This resource is part of our Treatment Navigator, a comprehensive guide to common behavioral/mental health diagnoses and the evidence based practices (EBPs) that help these conditions.

Overview

Borderline Personality Disorder (BPD) is a complex mental health condition characterized by pervasive instability in emotions, relationships, self-image, and impulse control. Individuals often experience intense fear of abandonment, rapidly shifting moods, chronic feelings of emptiness, and difficulty regulating anger or distress. Self-harming behaviors and suicidal ideation are common, particularly in response to perceived rejection or loss. Effective treatment focuses on developing emotional regulation, distress tolerance, and interpersonal stability through structured, evidence-based psychotherapy.

Indicated Evidence-Based Practices (EBPs)

• Dialectical Behavior Therapy (DBT) – comprehensive, skills-based treatment that combines individual therapy, group skills training, and coaching to target emotional dysregulation and self-destructive behavior
• Mentalization-Based Therapy (MBT) – enhances the ability to understand and reflect on one’s own and others’ mental states, reducing interpersonal conflict and emotional reactivity
• Transference-Focused Psychotherapy (TFP) – psychodynamic approach that uses the therapeutic relationship to explore and integrate fragmented self- and other-representations
• Schema-Focused Therapy (SFT) – integrates cognitive, behavioral, and experiential techniques to modify maladaptive core schemas formed in early life
• Good Psychiatric Management (GPM) – pragmatic, manualized approach emphasizing psychoeducation, case management, and supportive therapy; evidence shows outcomes comparable to DBT in some settings
• STEPPS (Systems Training for Emotional Predictability and Problem Solving) – group-based cognitive-behavioral program that teaches emotion regulation and problem-solving within a systemic framework

When to Choose What

DBT is the most widely studied and first-line treatment for BPD, particularly when self-harm or suicidality is present.

MBT is appropriate for clients with chronic relational instability or who benefit from a reflective, attachment-based framework.

TFP suits individuals with entrenched identity disturbances who can tolerate insight-oriented, relational work.

SFT may be best when long-standing maladaptive schemas drive mood and relational instability.

GPM offers a practical, accessible model for general clinicians, particularly in outpatient or integrated care contexts.

STEPPS can supplement individual therapy or serve as a lower-intensity group intervention in community programs.

Core Components of Treatment

• Psychoeducation about BPD, emotion regulation, and recovery pathways
• Skills training in distress tolerance, emotion regulation, mindfulness, and interpersonal effectiveness (DBT core modules)
• Identification and restructuring of maladaptive thought and behavior patterns
• Exploration of attachment dynamics and internal representations of self and others (MBT, TFP)
• Development of stable daily routines and crisis plans for managing self-harm urges
• Collaboration among treatment providers to ensure consistency and avoid splitting or conflicting interventions
• Gradual focus on identity formation, self-compassion, and meaning-making in later treatment phases

Measures and Monitoring

Screening and diagnostic tools

• McLean Screening Instrument for BPD (MSI-BPD): brief self-report screening tool
• Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD): gold-standard structured diagnostic interview
• Personality Assessment Inventory – Borderline Features Scale (PAI-BOR): measures affective instability, identity disturbance, and self-harm risk
• Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD): clinician-rated measure for tracking symptom severity
• Borderline Evaluation of Severity over Time (BEST): self-report tool for symptom and functioning tracking

Monitoring and outcome tools

• ZAN-BPD or BEST administered every 4–6 sessions to track improvement
• Columbia-Suicide Severity Rating Scale (C-SSRS) for ongoing suicide and self-harm risk
• Outcome Questionnaire (OQ-45) or CORE-OM to monitor distress and functioning
• DBT Diary Card or emotion log for weekly self-monitoring of triggers and coping
• Session Rating Scale (SRS) to maintain therapeutic alliance and engagement

Adaptations and Special Considerations

Therapeutic alliance: A strong, consistent alliance is essential—ruptures should be addressed immediately and transparently. Therapists should model calm, validation, and reliability.

Crisis management: Establish clear boundaries and crisis protocols early. Use structured safety planning and between-session coaching where appropriate.

Comorbidity: Treat co-occurring PTSD, depression, eating disorders, or substance use concurrently within an integrated plan.

Trauma-informed care: Many clients have histories of complex trauma; integrate stabilization and pacing to avoid retraumatization.

Team coordination: Multi-provider communication prevents splitting and supports continuity.

Telehealth: Can be effective for DBT or MBT with structured check-ins and digital skills tracking, provided safety measures are in place.

Cultural sensitivity: Recognize cultural influences on emotion expression, attachment patterns, and identity formation.

References

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.).

Linehan, M. M. (2014). DBT Skills Training Manual (2nd ed.). Guilford Press.

Bateman, A. W., & Fonagy, P. (2019). Handbook of Mentalizing in Mental Health Practice (2nd ed.). American Psychiatric Publishing.

Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. (2006). Psychotherapy for Borderline Personality: Focusing on Object Relations. American Psychiatric Publishing.

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema Therapy: A Practitioner’s Guide. Guilford Press.

Gunderson, J. G., & Links, P. S. (2014). Borderline Personality Disorder: A Clinical Guide (2nd ed.). American Psychiatric Publishing.

Blum, N., et al. (2008). Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: A randomized controlled trial. American Journal of Psychiatry, 165(4), 468–478.