Dr. Kenneth Levy provides an overview of the major evidence-based treatments for Borderline Personality Disorder and explains why clinicians shouldn’t limit themselves to just one model. Despite their different styles, these treatments share core elements and similar effectiveness, and Dr. Levy makes the case that therapists best serve patients when they understand multiple approaches and remain flexible in how they use them.

Published On: 11/20/2025

Duration: 48 minutes, 12 seconds

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Learning Objectives: 

After reading this article, you should be able to: 

1. Describe the five major evidence-based treatments for BPD (DBT, MBT, TFP, SFT, and GPM) and recognize their shared therapeutic elements.
2. Compare the relative effectiveness of five specialized treatments in the treatment of BPD.
3. Recognize the impact of treatment model allegiance (“alphabet divide”) on clinical decision-making and patient access to care.
4. Identify therapist behaviors, such as affect tolerance, that facilitate emotional regulation and therapeutic progress in patients with BPD.

Abbreviated Transcript

Abigail Rasol: Welcome to the Carlat Psychotherapy Podcast. I'm your host, Abigail Rasol, and I'm honored to be joined today by Dr. Kenneth Levy, PhD to kick off our multi-part series, delving into Borderline Personality Disorder.

Dr. Levy is a tenured professor in the clinical psychology doctoral program at Pennsylvania State University, where he leads the Laboratory for Personality, Psychopathology, and Psychotherapy research. He serves as an adjunct assistant professor of psychology and psychiatry at the Cornell Medical College, where he also serves as a faculty fellow and an executive committee member at Cornell's Personality Disorders Institute, and has been both a principal investigator and a co-principal investigator on many of the key projects of the PDI over the last 10 years. I am honored to have him here to kick off our series. 

Dr. Levy, welcome, and thank you so much for joining us. 

Can you start off by sharing anything that I might have missed in terms of your background and your expertise in the area? 

Kenneth Levy, PhD: Thank you for having me. I got interested in Borderline Personality Disorder when I started as a mental health worker working on an inpatient unit and being exposed to people who were struggling with the kinds of issues that are typical of people who are grappling with what we call Borderline Personality Disorder, and I wanted to understand and help people have the kind of lives that they aspire to. I was fortunate enough to be exposed to really dedicated and talented psychiatrists and psychologists, and although I was planning to go to graduate school in clinical psychology, it focused my interest in this area. Then, having read works of people like Otto Kernberg and others, I became interested in treatment, which has led not only to my clinical interest, but my research interests, which focus on the treatment of BPD, but specifically, understanding the mechanisms of the treatment, where the action is in the therapy, and how identity consolidates and provides structures that allow for the regulation of emotions, particularly under times of distress.

Abigail Rasol: I'd like to start off by giving our listeners a little bit of context on BPD, so could you please describe some of the core clinical features of BPD as you see them most commonly present in patients? 

Kenneth Levy, PhD: Probably the most prototypical presentation that clinicians will see is a patient who often comes into therapy, whether it be outpatient therapy or an inpatient unit or emergency department, highly distressed and in the midst of some crisis.

The patient may be tearful, crying, self-critical, or even suicidal. The tearfulness will often vacillate with frustration, even irritability and anger, and the self-criticism will often vacillate with the projection of, or anger towards, others about their situation.

True to the description in the DSM, these patients typically present with instability in their sense of self or self-concept (what we often call identity), instability in their reports and experiences of affects or emotions, which may also be observable in the consultation room. You may see the patient vacillate between feeling one way in one moment and another way the next moment. 

And finally, we see instability in interpersonal relationships, which often strikes the clinician as chaotic, with lots of ups and downs and idealizations and denigrations of the people who are being discussed, and perhaps some hypersensitivity to slight both, real and imagined, as well as concerns about people’s presence and abandonment. 

For example, one patient came to therapy after a recent breakup, in which a relationship she thought was going well quickly soured. This was not the first time this happened for her, and at the point she entered treatment she was acutely aware of this pattern, although that awareness often disappeared. In our initial visit she was quite distressed, sobbing, and in certain moments she was very self-critical, blamed herself, and was convinced she was unworthy and unlovable.  However, she quickly alternated to being angry and dismissive toward her ex. In those moments, she became demanding with me to know why and how he (and others) could abandon her. If I didn’t quickly side with her anger at others, she became angry with me. In those moments, any efforts to reassure her were met with doubt and resistance. When I tried gently pointing out that earlier in our conversations she was quite positive toward her ex and wondered about her own behavior, she screamed at me that she never said that. That swing between despair and rage often accompanied with a lack of awareness of the vacillation captured an essential aspect of BPD. 

