What is the DBT target hierarchy and how does it structure the treatment plan?

The DBT target hierarchy organizes treatment targets by clinical priority. Stage 1 targets are addressed in order: (1) Life-threatening behaviors — suicidal ideation, suicide attempts, self-harm, and homicidal ideation are always the highest priority. (2) Therapy-interfering behaviors — missed sessions, noncompliance, behaviors that prevent effective use of therapy time, and therapist behaviors that impede treatment. (3) Quality-of-life-interfering behaviors — substance use, eating disorder behaviors, housing instability, unemployment, untreated Axis I disorders. (4) Increasing behavioral skills — mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Your treatment plan goals should reflect this hierarchy, with the most serious behaviors addressed first. If a client is actively self-harming, you do not skip to interpersonal effectiveness work until self-harm is adequately addressed.

What outcome measures should I use for BPD treatment plans?

BPD treatment involves multiple targets that require multiple measures. For self-harm, track frequency, method, medical severity, and intent using a DBT diary card or structured self-harm log. For suicidal ideation, use the Columbia Suicide Severity Rating Scale (C-SSRS) at each session. For emotion dysregulation, the Difficulties in Emotion Regulation Scale (DERS) provides a validated pre-post measure with subscales for awareness, clarity, goals, impulse, nonacceptance, and strategies. For overall BPD symptom severity, the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD) or the Borderline Symptom List (BSL-23) are useful. For depression, use the PHQ-9. Track DBT skill use on the diary card — the frequency of skillful responses to emotional crises is itself an outcome measure.

How long does DBT treatment for BPD typically take?

Standard comprehensive DBT is a 12-month program consisting of weekly individual therapy, weekly skills group, phone coaching between sessions, and a therapist consultation team. Many clients benefit from a second year to consolidate gains and address Stage 2 targets (processing traumatic experiences, reducing avoidance). The 12-month timeframe is the research-supported standard, but insurance coverage varies. For treatment planning purposes, write 90-day plans that are renewed with updated progress data. Each 90-day cycle should show measurable progress on target behaviors. If comprehensive DBT is not available, DBT-informed individual therapy (using the target hierarchy and teaching skills) can be documented as a reasonable alternative with notation that comprehensive DBT is the gold standard.

How do I handle self-harm in a BPD treatment plan without being punitive?

Self-harm goals should be written in terms of reduction and replacement, not punishment. 'Client will reduce non-suicidal self-injury from 3 episodes per week to 0, using distress tolerance skills as replacement behaviors, within 12 weeks' is appropriate. The treatment plan should also specify how self-harm episodes are addressed in therapy: in standard DBT, any self-harm since the last session takes priority on the session agenda and is analyzed using a behavioral chain analysis and solution analysis. Do not write treatment plans that discharge clients for self-harm — this is both clinically counterproductive and potentially lethal. Instead, specify escalation protocols: 'If self-harm episodes increase in frequency or medical severity, clinician will reassess level of care and consider step-up to IOP, PHP, or inpatient stabilization.'

Can I treat BPD without being a DBT-certified therapist?

Yes, but with important caveats. DBT certification is not legally required to treat BPD, and many effective clinicians use DBT-informed approaches without full certification. However, comprehensive DBT (individual therapy, skills group, phone coaching, consultation team) has the strongest evidence base and should be offered when available. If you are providing DBT-informed individual therapy, document this clearly in the treatment plan — state that you are using DBT principles and the target hierarchy, specify which components of comprehensive DBT are and are not available, and note that a referral to a comprehensive DBT program was discussed. Other evidence-based approaches include Mentalization-Based Treatment (MBT), Schema-Focused Therapy, and Transference-Focused Psychotherapy (TFP). Choose one approach and implement it with fidelity rather than mixing techniques without a coherent framework.

Treatment Plan for Borderline Personality Disorder (BPD)

Treatment Plans|16 min read|Updated 2026-03-19|Clinically reviewed

What Is a Treatment Plan for Borderline Personality Disorder?

A treatment plan for Borderline Personality Disorder is a structured clinical document that specifies prioritized treatment targets, measurable goals, and evidence-based interventions for clients meeting diagnostic criteria for BPD (ICD-10: F60.3, Emotionally Unstable Personality Disorder, borderline type). The plan addresses the core features of BPD: pervasive instability in emotion regulation, interpersonal relationships, self-image, and behavioral control, including recurrent self-harm and suicidal behavior.

