A Critique of DBT as the “Gold Standard” for Healing from BPD

Dialectical Behaviour Therapy is widely considered the 'gold standard' for people with Borderline Personality Disorder, and in mainstream discourse on BPD treatment, this assertion remains largely uncontested. 

There have been people, both mental health practitioners and people with BPD alike, who have spoken up against the potential harms and even potential ineffectiveness of this modality for people with BPD, but these discussions are always invariably met with defensive responses and assertions that those who have been harmed by DBT weren't experiencing 'real' DBT, or that it was just a 'poorly conducted' form of DBT. 

It's dangerous that discussions on the potential harms and ineffectiveness of this modality have always been shut down and met with dissent, when it's clear that so many of us are dissatisfied or have even been traumatized by DBT, and there needs to be space for these conversations. I want to be clear that I'm not indicating that DBT can't be extremely helpful and hasn't helped many.

I'm grateful that there are so many individuals who have had positive experiences with DBT, but no form of treatment or healing practice at all should ever be considered above criticism, and anything that's meant to bring healing should be subject to frequent evaluation. DBT is no different– but the constant pushback against any and all criticisms of it would suggest otherwise. If we keep shutting down criticisms of DBT, we risk more people being harmed and we risk confining people to this one form of treatment that cannot work for everyone, nor fulfill everyone's needs. 

In hopes that those who have had positive experiences of DBT will allow for room for these discussions to take place, here are a few of the shortcomings I've considered of uplifting this treatment to the status of “gold standard” for BPD:

1. It is entirely Westernised and does not contain cross-cultural considerations. 

DBT is based on conceptualizations of social interactions that center a Western Eurocentric lens. The interpersonal effectiveness module is based on the idea that these ways of interacting are neutral and universal, with no consideration of the fact that different cultures have different norms and different ways of relating. Its perceived neutrality upholds the idea that these ways of communication, of socialising are the 'right' way. But relationships and communication look different across cultures. So, when we say that DBT is the gold standard for treating people with BPD– which people exactly are we talking about? 

It also does not account for the fact that the concept of 'emotional regulation' is not a neutral concept that can just be applied globally to everyone. What emotional expressions are considered 'acceptable' and 'normal' varies widely across cultures. 

What may be deemed 'emotional dysregulation' by these ‘Western’ standards may make a lot of sense and fit into the cultural norms of other communities. This doesn't make our emotions wrong. This doesn't make our emotional expressions wrong. But you can easily see how invalidating it can be for those of us from different cultures to have these standards of emotions and emotional expressions posited as the right way of being. 

2. It’s not actually meant for trauma

DBT asks to challenge our emotional responses to things by interrogating whether or not they actually make sense. It asks us to determine whether or not our emotional reactions are 'proportionate' to the current situation, but when we're dealing with racial trauma, intergenerational traumas– essentially traumas that are alive in us that we may not always have a known recognition of, how do we know if our reaction is proportionate?

These experiences impact us often in implicit ways, which means that we can't always tell that what we're actively responding to is not just the current situation or even childhood or interpersonal wounds, but wounds that go deeper and that are related to much larger historical and ongoing sociopolitical issues. DBT has no capacity to hold space for complex experiences like these. 

Of course, this is in conjunction with the fact that the experiences of those diagnosed with Borderline Personality Disorder are still conceptualized as the result of some sort of innate pathology. There's no room for an understanding of collective traumas experienced by targeted communities. There's no room for an understanding of all the possible types of traumas we're carrying. 

Not only is DBT not trauma-informed, but even if it were, there is no one form of treating trauma that works for everyone. Our traumas, our experiences, our histories, our identities, our bodies and minds are all unique. Our healing has to be tailored as well. While DBT may form a useful component of some people's healing, for others it won't, and there's nothing unusual about that.

We need to be able to have these discussions out in the open so that people can stop feeling "broken" or "disordered" when this form of treatment hailed as *the* thing to help them doesn't work. Everytime DBT is criticised, it's met with responses that make claims like "there are just shoddy versions of it now". What about an acknowledgement of the fact that this one, very limited in its scope, option just isn't for millions of people? 

3. It isn't intersectional at all

Further to the above points, DBT homogenizes all of us with this diagnosis, and doesn't account for how our experiences are vast. It takes no account of how our identities, our experiences of discrimination, our geographical locations, and so much more have impacted our suffering. We have to be able to hold space for the multitude of experiences each of us with this diagnosis brings and the unique ways that this may inform what healing could look like for us. 