Abigail Rasol: Would these symptoms be considered pretty clear indicators that this individual is likely struggling with BPD, or can there still be challenges in identifying it? 

Kenneth Levy, PhD: Even with this presentation, the recognition of BPD can be difficult. Patients may report histories of trauma, and there may be current sequelae from these experiences that are indicative of post-traumatic stress disorder. Sometimes it's easier to recognize the PTSD aspect of the patient's presentation than the more personality related issues. When the trauma is chronic, it's often called complex post-traumatic stress disorder, C-PTSD. This concept of C-PTSD is still controversial and in debate, and in my opinion, it’s often misused, in that it's often misdiagnosed as the central problem. But it's important to remember that this idea of c-PTSD is usually not a good explanation for what we're seeing with BPD. 

Another complication is that patients may present with other comorbid conditions, such as depression or bipolar disorder. Therapists often privilege such comorbid conditions, but it's important to recognize that the evidence suggests the opposite is true, and that when BPD is present, it actually warrants strong consideration.  

Abigail Rasol: I'm curious if you can speak a little bit to what the differential diagnosis would look like for c-PTSD and BPD and what the fundamental differences are that would enable a clinician to be able to tell one apart from the other.

Kenneth Levy, PhD: That's an excellent question, and it can be very difficult for a clinician. There is a PTSD researcher named Marylene Cloitre who ran a randomized control trial looking at an emotion-focused treatment for PTSD, and she was able to empirically examine the very question that you asked: how might you actually differentiate people with BPD from somebody with c-PTSD?

What she found was that the people with c-PTSD had problems with their sense of self, but it looked different than those with BPD. In people with c-PTSD, their sense of selves tended to be on the overly negative, self-critical side, and there was a self-concept difficulty for people with c-PTSD, but this negative self concept was stable, as opposed to a vacillating self-concept that you see in BPD. Likewise with interpersonal difficulties: people with c-PTSD often fear relationships and isolate themselves in a relatively stable way, while those with BPD show fluctuating patterns – getting close, withdrawing, or lashing out at others.

And then, importantly, although about 15% of the c-PTSD sample had suicidality, in the BPD sample you saw about 70% of individuals showing some suicidality, including non-suicidal self-injury. 

For example, a patient with a long history of trauma and multiple failed psychotherapy treatments presented with suicidality, angry outburst, emotion dysregulation, impulsivity, promiscuity, including prostitution.  She grew up in a neglectful family and was repeatedly sexually abused, including penetration, by relatives during her early adolescence and through young adulthood. When she told her parents, they did not believe her. The abuse was extensive and she met criteria for PTSD. For many years, she carried that diagnosis and the patient highly identified with it, as well as bipolar disorder. However, there was no indication of BPD in her records. During the assessment and subsequent treatment, the patient showed the instability of self, affect, and relationships that was unmistakably indicative of BPD, and she often recognized her problems with her sense of self and talked openly about thinking she might have BPD. It is not that the trauma isn’t relevant — it often is, and it was in her case too. But about a third to two thirds of patients with BPD don’t have trauma histories at all. So while trauma can contribute when it’s present, it doesn’t define the disorder.

So when you really look at the clinical pictures, you can actually differentiate these two presentations. And it's important not simply from a conceptual level, but it has treatment implications. Because if you're diagnosed with c-PTSD, you're likely to not get one of the specialized treatments for BPD that have shown reasonable amounts of efficacy. So you're not only misdiagnosed, but you're also mis-dosed in terms of the treatment.

Abigail Rasol: You touched briefly on some of the specifically proven treatments to work for BPD, and I'd like to discuss those. Could you please speak to what the five specialized treatments for BPD are, and how each of them are implemented in practice and what that model looks like in the room? 

Kenneth Levy, PhD: You're pointing out importantly that there are multiple treatments available. I tend to refer to the five main ones as the big five. That would be Dialectical Behavior Therapy (DBT), Mentalization Based Therapy (MBT), Transference Focused Psychotherapy (TFP), Schema Focused Therapy (SFT), and Good Psychiatric Management (GPM). 

