Marsha Linehan appreciated the powerful effect of CBT’s theory and specifically recognized the relevance of this theoretical approach to patients with complicated clinical profiles. Linehan found that the efficacy of a basic CBT orientation in treating patients with self-harming and suicidal tendencies was limited. She modified standard CBT to suit these recurrently suicidal patients, who beyond their acute self-destructive tendencies had BPD. In her treatment, which she later called Dialetical Behavioral Therapy (DBT), she organized the basic premise of a CBT treatment around the problem of emotional dysregulation, which she posited to be the core feature of BPD. In addressing this core feature of the borderline individual’s emotional dysregulation, Linehan integrated both mindful and validating techniques. While mindfulness worked to increase the individual’s tolerance and effective management of emotions, validation served to mitigate the tendency for symptomatic reactions to responses from others.

Linehan’s explanation of the biosocial theory of BPD implicates both biological and environmental factors in the development of the disorder. She proposed that there is a transactional relationship between genes and environment that leads to difficulties in learning, labeling, expressing, and modulating emotions. Linehan explains BPD’s core vulnerability as an outcome of the interface between an individual’s emotional sensitivity and their environment’s ineffective and invalidating responses towards the individual’s expressions of their emotional vulnerabilities. In an invalidating environment, caregivers punish, correct, trivialize, or ignore the child’s expressions of private experiences. Over time, individuals in these environments learn to doubt their ability to interpret their internal experiences or self-invalidate and instead look to the environment to help label, organize, and express emotions. As a result, a person with BPD has little self-awareness of their internal states or the ways in which their emotions are connected to thoughts and behaviors. These individuals often oscillate between extreme emotional expression and complete emotional inhibition. In DBT, patients learn to regulate their emotions by increasing their skills to both self-assess and self-regulate.

In developing this model, Linehan outlined very clear instructions as to how a patient can self-assess and reevaluate one’s thoughts, feelings, and subsequent reactions when distressed. DBT focuses on four modules including distress tolerance, emotion regulation, interpersonal effectiveness, and mindfulness. Each module clearly outlines specific skills patients can use to self-assess and self-regulate in order to decrease impulsive and self-harming behaviors. Linehan’s model also includes psychoeducation about how patients could better understand and later intervene across these four domains [9].

Core mindfulness skills, a key component of DBT, train individuals to increase self-awareness by being present in the moment. Mindfulness is defined as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” [35]. Mindfulness involves refocusing attention away from distressing and distracting thoughts, feelings, and behaviors and instead attending to and participating in the current context. Training individuals to fully engage in the present moment is challenging; therefore, DBT outlines specific skills to facilitate the development of a mindful stance. Linehan enumerates three guidelines, called the “what” skills, to clarify steps involved in practicing mindfulness: observe (actively observing whatever is happening in oneself and one’s environment), describe (applying verbal labels to the situation, being as objective as possible in order to more accurately outline the events), and participate (entering completely into the present activity without self-consciousness, fully engaging with both mind and body). Individuals are further instructed by the three “how” skills, which ask them to engage in mindful activities nonjudgmentally, one–mindfully (doing one thing at a time), and effectively (doing what works).

By following the “what” and “how” skills of mindfulness, individuals with BPD can increase their capacity for emotional and behavioral control. Developing a mindful stance in the face of emotional stimulation allows individuals with BPD to more effectively identify, label, evaluate, and manage their responses to otherwise tumultuous situations [36]. Increasing control involves cultivating an acute awareness of one’s own unique thoughts and behaviors and how they impact emotional experiences, as well as implementing more effective ways of responding to these internal states. Through full participation using a mindful stance, individuals with BPD can develop the capacity to label their private experiences more accurately and evaluate these experiences using structured techniques. This increased structured self-awareness leads to more effective processing of emotional experiences and facilitates the integration of effective behavioral responses into an individual’s coping style.

The organization of DBT’s content and techniques around a core formulation of BPD in Linehan’s biosocial theory enhances its coherence as a relevant treatment approach for both clinicians and patients. The use of validation as a balancing point to imperatives to change is thought to make DBT more tolerable to patients with BPD who are prototypically rejection and criticism sensitive. According to biosocial theory, patients with BPD will become more not less emotionally dysregulated if confronted with their problems without simultaneous acknowledgment from the therapist of the reasons why the patient developed those symptomatic adaptations. DBT’s incorporation of mindfulness techniques as a core skill set may also ameliorate other symptoms often found to be comorbid with BPD, ranging from mood [37, 38], anxiety [39, 40], eating [41, 42], and substance use disorders [43]).