BPD is characterized by a pattern of marked impulsivity and instability in affect, self-image, and interpersonal functioning beginning by early adulthood. DSM-5 diagnostic criteria include frantic efforts to avoid abandonment, unstable and intense interpersonal relationships alternating between idealization and devaluation, identity disturbance, impulsivity in at least two self-damaging areas, recurrent suicidal behavior or self-harm, affective instability with rapid mood shifts lasting hours to days, chronic emptiness, inappropriate intense anger, and transient stress-related paranoid ideation or dissociation. A client must meet at least five of nine criteria for diagnosis.

Effective treatment planning for BPD requires a different approach than treatment planning for most Axis I conditions. The treatment plan must account for the pervasive, cross-domain nature of the disorder, the high risk of self-harm and suicide (approximately 75% of individuals with BPD engage in self-harm, and the completed suicide rate is estimated at 8-10%), the likelihood of therapy-interfering behaviors, and the need for a structured treatment framework that can tolerate crises without abandoning the treatment relationship. Dialectical Behavior Therapy (DBT) provides the most well-established framework for organizing BPD treatment, and the DBT target hierarchy — which prioritizes life-threatening behaviors above all other treatment targets — should inform the structure of the treatment plan regardless of the specific modality used.

When You Need It

After a comprehensive diagnostic assessment confirms BPD, including a thorough evaluation of self-harm history, suicidal behavior, and comorbid conditions
When beginning DBT, MBT, schema therapy, or another structured BPD treatment following the assessment and commitment phase
When a client transitions from inpatient psychiatric stabilization or residential treatment to outpatient care and needs a step-down plan that addresses ongoing safety concerns
When a 90-day treatment plan renewal is required and updated data on self-harm frequency, diary card compliance, skill use, and functional measures are available
When a crisis episode (suicide attempt, psychiatric hospitalization, significant increase in self-harm) necessitates treatment plan modification and reassessment of level of care
When adding treatment components — for example, adding a DBT skills group to individual therapy, or beginning trauma processing after Stage 1 targets are adequately controlled
When a utilization reviewer requests documentation of medical necessity for continued BPD-specific treatment

Key Components

Diagnosis, Risk Assessment, and Safety Plan

Document the ICD-10 code (F60.3), specify which DSM-5 BPD criteria are met, list all comorbid diagnoses (BPD rarely presents alone — common comorbidities include MDD, PTSD, SUD, eating disorders, and other anxiety disorders), and conduct a thorough risk assessment including history of self-harm (methods, frequency, medical severity, most recent episode), history of suicide attempts (number, methods, most recent, highest intent/lethality), and current suicidal ideation. A safety plan should be completed at intake and referenced in the treatment plan. Document the level of risk and the rationale for outpatient treatment versus a higher level of care.

Treatment Goals Organized by Target Hierarchy

BPD treatment plans should follow the DBT target hierarchy:

Life-threatening behavior reduction — Decrease suicidal ideation, suicide attempts, non-suicidal self-injury, and other life-threatening behaviors; this is always Goal 1
Therapy-interfering behavior reduction — Decrease missed sessions, late arrivals, noncompliance with treatment expectations, in-session dissociation, and any behaviors that prevent effective treatment
Quality-of-life-interfering behavior reduction — Decrease substance use, disordered eating, housing instability, relationship crises, legal problems, employment instability, and comorbid Axis I symptoms
Behavioral skill acquisition — Increase mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness skills

Evidence-Based Interventions

Dialectical Behavior Therapy (DBT) — The most extensively researched treatment for BPD; includes individual therapy, skills group, phone coaching, and therapist consultation team; targets behaviors using chain analysis and solution analysis
Mentalization-Based Treatment (MBT) — Enhances the capacity to understand behavior in terms of underlying mental states; particularly effective for attachment-related difficulties
Schema-Focused Therapy — Identifies and modifies early maladaptive schemas and schema modes through cognitive, experiential, and behavioral techniques
Transference-Focused Psychotherapy (TFP) — Psychodynamic approach that uses the therapeutic relationship to address identity diffusion and object relations