It’s important for clinicians to be aware of the various treatments because at this point, we know that there are no differences in the effect sizes of the various treatments. This means that all treatments seem to be equally effective overall across a range of patients. 

What we also know is that although many patients get better in these treatments, and these treatments have efficacy over treatment as usual out in the community, the treatments aren't universally effective for all patients. We think about 50 to 60% of patients will show improvement within a year, and that improvement is partial, meaning they're showing improvement in terms of reductions in suicidality and ER visits and increased functioning, but they're not at the levels or thresholds that one might aspire to in their lives.

So there's still work that needs to be done. And sometimes, for those patients that aren't getting better in any given treatment, it's quite possible that an alternative treatment would be useful in addressing their difficulty. And that's a tricky thing to decide – when you have to increase the dose of what it is that you're doing, versus when it might make sense to actually change what it is that you're doing or what the patient is receiving. 

Abigail Rasol: What would you say are some of the key distinctions between these treatments, whether in their underlying conceptualization or in the techniques that they utilize that really set one apart from the other?

Kenneth Levy, PhD: First off, I would say that it's important to recognize that these treatments are actually much more similar than people might think. They share certain commonalities that might be responsible for their effectiveness. 

For starters, all of the treatments are well-articulated conceptually and have a model to them that typically resonates with the clinician that's actually practicing it, but also can resonate with patients. I think that having a coherent model that resonates is actually an important aspect of psychotherapy. 

Second, all of these treatments actually devote a lot of attention to training and supervising therapists, and getting clinicians to a certain level of adherence and competence of the models. So you have people who are quite conscientious and committed to a specific way of working, and a lot of attention is paid to making sure that they are working in ways that are consistent with the model. 

Another commonality is the emphasis on assessment. These treatments make explicit what the difficulties are, the therapist’s and patient’s roles and responsibilities, and practical aspects like starting and ending sessions on time. But more importantly, what becomes explicit is how the therapist sees the therapy working and what the tasks and the goals of the therapy will be.

These treatments also put a lot of attention to dealing with the interpersonal relationship between the therapist and the patient – paying attention to ruptures in the relationship and not shying away from those, but rather turning into them and trying to understand what's happening and how those ruptures can be repaired. In doing that, all of these treatments are very focused on the interpersonal context. 

So there really are a lot of similarities between these treatments, regardless of how they're actually carried out in session.

Abigail Rasol: Can you elaborate on this focus on the ruptures in patient/therapist relationship? What does that look like in practice and why is it an important focus of therapy? 

Kenneth Levy, PhD: The ruptures in the relationship can be very subtle. For example, with one patient I made a simple clarification, asking if he could “say more about that.” He seemed unexpectedly annoyed, which surprised me because my question came from sincere interest. At first, I debated whether to mention it, but when his irritation continued, I gently said I wasn’t sure if I was perceiving it correctly, yet it seemed like he reacted to my question. I asked if he noticed that too.

He reflected and said that when I asked him to say more, he took it as a challenge, as if I doubted him and wanted him to prove what he’d just said. That was far from my intention, which was to better understand him. When I clarified this, it resonated with him, and he apologized. I told him there was no need – it wasn’t an error, but a window into how he experiences others. His tendency to doubt others’ motivations, including mine, is part of why he is in treatment and something we need to explore. As we did, it became clear that his doubts about others reflected deeper doubts about his own understanding of himself.

Abigail Rasol: That’s very interesting. Going back to comparing the treatments – you mentioned a lot of their similarities; what are some of the differences between them? 

Kenneth Levy, PhD: The treatments can look very different from one another in session.

DBT in particular appears more skill focused. There may be diary cards that are used, there may be exercises that are done. For example, an easel will often come out in DBT, whereas an easel rarely will be brought out by the therapist in TFP. 

So the treatments can look different. I've heard from therapists that TFP may feel too unstructured to therapists that like the kind of structure that DBT provides, and likewise, I've heard from therapists that DBT can sometimes feel too scripted and rigid to therapists that are more interested in the evolving interpersonal context.