However, as previously argued, DBT and SFT adaptations of CBT for BPD populations require intensive training for therapists and may not be available to the majority of patients suffering from BPD. Understanding the effective adaptations of CBT in DBT and SFT can inform more accessible and effective approaches to managing complex clinical profiles. All of the existing manualized evidence-based approaches to BPD integrate a basic understanding of the core problems underlying the complex symptom profile of these patients. While the formulation of the core problem of BPD differs among the approaches, each educates the practitioner to understand BPD as a syndrome and to organize technique around these formulations. Structured clinical or general management approaches, which are based primarily on an informed understanding of BPD, have more recently been found to be effective for reducing symptoms of the disorder with less intensive treatment [44, 45]. In addition, both DBT and SFT emphasize management of the therapeutic relationship between the therapist and the patient with BPD, who presents with both limitations in reflective capacities as well as inherent interpersonal sensitivities. We consider these three features—a basic formulation of the problems of BPD, interpersonal management of the therapeutic relationship according to an understanding of BPD, and an expectation of limitations in self-awareness and reflectiveness as a core problem of BPD—as essential to the adaptation of any therapeutic approach to treating BPD patients.

Given the complex issues that arise when treating patients with characterological problems in “real-world” clinical contexts, it becomes important to identify a theoretical framework that has validity in treating patients with a range of problems. CBT, as described earlier, is a clearly outlined, well-established treatment approach that has received growing attention due to its efficacy and effectiveness in treating patients with a host of disorders [46]. Though there is some controversy in the field of psychotherapy research about what factors predict change in treatment, the growing consensus is that CBT is a well-supported orientation for treating mood, anxiety, and some personality disorders [47]. Despite the ongoing debate about whether “specific factors” or “common factors” (i.e., therapeutic alliance, expectancy factors, and hope) account for change in therapy, there is clear evidence that cognitive and behavioral therapies can be implemented effectively in a variety of contexts and diagnoses, which makes it appealing for real-world clinical situations [48].

Some mental health researchers have proposed that cognitive and behavioral therapies are consistently effective in treating patients with emotional disorders because such orientations focus on helping patients confront their problems, including confronting their fears [49]. According to Weinberger [49], helping patients confront their fears is a critical aspect of successful therapies, and he views this as a common factor across several theoretical orientations. Weinberger [49] proposes that perhaps CBT is more effective in the treatment of particular disorders because exposure (i.e., confronting fears) is a central focus of most CBT treatments [49].

While CBT may not be the gold standard for treatment of BPD, it is a widely available treatment regarded as effective in the treatment of disorders which commonly co-occur with BPD, especially mood disorder [37–43]. Studies suggest that CBT is as effective as antidepressant medication and other forms of psychotherapy in reducing symptoms of depression and maintaining remission [50]. It is also found to be effective in conjunction with medication management in the prevention of relapse in bipolar disorder, reduction in length of mood episodes and medication use, as well as increase in coping with bipolar symptoms and social functioning [51, 52]. Though pharmacotherapy has been the predominant treatment approach for patients with mood disorders, medication alone fails to prevent recurrence in patients approximately 50–75 % over several years [53, 54]. Even when patients are responsive to pharmacotherapy, there are additional problems associated with using medications as the only intervention to manage the illness. Patients who are responsive to pharmacotherapy often struggle with basic aspects of adherence to a medication regimen thereby increasing relapse in bipolar symptoms. Approximately 50 % of patients who manage their illness via pharmacotherapy have at least one episode of noncompliance with their medication regimen [55]. For many patients, particular medications may be contraindicated due to psychiatric or medical comorbidities or intolerance of side effects, so psychotherapy may be indicated as the treatment with the best risk-benefit profile. In addition, many patients prefer psychological treatments over psychopharmacologic treatments [56].

As noted throughout this book, depression and BPD are estimated to co-occur in up to 70 % cases of BPD [57] and can co-occur with or be misdiagnosed as bipolar disorder. The evidence that CBT is effective for this group of disorders suggests that CBT is a practical treatment approach for patients with BPD and a mood disorder when specialized intensive treatments such as DBT, SFT, MBT, or TFP are unavailable. More research is needed to confirm the effectiveness of CBT approaches in patients with comorbid mood and borderline personality disorder, but until such research is available, understanding the common features of CBT approaches to mood disorders and modified CBT protocols for BPD, such as DBT, may help the general clinician tailor their psychotherapeutic treatment plan for the complex patient with these comorbidities.

Several specific treatment approaches have been examined to assess the efficacy of psychotherapy in conjunction with medication management to optimize patient functioning and minimize recurrence in patients with bipolar disorder. Frank and colleagues [58] compared two established psychosocial interventions for treating bipolar patients including interpersonal and social rhythm therapy (IPSRT) and a therapy that focused on intensive clinical management [58]. IPSRT is a manualized evidence-based treatment approach developed as an adaptation of CBT for bipolar disorder.

ISPRT was developed based on acknowledgment that both biological factors as well as psychosocial factors play integral roles in determining the course and outcome in treating patients with bipolar disorder [59]. The overlaps between core features of IPSRT and DBT are also illustrated in Table 12.2. Both approaches integrate basic cognitive behavioral techniques to stabilize the affective instability observed in both BPD and bipolar disorder. DBT as well as other mindfulness-based approaches have proven effective for patients with bipolar disorder [37, 38]. There are shared features which target underlying emotional factors and vulnerabilities shared between these disorders.