Treatment Plan: Borderline Personality Disorder

Client: Angela R. (pseudonym) Date of Plan: 03/19/2026 Target Review Date: 06/17/2026 (90 days) Diagnosis: Borderline Personality Disorder (F60.3); Major Depressive Disorder, recurrent, moderate (F33.1); Post-Traumatic Stress Disorder (F43.10) Current BSL-23 Score: 3.2 (severe, range 0-4) Current PHQ-9 Score: 19 (moderately severe) Current C-SSRS: Active suicidal ideation without plan; lifetime history of 2 suicide attempts (overdose 2022, cutting requiring sutures 2024) Safety Plan: Completed 03/05/2026, copy in chart and with client; emergency contacts identified; means restriction counseling completed (sharps and medications secured by roommate) Treatment Modality: DBT-informed individual therapy with concurrent DBT skills group Presenting Concerns: Client presents with recurrent non-suicidal self-injury (cutting forearms, 2-4 episodes per week, most recent 5 days ago), chronic suicidal ideation that intensifies during interpersonal conflict, severe emotion dysregulation (rapid mood shifts from baseline to intense despair triggered by perceived rejection, lasting 2-6 hours), unstable interpersonal relationships (4 romantic relationships in the past 18 months, each characterized by rapid idealization followed by intense conflict), chronic emptiness, identity disturbance ("I don't know who I am without a relationship"), and impulsive spending during emotional crises. Client has been fired from 3 jobs in 2 years due to interpersonal conflicts with supervisors. Client meets criteria for comorbid PTSD related to childhood emotional abuse and neglect. Client is currently taking lamotrigine 200mg and escitalopram 20mg, prescribed by psychiatrist Dr. Hernandez.

Goal 1: Reduce life-threatening behaviors including self-harm and suicidal crises.

Objective 1.1: Client will reduce non-suicidal self-injury from 2-4 episodes per week to 0 episodes per week for at least 4 consecutive weeks, as tracked on the DBT diary card, within 12 weeks.

Objective 1.2: Client will reduce intensity of suicidal ideation from a C-SSRS rating of active ideation with some intent to passive ideation or below, as assessed weekly by clinician, within 10 weeks.

Objective 1.3: Client will use at least one distress tolerance skill (ice, TIPP, paced breathing, distraction, self-soothe) before engaging in any self-harm urge, on at least 80% of occasions when urges arise, as tracked on the diary card, within 8 weeks.

Interventions for Goal 1:

Review diary card at the start of every session; any self-harm or suicidal behavior since the last session takes immediate priority on the session agenda per the DBT target hierarchy
Conduct behavioral chain analysis for every self-harm episode — identify the prompting event, vulnerability factors, the full chain of thoughts, emotions, and behaviors leading to self-harm, and the consequences that reinforce the behavior
Conduct solution analysis following each chain analysis — identify points in the chain where a different response could have changed the outcome, and generate specific skills to practice at each point
Teach and rehearse crisis survival skills from the DBT distress tolerance module: TIPP (Temperature, Intense exercise, Paced breathing, Paired muscle relaxation), ice to face/hands, distraction with ACCEPTS, self-soothe with five senses
Provide between-session phone coaching for skill generalization — client may call for coaching when experiencing urges to self-harm but before acting on them, per the 24-hour rule (no coaching calls for 24 hours after self-harm occurs)
Review and update safety plan monthly or after any suicidal crisis; ensure means restriction is maintained

Goal 2: Reduce therapy-interfering behaviors and strengthen treatment engagement.

Objective 2.1: Client will attend at least 90% of scheduled individual therapy sessions (miss no more than 1 session per month), tracked via attendance log, throughout the 90-day treatment plan period.

Objective 2.2: Client will complete the DBT diary card daily and bring it to each session on at least 80% of sessions, tracked via clinician review, within 6 weeks.

Objective 2.3: Client will reduce in-session dissociative episodes from approximately 2 per session to 0-1 per session, using grounding skills to return to the present within 2 minutes of dissociation onset, as observed and documented by clinician, within 10 weeks.

Interventions for Goal 2:

Establish clear treatment expectations in a written therapy agreement covering attendance, diary card completion, phone coaching protocols, and the four-missed-sessions rule
Address missed sessions, late cancellations, and diary card non-completion directly in session using a non-judgmental, problem-solving approach — identify the barrier and generate solutions rather than interpreting the behavior as resistance
Teach grounding skills for dissociation management: 5-4-3-2-1 sensory awareness, strong sensory stimuli (peppermint oil, cold water), orienting to the room, and verbal grounding ("I am in my therapist's office, it is March 2026, I am safe")
Monitor therapist-side therapy-interfering behaviors in consultation team — therapist burnout, unwarranted limit-setting, avoiding discussing self-harm, or treating the client as fragile
Validate the difficulty of treatment engagement while reinforcing the functional relationship between attendance, skill acquisition, and progress on life goals

Goal 3: Improve emotion regulation and reduce crisis-driven impulsive behaviors.

Objective 3.1: Client will reduce the frequency of emotional crises (defined as episodes of intense distress lasting more than 2 hours that result in impulsive behavior such as self-harm, impulsive spending, or aggressive confrontation) from 4-5 per week to 1 or fewer per week, as tracked on the diary card, within 12 weeks.

Objective 3.2: Client will reduce Difficulties in Emotion Regulation Scale (DERS) total score from 142 (clinically elevated) to 100 or below within 16 weeks, as assessed at intake and every 8 weeks.

Objective 3.3: Client will independently use at least one emotion regulation skill (opposite action, check the facts, ABC PLEASE, or building mastery) on at least 5 of 7 days per week, as tracked on the diary card, within 10 weeks.

Interventions for Goal 3:

Teach the DBT emotion regulation module: identifying and labeling emotions, understanding the function of emotions, reducing vulnerability to emotion mind (ABC PLEASE skills — accumulating positive experiences, building mastery, coping ahead, treating physical illness, balanced eating, avoiding mood-altering substances, balanced sleep, exercise), and changing unwanted emotions through opposite action and problem-solving
Implement "check the facts" skill for situations where perceived rejection triggers crisis responses — examine whether the intensity of the emotional response fits the actual facts of the situation
Teach opposite action for unjustified emotions — when the emotion does not fit the facts or acting on it is not effective, act opposite to the action urge all the way (e.g., approach rather than withdraw when the urge to isolate is unjustified)
Address impulsive spending through impulse control strategies: 24-hour purchase rule, removing saved credit card information from devices, and chain analysis of spending episodes to identify emotional triggers
Coordinate with psychiatrist Dr. Hernandez regarding medication optimization for mood instability — lamotrigine dosage adjustment if emotion dysregulation remains severe despite consistent skill use

Goal 4: Improve interpersonal functioning and reduce relationship instability.

Objective 4.1: Client will maintain current employment for the full 90-day treatment plan period without interpersonal conflicts resulting in disciplinary action, as verified by client self-report.

Objective 4.2: Client will use DEAR MAN, GIVE, or FAST interpersonal effectiveness skills in at least 2 interpersonal situations per week, as tracked on the diary card, within 8 weeks.

Objective 4.3: Client will reduce the frequency of relationship-ending ultimatums or threats from approximately 3 per month to 0 per month, as self-reported and tracked in session, within 12 weeks.

Interventions for Goal 4:

Teach the DBT interpersonal effectiveness module: DEAR MAN (Describe, Express, Assert, Reinforce, stay Mindful, Appear confident, Negotiate) for objective effectiveness, GIVE (Gentle, Interested, Validate, Easy manner) for relationship effectiveness, and FAST (Fair, no Apologies, Stick to values, Truthful) for self-respect effectiveness
Role-play interpersonal scenarios in session — practice assertive communication with supervisor, expressing needs in romantic relationships without threats, and tolerating the discomfort of unresolved conflict
Use chain analysis to examine interpersonal crises — identify the prompting event, the interpretations and emotions that escalated the situation, and the point at which a different skill could have changed the outcome
Address idealization-devaluation patterns through psychoeducation about the splitting mechanism, mindfulness of judgments, and dialectical thinking (both/and rather than either/or)
Explore the relationship between abandonment fear and interpersonal behavior — how frantic efforts to prevent perceived abandonment (threats, ultimatums, clinging) paradoxically increase the likelihood of relationship rupture

Session Frequency: Weekly individual therapy (CPT 90837, 53+ minutes); weekly DBT skills group (CPT 90853, 120 minutes); phone coaching between sessions as needed; monthly psychiatry Modality: Dialectical Behavior Therapy (DBT-informed individual with comprehensive skills group) Estimated Duration of Treatment: 12 months (Stage 1); current plan covers first 90-day period

This is a sample for educational purposes only — not real patient data.

How to Write It Step by Step

Step 1: Conduct a comprehensive BPD-specific assessment with thorough risk evaluation. BPD assessment must go beyond confirming diagnostic criteria. You need a detailed self-harm history (age of onset, methods, frequency, medical severity, function — is it affect regulation, self-punishment, communication, or dissociation management?), a complete suicide attempt history (number, methods, circumstances, intent, medical lethality), a substance use screen, an eating disorder screen, and a trauma history. This information directly shapes your treatment targets. A client whose self-harm is primarily dissociation-driven requires different interventions than a client whose self-harm is primarily affect regulation-driven, even though both may cut with similar frequency.

Step 2: Organize goals according to the DBT target hierarchy. Regardless of whether you are doing comprehensive DBT, the target hierarchy provides the most clinically sound framework for prioritizing BPD treatment targets. Life-threatening behaviors always come first. If a client is self-harming three times a week, you do not write Goal 1 about improving interpersonal effectiveness. The hierarchy prevents the common clinical error of working on "easier" targets while avoiding the high-risk behaviors that could kill the client. Document your rationale for the goal sequence in the treatment plan.

Step 3: Make self-harm and suicide goals specific and measurable. "Client will reduce self-harm" is insufficient. Specify: the current frequency (episodes per week), the target frequency (zero for a specified continuous period), the measurement method (diary card, session report), and the skills that will replace the self-harm behavior. Include the specific distress tolerance and emotion regulation skills you will teach and the protocol for responding to self-harm when it occurs (chain analysis, solution analysis, skill rehearsal).

Step 4: Include therapy-interfering behaviors as a formal goal. BPD treatment is frequently disrupted by missed sessions, crisis calls that serve an avoidance function, noncompliance with homework, dissociation during session, or hostile behavior toward the therapist. These are not reasons to terminate treatment — they are treatment targets. Including them as a formal goal normalizes them as part of the disorder and establishes a collaborative framework for addressing them. Specify attendance expectations, diary card compliance targets, and how therapy-interfering behaviors will be addressed in session.

Step 5: Write emotion regulation goals with observable behavioral anchors. "Improve emotion regulation" is a concept, not a goal. Observable behavioral anchors include: frequency of emotional crises, duration of emotional episodes, use of specific DBT skills during distress, impulsive behaviors driven by emotions (spending, substance use, aggressive outbursts), and validated questionnaire scores (DERS, BSL-23). Your treatment plan should specify which of these indicators you will track and what constitutes clinically meaningful change.

Step 6: Plan for the long arc of treatment. BPD treatment is not a 12-session intervention. Standard DBT is a 12-month commitment, and many clients benefit from additional treatment beyond Stage 1. Write your 90-day treatment plan with the understanding that it will be renewed multiple times. Each renewal should show incremental progress — if self-harm has decreased from 4 episodes weekly to 1, that is clinically significant even if the client has not yet achieved zero. Document progress in terms of trajectory, not just whether the ultimate goal was met.

Common Mistakes

Discharging clients for the behaviors you are supposed to be treating. Terminating treatment when a client self-harms, makes a suicide attempt, or has an emotional crisis in session is clinically indefensible for a disorder whose defining features include self-harm, suicidal behavior, and emotional dysregulation. The treatment plan should specify escalation protocols (step up to IOP, PHP, or inpatient stabilization) rather than discharge criteria based on symptom expression. The only behavioral grounds for discharge in standard DBT is missing four consecutive scheduled sessions.

Writing treatment plans that avoid addressing self-harm directly. Some clinicians, uncomfortable with self-harm, write treatment plans that focus on "improving self-esteem" or "processing trauma" while avoiding specific goals targeting the self-harm behavior itself. This is clinically dangerous. Self-harm must appear as a treatment target with specific frequency data, reduction goals, replacement behaviors, and a chain analysis protocol. Avoiding the topic in the treatment plan mirrors the avoidance that many clinicians feel in session — both must be addressed.

Using only crisis management without skill building. A BPD treatment plan that consists entirely of "supportive therapy" and "crisis management" is not evidence-based treatment. While crisis management is necessary when crises occur, the treatment plan must include systematic skill acquisition in mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Without skill building, the clinician is managing an endless series of crises without equipping the client to manage them independently.

Neglecting the therapeutic relationship as a treatment tool. The treatment relationship in BPD treatment is not just the context for intervention — it is itself a primary intervention. The client's patterns of idealization, devaluation, abandonment fear, and interpersonal mistrust will manifest in the therapeutic relationship, and addressing these patterns in real time is central to treatment. A treatment plan that does not acknowledge therapy-interfering behaviors and the therapeutic relationship as a domain of work is missing a core element.

Pathologizing all emotion as dysregulation. Not every intense emotion in a client with BPD is dysregulated. Many BPD clients have trauma histories that make intense emotional responses entirely warranted. The treatment plan should specify the distinction: the target is not eliminating emotional intensity but developing the capacity to experience emotions without impulsive action, dissociation, or self-harm. Goals should reference skillful response to emotions, not emotional flatness.

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