There are other things that can look different as well. In DBT there is validation and cheerleading as a technique, as well as self-disclosure. In TFP, self-disclosure is minimal and you wouldn't necessarily have as overt validation in the same way that you would have it in DBT so it can look very different. And so it can feel very different to patients in that way, and it can also feel very different to therapists that are actually enacting the treatments.

Abigail Rasol: Can you elaborate on the differences in the validation techniques? 

Kenneth Levy, PhD: The validation process in DBT and TFP is nuanced and focuses on validating emotional experience rather than the actual events a patient shares. One might say, “I can see how upset you are right now,” or, in TFP, empathize with how difficult it feels to share something when one fears their therapist doesn’t care. Rather than convincing the patient you care, TFP explores the projection itself.

For example, when a patient asked if I thought they could get better, I said, “I wouldn’t be treating you if I wasn’t hopeful you could have the kind of life you aspire to.” But I added, “I imagine my simply saying that isn’t convincing because you doubt you can get better, and it’s hard to trust me – or anyone.” Later, when she asked if I truly cared about her, I replied similarly: “I can tell you that I do, but I don’t think that will satisfy you because you doubt anyone can truly care. What’s important is that we explore that doubt.”

Another example comes from a supervisee. His patient repeatedly declared, “I’m a shit.” The therapist responded, “I don’t think you’re a shit – I think you’re a good person,” but the patient only repeated the statement louder and more forcefully, eventually slamming his arm on the table and breaking it. No amount of reassurance or validation satisfied him because the doubt was real and had to be explored rather than soothed.

Abigail Rasol: You’ve mentioned that these different treatments share a lot in common. But in the field, there still seems to be a divide between camps. You’ve coined this concept the “alphabet divide.” Can you elaborate on what you mean by that? 

Kenneth Levy, PhD: The idea of the “alphabet divide” came to me from the sheer number of three- or four-letter treatments – DBT, TFP, and so on. I pictured different camps or fiefdoms, where clinicians know a lot about the treatment they were trained in but little about the others. This divide isn’t helpful – conceptually for the field or pragmatically for patients. I’ve spoken with clinicians who only know their own approach and are unaware of the others, which is concerning given that empirical data shows no differences in effectiveness among treatments.

So my idea was that we need to move away from this alphabet divide. Early on, I felt that while many communities had DBT, they also needed access to other options, since DBT doesn’t help every patient. Over time, I’ve come to believe that not only should every community have more than one treatment available, but every therapist should at least be aware of multiple treatments. They don’t need to practice them all, but they should know about them.

So the alphabet divide is really a concept that's meant as a critique to where the field is at, and an effort to move away from that to a more cohesive and comprehensive view of how we might provide for patients in need.

Abigail Rasol: Given the evidence that all of the treatments are pretty equally effective, what do you think is keeping the field so stuck to this concept of the alphabet divide?

Kenneth Levy, PhD: We don't have the studies. We have several RCTs, they've been maybe 25 to 30 of DBT alone in the United States. We have several others of MBT and TFP and SFT, and we know that the effect sizes are similar and in direct comparisons, there aren't differences. But we know very little about what would predict who might do better in one treatment or another. So we're really not at a great place to be able to say empirically, ‘here's how I would identify who would go to TFP versus DBT or MBT or GPM’. 

Abigail Rasol: So given this lack of information, how do you recommend a therapist that is just starting off working with a client with BPD determine which treatment is really the best one for them to start with?

Kenneth Levy, PhD: Pragmatically, therapists need to start where they have some expertise. So if you're in a community where you can get trained in DBT, you get trained in DBT. If you're in a community where you might have TFP, you train in TFP. 

But at the same time, clinicians need to be very reflective and humble. What bothers me sometimes is when I see people in one camp or another, where they think that their treatment is the only treatment and to do anything else is derelict. 

I think the better attitude is to believe in what you're doing, but to also be humble about it and to share with patients what the options are and why you're suggesting what it is that you're suggesting, and then remaining vigilant about whether that's working for you and for them. 

I do think it behooves people to be aware of the different modalities at sufficient depth so that they could actually convey that information to patients. They should not simply say to a patient, I'm recommending DBT or TFP because that's what I do, but they should have a rationale for why they think this treatment would be appropriate for the kinds of difficulties that the patient is having.

And they should be very cognizant and even have this discussion about what getting better would look like and what not getting better might look like, and whether and when we would need a consultation about potentially changing the treatment.

