the study design (observational, non‐randomized study), we hypothesize that patients with more severe BPD symptoms may be more motivated (ie, negatively reinforced) to change, and thus more likely to agree to participate in a skills training program to learn how to better manage their condition. This increased motivation to change also points to a greater interest in reducing pharmacological treatment. In this regard, findings from other studies have shown that individuals with greater levels of pretreatment distress were less likely to drop out of treatment, benefit more from DBT, and have better outcomes. 33 In turn, this suggests that patients with less severe BPD may less motivated than those with greater severity to enroll in a weekly DBT program, which requires a strong commitment and high level of motivation. 34

The findings of the current study suggest that DBT‐ST leads to deprescription in these patients, thus reducing the medication load, as we had hypothesized. The deprescription effect observed in patients who attended the DBT‐ST sessions is consistent with previous studies showing that DBT‐ST is an important component of the more comprehensive DBT program. 20 , 21 Those studies demonstrated the relevant role of this DBT modality in mediating reductions in suicide, depression, anger, and—at least partially—self‐harm, as well as in improving variables associated with psychopathology, mood, and affect. Those same studies have also shown that group DBT‐ST may even be more effective than individual DBT therapy alone. 20 , 21

Dialectical‐behavioural therapy is based on a biosocial model in which a skill deficit leads to the behavioural problems associated with BPD, such as parasuicide or aggressive behaviours, which are often a response to emotion dysregulation. 18 Accordingly, one of the main objectives of DBT‐ST is to help patients to build a new behavioural repertoire, which should enhance emotion regulation and functioning. The strategies taught in the four DBT‐ST modules allow patients to better understand and regulate their emotions, better tolerate suffering, to more effectively respond on an interpersonal basis, and to participate mindfully and non‐judgmentally in life. The strategies taught in DBT‐ST allow patients to better understand their behaviours and thus to more effectively manage crises, by reducing emotional vulnerability and fostering the capacity to identify different emotional states to deploy respond more effectively to those emotional states. Skills training may empower the patients and increase self‐efficacy, thus consequently decreasing the number of medications, although this was not a goal per se of the intervention, but rather a consequence.

Although we observed an overall trend toward deprescription for some medications, this was not true for all prescription medications. For example, in both groups, antidepressant prescriptions were either unchanged or increased slightly, perhaps because of the prescribing clinicians' confidence in the effectiveness of antidepressants, leading them to exclude these from the deprescription goal. The preference to reduce sedative drugs may be explained because DBT skills training increases tolerance to distress, promotes coping and exposition, leading to habituation, extinction, or a change in the emotional experience, thus reducing dependence on medication as a main strategy for emotion regulation.

In some contexts, the use of certain medications (notably benzodiazepines and antipsychotics) allows the patient to avoid or escape from negative emotional states. Thus, when effective alternative strategies are available to achieve the same objective, this consequently leads to a reduction in medication intake. Not surprisingly, no changes in prescription patterns were observed in the control group, perhaps because these patients—who obviously did not receive DBT‐ST—may believe that symptom‐targeted pharmacological treatment is the only viable strategy to manage BPD and comorbid distress. Maybe, these patients were not looking for new strategies or skills and they preferred a complete assistance in the BPD unit with greater accessibility, attention in crisis, higher frequency and duration of visits, and family care. Indeed, it is also possible that non‐participation in DBT skills training influenced psychiatrists' practice because they were less motivated to reduce medication since patients did not have alternative tools to manage difficulties.

The most significant change observed in the study group was the marked reduction in the prescription of benzodiazepines, which decreased from 54.4% of patients at baseline to 27.5% post‐intervention. All major clinical guidelines advise against the use of benzodiazepines in BPD (except for short‐term use to address a specific, temporary crisis). 8 , 9 , 10 Notwithstanding the clear recommendations against benzodiazepines, prescription rates for these pharmaceuticals remain high. Because of the addictive potential of these medications and their risk of increasing suicidal tendencies and disinhibition, an important goal in the psychiatric management of BPD is to reduce their use. These drugs are often prescribed in psychiatric emergency rooms to manage exacerbations or crises, as they can rapidly alleviate anger and/or negative emotions. In this regard, if patients received DBT‐based skills training to improve emotion regulation and distress tolerance, the use of these drugs would likely be reduced.