 4. It posits Western [Eurocentric] knowledge and healing practices as superior to all others 

DBT being held as the "gold standard" of treatment for BPD also reinforces the superiority of Western modes of healing, falling in line with a long history of minimising and even criminalising the healing and spiritual practices and medicine of racially oppressed peoples.  

There are people with BPD who have turned to the ancestral medicine of their lineage as part of their recovery. Other people who have been reconnecting with their ancestors as part of their recovery. There are endless other forms of healing and none of them are 'inferior'. DBT can be helpful, but it is one very small speck in a large tapestry of healing practices across the globe, all of which are just as valid. 

In my own culture in Trinidad and Tobago, there are so many natural ways that we heal that aren't considered "real" healing because they don't take place in a clinical setting– 'liming' or spending time with one another and laughing and talking and sharing stories, sharing and making meals together, dancing, singing, spending time near the sea. All of these can facilitate transformation and healing. Why is DBT considered the "gold standard" of healing, why is it uplifted above all other forms of healing, then, when these practices often also involve components of embodiment, community connection, and connection with land and environment, which DBT, with its individualistic, entirely cognitive approach does not? As Prentis Hemphill says, "we have not been taught to look at our own practices as knowledge". 

I say this particularly to people whose cultural, spiritual and healing practices and medicines have been oppressed or historically treated as inferior: if you find other things more helpful than using your dbt skills, that's fine! If you prefer to turn to other things that make more of a difference than your DBT skills, that really doesn't mean that you're doing a "bad job" at your recovery. 

5. It is not relational or attachment-focused 

Building off the last point, DBT is essentially an individualistic approach to healing that doesn't account for the importance of the relationship itself in therapy. A lot of people have pointed out that those who have had successful experiences with DBT likely had care providers who were validating and compassionate. DBT itself, however, doesn't account for the significance of the relationship itself in our healing from attachment trauma. 

By and large, people with BPD will attest to how difficult relationships can be, particularly maintaining them in the long-term. The relational aspect of therapy is not emphasised, however, in DBT, and DBT-administering practitioners often uphold some very harmful dynamics that are rooted in ableism and power-over, which can further traumatise people with BPD. When it comes to helping us heal, the relationship itself absolutely matters. 

6. It defines what recovery means for us

DBT as a path to recovery depends on what recovery is defined as in the first place. Recovery from DBT is essentially defined behaviourally, but recovery can also be defined as no longer struggling to feel safe, no longer struggling with abandonment and rejection wounds appearing in your relationships, and the many other ways that we can define recovery. Again, this doesn’t mean that DBT can’t be a significant part of your recovery journey, but that it also really depends on what recovery means to you.

The idea of DBT being the “gold standard” of BPD treatment, however, often leads to mental health workers imposing DBT onto almost everyone with a BPD diagnosis, essentially defining recovery for them. There is a both / and here in that: DBT can be a helpful part of your recovery, but there are people with BPD who may define recovery for themselves differently from the way that DBT has defined it, and the imposition of this modality onto everyone with a BPD diagnosis means that recovery has already been defined for them— potentially without any input on the part of the individual with BPD.

I hope these serve as some starting points into understanding why DBT may not be for everyone with this diagnosis, why even if it is helpful, it may not be the only thing that's needed for recovery, and why practitioners need to be open to considering options beyond DBT, where applicable. No one should be shamed for not finding recovery through DBT, and bearing this diagnosis should not limit the options that we’re offered for recovery— and, yet, unfortunately, upholding DBT as the “gold standard” for BPD has frequently led to both of those things.

We're already aware that DBT can be useful; that's already the dominant narrative on it– but we have to also make space to discuss the shortcomings of continually representing this as the “gold standard” of treatment.

For anyone looking for even more reading on critiques of DBT, here is a link to the original post that inspired me to share my own concerns about DBT as the gold standard of treatment. Here is a link to a post where Dr. Jennie Wang-Hall speaks about a DBT secret, ‘turning down the warmth’, that therapists are taught.

I want to emphasize again: this does not mean that DBT can't be helpful and that it hasn't helped people, and of course none of this is meant to replace any clinical advice. Please make decisions that are right for you.

With that in mind, I hope that practitioners reconsider its position as the “gold standard” and what that means for how you’ve approached treatment for people with this diagnosis. 

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