Abigail Rasol: What would you say are some indicators that serve as a warning sign that perhaps it's necessary to look elsewhere or to adapt one’s strategy or approach with a given client?

Kenneth Levy, PhD: That’s a good question. I'm not sure I have a good answer to it because the reality is, when you're treating patients with BPD, the treatment is going to take time, and so there can be long periods of time where you may not necessarily see much improvement, or you see some improvement and then the patient reverts back to earlier ways of functioning. I don't necessarily know that those are indicators that the treatment isn't working. 

I think you can periodically assess whether people are moving towards their goals. It's not uncommon to have a patient come into therapy really frustrated and feeling as if they think they're not getting better fast enough. And that's understandable. But the metaphor I often use is you can't cook a stew any faster just simply by turning up the flame. A stew takes time for flavors to be released and for ingredients to coalesce, and it often happens over a low steady flame. Sometimes the treatment of people with personality disorders is similar, in that it's going to take a long time. But if you’re moving in the proper direction, you should see indicators that suggest that the patient is showing some improvement.

One patient came into session and said she was frustrated because she didn’t feel she was getting any better. The way she said it hit me like a punch to the gut, and for a moment I questioned whether I was helping her. I then reflected and pointed out the progress I had seen. When she first came to therapy, she was often in crisis – agitated, with pressured speech, her mind racing. She sometimes broke down or screamed in frustration, saying she couldn’t even think about her situation because it was too upsetting. She was unhappy in her relationships and refused to set goals or agree to refrain from hurting herself.

Now, although she was still unhappy and striving for stability, she could stay calm in session, raise concerns without becoming overwhelmed, and remain reflective even with difficult topics. She was less frenetic, more thoughtful, and able to engage rather than withdraw. As I shared this with her, she agreed and became calmer, though also more mournful. She admitted she could see she was improving, but not as fast as she wanted. I empathized with that feeling and validated the desire we all have to get better quickly, while recognizing how hard it is that real change takes time and effort. 

Abigail Rasol: That definitely makes sense. Are there any indicators that do suggest that it’s time for a provider to change up the approach? 

Kenneth Levy, PhD: One thing I've seen that has suggested somebody should be in another therapy is when you see this revolving door of somebody going into treatment, leaving treatment, then coming back into treatment. To me, that suggests that maybe something different is needed.

The other time I think a different approach is needed is not when a patient isn’t improving, but when they are. In some cases, patients benefit from the structure of DBT to help them stay contained. As they become more stable, they may then be ready to transition into a treatment like TFP.

Abigail Rasol: It’s a great point that sometimes it is necessary or valuable to switch gears not only when something isn't working, but also when something is working.

What do you think are the core active ingredients that are shared amongst the treatments that actually drive the improvement in BPD patients, regardless of the specific treatment model?

Kenneth Levy, PhD: One thing I've consistently heard from my patients when our treatments have finished and I've asked them what they thought was helpful is my remaining calm when they've gotten upset, whether it be with someone else or with me, during a session. 

One patient told me she used to get furious that I stayed calm during her angry outbursts. She couldn’t believe I didn’t get dysregulated and even tried harder to upset me. Over time, though, my calmness made her curious—she began to wonder how one could think clearly in the middle of such “storms.” She eventually recognized that her anger was tied to envy, a part of her wanting what she saw in me. As we explored these feelings, she became more able to reflect even when upset, tolerate aspects of me she disliked, and still appreciate me. This also allowed her to express gratitude without becoming overwhelmed by sadness or anger about what had been lost.

I think that regardless of treatment, when therapists do that—listen, stay present, and not be thrown off balance—they help the patient tolerate their experience as the therapist is tolerating it, and develop a more integrated sense of themselves and of others. That nonjudgmental stance allows the patient’s experience to be reflected on and understood, which fosters greater self-compassion. I think that is the active ingredient across treatments.

Abigail Rasol: I think that's all the time that we have today. Do you have any closing thoughts you’d like to share before we sign off? 

Kenneth Levy, PhD: Thank you for inviting me. I think this series is important to familiarize clinicians with the various treatments available, and hopefully it will lead to the remediation of this alphabet divide that exists in our field. 

Abigail Rasol: Thanks again, Dr. Levy, and thanks to our listeners for joining us. 

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Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one (1) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity