How DBT helps teens living with BPD

One of my first professional experiences in the mental health world was at a residential Dialectical Behavior Therapy (DBT) treatment center for adolescent girls. DBT is an evidence-based modality originally designed to treat Borderline Personality Disorder (BPD), especially those with suicidal thoughts and behaviors. In fact, it is the only method shown to be effective in the treatment of BPD. My early exposure to this modality and to patients living with this disorder has shaped the way I work as an emerging clinician, and with a new wave of technology, has created an interest in the ways that AI tools could play a role in enhancing treatment effectiveness in approaches like DBT.

The complexity of BPD (and adolescent diagnosis) 

Borderline Personality Disorder (BPD) is a complex mental health condition marked by intense emotional experiences, unstable relationships, and a distorted sense of self. For clinicians unfamiliar with BPD, it may be helpful to know that individuals with this disorder often struggle with a pervasive fear of abandonment, chronic feelings of emptiness, and difficulty regulating emotions. These challenges can lead to impulsive behaviors, difficulties in maintaining stable relationships, and intense mood swings. For the person living with BPD, emotions can feel overwhelming and uncontrollable—like being trapped in a cycle of pain and confusion. The experience of shifting from extreme love to intense anger or fear is not uncommon, making interpersonal relationships particularly difficult. 

Diagnosing BPD in adolescents can be especially challenging due to the overlapping hallmarks of the teenage experience, such as emotional volatility and identity exploration. For this reason, the disorder is not often diagnosed before the age of 18. However, for a person living with BPD, the developing brain, particularly these areas responsible for impulse control and emotional regulation, can exacerbate BPD symptoms. Early diagnosis is therefore crucial, as untreated BPD in adolescence can lead to long-term difficulties in emotional regulation, relationships, work, and overall mental health. 

What I imagined vs. the reality

Being so new to the field when I began working with this population, what I imagined and the reality around the disorder itself was fairly minimal. I had the benefit of having little to no preconceptions past a peek at the DSM-5 (pre-TR) and a few Google searches. However, within my search, I was surprised to find clinician forums with sentiments reading “be careful” and “good luck”. I quickly learned that there is a significant stigma surrounding BPD, with some clinicians even refusing to work with this population altogether. This is due to several factors, including emotional volatility and high rates of self-harm and suicidal behaviors associated with BPD, as well as misconceptions around “manipulative behavior”. Some falsely believe that these patients are far too self-destructive, too manipulative, and too committed to being entrenched in their patterns of behavior to make meaningful progress. Some even suspend empathy, signaling the belief that patients engage in these behaviors on purpose or simply for attention. In my experience, these ideas could not be further from the truth. 

While it is essential for clinicians to have the tools and training to address high-risk behaviors such as suicidality and self-harm, I’ve found that the misunderstandings surrounding BPD contribute to an undue aversion from those who are equipped to help. One of the main misconceptions that leads to this avoidance is the belief in self-serving manipulative behavior. Many unfairly interpret strong emotional reactions as attempts to “make others feel sorry for them” or to seek attention for attention’s sake. While expressions of intense emotions, such as crying or screaming, can be seen as manipulative in a technical sense, the underlying function is often to communicate deep pain and seek relief, rather than to deliberately control others. 

The majority of the patients that I worked with had experienced trauma and had never felt that their pain was fully acknowledged, or they were shamed for their emotional response. While there are many factors that in combination may lead to the development of BPD, Dr. Marsha Linehan (the creator of DBT) suggests that these chronically invalidating environments contribute to difficulties regulating emotions. This makes the person living with BPD feel emotions more intensely, and it is more challenging to calm down once activated. 

People living with BPD also experience an intense fear of abandonment. This creates difficulty in forming and maintaining relationships, as this often causes hypervigilance of behaviors or emotional cues of friends, partners, or loved ones. In turn, the person with BPD may interpret a benign shift in mood as a rejection, and may “split” and lash out with anger or display the intensity of their emotions to protect themselves from or prevent imminent perceived abandonment. In those moments, the person may believe that the only thing that could calm them down is the person that they are yelling at and pushing away or crying for and begging to stay. This may sound counterintuitive or manipulative, but it is often a desperate attempt to relieve the deep pain and overwhelming distress they are experiencing at that moment — distress they feel unable to soothe on their own. This inability to self-soothe can lead the person to turn to things like self-harm, substances, and suicidal behavior to cope. 

Seeing these cycles play out in real time in the unit, I can say with confidence that there is not a person in the world who would want to feel that way on purpose. While it’s not fun to be the loved one or clinician on the other side of a person’s intense anger or expression of emotion, I have learned that when I focus on identifying and understanding a person’s pain, I can generate more compassion and empathy in my approach. These patients deserve care, and luckily, there is a method that has been proven to work. 

How DBT helps – lessons learned from working in DBT

The term dialectical in Dialectical Behavior Therapy (DBT) refers to the concept of balancing two seemingly opposing forces: acceptance and change. This is at the core of DBT’s philosophy and is designed to help individuals manage the intense emotional experiences associated with Borderline Personality Disorder (BPD) and other mental health conditions. 

Acceptance means recognizing and validating the individual’s current emotional state, behaviors, and experiences. It involves acknowledging the reality of the person's feelings and struggles without judgment or criticism. For individuals with BPD, this acceptance is particularly important because they often feel misunderstood or invalidated, leading to a deep sense of emotional pain.

Change, on the other hand, is about encouraging the individual to take active steps toward healthier behaviors and emotional regulation. Change is essential because DBT believes that individuals can make meaningful progress and create a life that is "worth living," despite the emotional challenges they face.

The dialectical aspect comes from the recognition that both of these forces — acceptance and change — are necessary for healing. In DBT, clients learn to accept their feelings and experiences as they are in the present moment, while also working toward change by using the skills and tools taught in therapy. In practical terms, this means that when a person with BPD is experiencing emotional distress, the therapist might first validate and accept the distress (acknowledging that it’s real and understandable) before encouraging the person to use DBT skills to manage that emotion or change the behavior that might be causing harm. 

With this core concept in mind, DBT focuses on providing individuals with practical, skills-based tools to manage emotional dysregulation, build healthier relationships, and reduce self-destructive behaviors. The therapy centers on teaching four key skill areas: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. 

Mindfulness:‍

Mindfulness in DBT teaches individuals to be present in the moment, observing their thoughts and feelings without judgment. It helps people build awareness and acceptance of their emotions rather than reacting impulsively to them. I worked with a patient who often felt overwhelmed by waves of sadness. Through mindfulness, they learned to observe and name their feelings as they arose — saying to themselves, “I’m noticing sadness right now” without trying to push it away. This simple shift helped them accept their emotions as temporary, reducing their need to act on those feelings immediately.

Distress tolerance:‍

Distress tolerance skills help individuals cope with intense emotional pain without resorting to self-destructive behaviors. These skills provide practical strategies for managing crises and enduring emotional discomfort. One patient, who had previously self-harmed during emotional crises, began using grounding techniques like holding ice or taking a walk, significantly reducing the need to engage in harmful behaviors during moments of distress.

Emotional regulation:‍

Emotional regulation skills enable individuals to identify and manage intense emotions, preventing them from becoming overwhelming. These techniques allow patients to respond more effectively to emotional triggers. I observed a patient who frequently experienced intense anger use emotional regulation skills such as "opposite action" to calm down during moments of frustration, reducing the frequency and intensity of their outbursts.

Interpersonal effectiveness:‍

Interpersonal effectiveness skills help individuals communicate their needs, set boundaries, and navigate conflicts in a healthy way. This component is particularly important for individuals with BPD, who often struggle with unstable relationships. I worked with a patient who had difficulty expressing their needs without feeling overwhelmed by fear of rejection. Through DBT, they learned how to use the DEAR MAN skill—describing the situation, expressing their feelings, asking for what they need, and reinforcing the importance of the request—in a calm, direct way. This allowed them to set clear boundaries with friends, leading to healthier, more balanced relationships. 

Reflecting on my time at a DBT program, having done traditional talk therapy for the last two years, I believe it is effective because it offers more than just emotional insight— it equips individuals with practical solutions that can be immediately applied to real-life challenges. These practical tools not only help individuals cope in the moment but also support long-term emotional stability and healthier relationships. In addition, I find that the tools offered in DBT are helpful for anyone, not just those struggling with BPD. Not only have I incorporated skills with most of my clients at one time or another, I have adopted an overall mindset of balancing acceptance and change, utilizing self-validation when I’m faced with challenges in my own life. 

Potential uses for analytics and AI tools (like Upheal) in DBT

I believe there are valuable potential applications of AI tools like Upheal that could be offered for clinicians working with DBT, especially in tracking client behavior patterns and progress. 

At its core, Upheal allows clinicians to be more present in session by taking care of the documentation process in real time. With Upheal handling the note-taking, therapists can stay engaged and connected, offering undivided attention to the conversation and emotional dynamics unfolding in the moment. This shift allows clinicians to build stronger rapport, respond more thoughtfully to the client's needs, and provide more effective therapeutic support.

The session summary tool, which aggregates data from session notes to highlight the key topics discussed, could be incredibly valuable for clinicians in tracking treatment progress. By providing a concise overview of the client's statements, behaviors, and emotional tone, the tool helps identify patterns and shifts in focus over time. For example, if the summaries consistently show increased discussions around interpersonal conflicts, it may indicate a need to prioritize interpersonal effectiveness skills in upcoming sessions. Additionally, the tool can help assess risk by flagging any recurrent themes of distress or negative language, alerting the clinician to potential concerns such as self-harm or suicidal ideation. Overall, these summaries could allow clinicians to evaluate the client's progress, determine areas requiring additional support, and assess ongoing risk, all while saving valuable time and ensuring no critical issues are overlooked.

In addition, with analytic data such as the sentiment tracking tool, clinicians may be able to gain insights into behaviors such as the client’s patterns of “splitting”. Splitting, or viewing people or situations as entirely good or bad, is a common feature of BPD. A sentiment tracker could help highlight instances of extreme positive or negative statements, offering opportunities to address splitting in therapy. For example, if a client frequently alternates between highly idealized and critical statements about someone, the clinician could explore the underlying emotions and guide the client toward more balanced perspectives. Additionally, with larger caseloads, it can be challenging for clinicians to keep track of every detail of a client’s progress. A sentiment tracking tool can provide a summary of a client’s overall emotional tone and shifts between sessions, helping clinicians tailor their approach and focus on areas of greatest need during therapy.

Overall, I see it as being able to provide these benefits:

• Increased Presence: Clinicians can remain fully present in session, knowing Upheal is tracking client behavior and taking notes for you.
• Improved insight: Helps clinicians identify and address patterns in client behavior, such as splitting or emotional dysregulation.
• Progress tracking: Provides a macro view of client progress over time, highlighting areas needing more focus.
• Efficient risk assessment: Flags recurring negative language or distress, enabling timely interventions for at-risk clients.
• Time-saving: Summarizes session data, allowing clinicians to quickly assess treatment progress and adjust focus.

The final takeaway

My experience working in a residential DBT treatment center for adolescent girls shaped not only my understanding of Borderline Personality Disorder but also my appreciation for the transformative potential of DBT. Through its structured, skills-based approach, DBT provides clients with tools to navigate emotional distress, build healthier relationships, and, most importantly, create a life worth living. The balance of acceptance and change fosters a pathway for genuine progress, even for those who have felt stuck in cycles of emotional pain. As the field of mental health evolves, I’m excited about the possibility of integrating AI tools like Upheal into DBT treatment as a way to enhance our ability to track progress, monitor risk factors, and personalize care. By combining the human connection of therapy with the precision of technology, we may be able to ensure that more individuals receive the effective care and support they deserve.