Efficacy and mechanisms of dialectical behavior therapy (DBT) in borderline personality disorder: integrating evidence, clinical practice, and implementation

Abstract

Borderline Personality Disorder (BPD) and disorders of emotional dysregulation represent significant challenges in both diagnostic assessment and therapeutic management. DBT was developed to address these core features, combining mindfulness and skills training with a therapeutic framework that emphasizes validation and behavioral management. Randomized and observational studies consistently support DBT’s efficacy in reducing self-harm, suicidal behaviors, emotional dysregulation, and hospitalizations, while improvingoverall functioning. This abstract synthesizes contemporary evidence regarding DBT for BPD, highlights mechanisms of change, and discusses implementation considerations in clinical settings and training programs. The DBT model comprises individual therapy, group skills training, phone coaching, and a therapist consultation team. Major randomized trials have demonstrated reductions in self-injury and suicide attempts, decreased emergency service utilization, and improvements in global functioning and quality of life compared with treatment-as-usual or community expert standards. Meta-analyses indicate moderate to large effects in reducing self-harm and symptom severity, with sustained benefits during follow-up periods. Mechanistic studies reveal improvements in emotion regulation, reduced impulsivity, optimized coping strategies, and validation within the therapeutic relationship as mediators of therapeutic effects. DBT can be adapted to various clinical contexts, including inpatient, day-treatment, outpatient, and integrated care models. It informs personalized treatment planning by targeting core processes such as emotional dysregulation, distress tolerance, mindfulness, and interpersonal effectiveness. Fidelity in implementation, quality supervision, and adaptation of programs to resource constraints are essential for optimal outcomes. Robust research evidence supports DBT as an evidence-based treatment for BPD, with benefits extending to comorbid conditions and overall functioning. Future research should refine mechanisms of change, optimize treatment intensity and delivery format, and evaluate cost-effectiveness in real-world practice.