The prescription of mood stabilizers and antipsychotics, especially SGAs, for patients with BPD, has increased significantly in the last two decades, 15 likely because of the promising results reported in clinical trials (especially for olanzapine, quetiapine, topiramate, and lamotrigine) in the treatment of affect dysregulation and impulse control. 7 Antipsychotics have a sedative profile and could be an alternative to benzodiazepines. In any case, the application of DBT‐ST in patients with BPD would likely reduce the need for these drugs.

Dialectical‐behavioural therapy skills training could be a highly effective strategy to improve emotion regulation in patients with BPD. Unfortunately, DBT is not always available in the public health system, in part because it is a resource‐intensive treatment, requiring specific clinical training, staffing, and time. Consequently, it is essential to consider other efficient options that could reduce pharmacological strategies. In this regard, the application of the principles recommended in the Good Psychiatric Management model 30 could help to reduce the medication load and provide alternative tools to help BPD patients cope with distress.

This study has several limitations. First, because of the non‐randomized, retrospective study design, there is a risk of selection bias. Although clinical guidelines recommend avoiding polypharmacy and unnecessary drugs in individuals with BPD, there may have been a more active deprescription activity in the DBT‐ST group compared to controls. It is also possible that there exist differences between groups regarding the motivation to reduce medication on both individuals and psychiatrists. Therefore, these findings will need to be confirmed in a prospective, double‐blind randomized clinical trial. Another potential limitation is that the observed decrease in the medication burden does not necessarily imply better functional outcomes. Consequently, other variables need to be included and evaluated in future studies to confirm that the reduced medication burden is because of clinical improvement and not because of other factors. Finally, uncontrolled clinical factors could also have influenced the results. By contrast, the main strength of this study is the naturalistic study design, which allowed us to analyze data obtained in the course of routine clinical practice, in contrast to other studies performed outside of real‐life clinical practice (eg, clinical trials). This design provides clinically relevant information since it was carried out in the context of usual psychiatric care in the Spanish public health system. Finally, the results of this study support the value of a coordinated and synergistic approach between psychopharmacologic and psychotherapeutic interventions in BPD.

In conclusion, the findings of this study suggest that DBT skills training appears to be an effective strategy to reduce polypharmacy in patients with BPD. Providing patients with tools to effectively manage distress could reduce the need for these patients to resort to the use of pharmaceuticals as their main approach to reducing distress. Further research into the role of deprescription in the context of skills training would be invaluable to better understand whether the decrease in medication load is followed by clinical and functional improvement.

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest.

AUTHOR CONTRIBUTIONS

JS and JCP conceived the study. AMB and JCP performed the statistical analyses. ECP and IFF drafted the first version of the manuscript. JS, ECP, and DA performed the psychotherapeutic intervention. All authors contributed to the writing and reviewing of the manuscript.

PEER REVIEW

The peer review history for this article is available at https://publons.com/publon/10.1111/acps.13403 .

ACKNOWLEDGMENTS

This study was supported by Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM). The authors would like to thank Bradley Londres for professional English language editing.

Soler J, Casellas‐Pujol E, Fernández‐Felipe I, Martín‐Blanco A, Almenta D, Pascual JC. “Skills for pills”: The dialectical‐behavioural therapy skills training reduces polypharmacy in borderline personality disorder . Acta Psychiatr Scand . 2022; 145 :332–342. doi: 10.1111/acps.13403 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Joaquim Soler and Elisabet Casellas‐Pujol contributed equally to this work.

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Lindenboim, N., Chapman, A.L., Linehan, M.M. (2007). Borderline Personality Disorder. In: Kazantzis, N., LĽAbate, L. (eds) Handbook of Homework Assignments in Psychotherapy. Springer, Boston, MA . https://doi.org/10.1007/978-0-387-29681-4_14

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Borderline Personality Disorder

Borderline personality disorder and the pain paradox, personal perspective: recovering from surgery, i recall times when i cut myself..

Posted August 19, 2024 | Reviewed by Gary Drevitch

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As I recover from my recent surgery , I continue to experience periodic pain in my abdomen where the surgical incisions were made. The pain is not coming from the incisions, but seems to be coming from deep within my belly. Less than a week after the surgery, I was doing well, managing my post-op pain only with Tylenol, when the pain suddenly became intolerable, and I went to the emergency room. They did a CT scan of my stomach and couldn’t find anything. I saw the surgeon a couple of days later and he also had no explanation. The pain has decreased some and I manage it with Toradol which doesn’t make me drowsy. I wonder how long it’s going to last, and if it is me somatizing—or if the doctors somehow missing something?

I began to wonder about my level of pain tolerance. Pain is so subjective. My brother underwent an emergency appendectomy at the same time I had my surgery; he had tolerated his pain for two days before he went to his PCP and she sent him to the emergency room. It turned out his appendix had ruptured.

I think back to when I was symptomatic with borderline personality disorder (BPD) and actively cutting myself. Like so many individuals who are diagnosed with BPD, I didn’t feel the pain of the cutting; I cut to numb myself from the intolerable emotional pain I was constantly feeling. I still have scars on my forearms and upper arms, though I never needed medical attention for my cuts.

In a study by Randy Sansone and Lori Sansone, " Borderline Personality and the Pain Paradox,” the authors state: “The intersection of BPD and pain is a complex one. On the one hand, patients with BPD appear to be impervious to acute pain, which is commonly reported during episodes of self-mutilation , such as cutting. On the other hand, clinical experiences and empirical findings with chronic pain suggest just the opposite—that patients with BPD are more sensitive to pain than individuals without this Axis II disorder.”

I stopped cutting when I entered transference -focused psychotherapy ( TFP ) with my then psychiatrist, Dr. Lev. When I initially agreed to work with her, I signed a contract and one item on the contract was if I cut myself, even a scratch, I had to seek medical attention before I could return to therapy. I pictured myself going to a doctor with a scratch on my arm and feeling embarrassed. The last time I actually cut myself was in 2006 when, to retaliate against Dr. Lev because she hospitalized me, I snuck razor blades into the hospital and cut myself early one morning when the hospital staff wouldn’t let me sit in the hallway and journal. It was a stupid thing to do as it only got me put on one-to-one observation for a week.

I started seeing the neurologist who is my headache specialist for my migraines in 2013. She is also board-certified in psychiatry . Following my suicide attempt in 2014, she could tell I was not myself and I confided in her, including my history of BPD. I had come such a long way working with Dr. Lev using TFP that she had a difficult time reconciling my diagnosis of BPD with the person who stood before her. I don’t know if she held some of the misconceptions of patients diagnosed with BPD: manipulative, attention-seeking, etc.

At that time, I was seeing her for Botox injections every three months and nerve block/trigger point injections every two weeks. Both treatments involved multiple injections in the face, head, neck, and shoulders. The injections never bothered me. When her new fellows started every July, sometimes she would ask me if I minded if they practiced their technique on me as she knew I wouldn’t flinch. I always said I didn't mind.

A study from earlier this year echoes the reults cited above and states that “BPD has been associated with greater chronic and everyday pain and, in contrast, reduced sensitivity to acute pain. This apparent contradiction has been termed the 'pain paradox' of BPD.” I carry among my myriads of medical diagnoses fibromyalgia and an autoimmune illness ( undifferentiated connective tissue disease ), both of which cause chronic pain. For fibromyalgia, no medication is effective and for UCTD, I am prescribed Plaquenil for which I need to have biannual eye exams for it carries a risk of harming the retina. My rheumatologist recently lowered the dose which I understood the need for as I have been on a high dose for years. It’s a balancing act between pain and risk level.

As the new study reports: “People with BPD utilize healthcare services at rates greater than the general population, and yet, many who seek treatment for chronic pain experience barriers to accessing treatment, which again underlines the need for scientific attention. Chronic pain is a subjective experience and medical providers must rely on patient reports of their pain experiences. However, patients with BPD may be perceived as untrustworthy by healthcare providers, even when their diagnosis is not known."

I know that I access healthcare services more frequently than others and don’t like that about myself. I’ll debate at home before calling the doctor’s office or going to the emergency room. The last time I went to the ER, I debated into the evening and didn’t arrive until 10 PM. I waited three hours to be seen by a physician’s assistant and by the time I was discharged and got home, it was 6 AM and it was time to jump in the shower and get ready for work.

Do I try harder to tolerate pain? I get into a debate with myself: What if it is something? What if it's nothing? With my extensive history, I can never be sure. I think of the times I have gone and I was admitted because it was significant. And I think of the times I've gone and I was discharged because there was nothing. It's an ongoing dilemma with no good answer.

Andrea Rosenhaft, LCSW-R is a licensed clinical social worker.

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