What I Wish Insurance Companies Understood About DBT and Borderline Personality Disorder
If you work in (or use…) healthcare, insurance is probably the bane of your existence. If you work in mental healthcare, this is certainly true. But, after two years of billing insurance for comprehensive Dialectical Behavior Therapy (DBT) at two different levels of care (outpatient and intensive day program), it’s so clear to me that insurance particularly does not understand our clients or our treatment. So, here’s my wishlist of what I desperately want insurance companies to understand about DBT and borderline personality disorder (BPD).
1. Borderline personality disorder is absolutely treatable.
Let’s start here, because somehow, in 2026, we are still acting as if borderline personality disorder (BPD) is an untreatable condition, which can’t be listed as a primary diagnosis.
This is wildly outdated (and frankly, offensive).
There are multiple evidence-based treatments for BPD, including DBT, mentalization-based treatment, transference-focused psychotherapy, and schema therapy. Current American Psychiatric Association guidelines explicitly recommend structured psychotherapy that targets the core features of BPD. (American Psychiatric Association, 2024; Storebo et al., 2020).
BPD does not need another diagnosis to make it worthy of treatment. It’s like if insurance companies said you couldn’t list cancer as a primary treatment because previously there wasn’t an effective treatment for cancer. Now there are numerous effective treatments for cancer. Would you ask us to pretend that we’re treating something else (say, the flu) while delivering the evidence-based treatment for cancer?
Besides the obvious barrier to evidence based treatment, the refusal to provide coverage for BPD directly perpetuates BPD stigma and beliefs about it being “untreatable.”
2. BPD is not inevitably chronic and the term “personality disorder” is wildly misleading, judgmental, and outdated
The old idea of BPD as a lifelong, unremitting condition is simply inaccurate.
In one major 10-year prospective study, 85% of people with BPD experienced diagnostic remission. Even more strikingly, only 11% relapsed after remission—a relapse rate significantly lower than that seen among patients with major depressive disorder in the same study. People with BPD did take longer to remit than people with depression, and functional impairment often persisted even after symptoms improved, so this is not to say that recovery is simple or easy. But BPD is emphatically not an inevitably chronic condition. (Gunderson et al., 2011).
This of course relates directly to the treatability issue.
3. Saying you “do DBT” does not necessarily mean you are providing DBT.
I’m really not saying this to be picky or elitist about treatment fidelity.
Personally, I care enormously about making DBT more accessible. In many circumstances, I would rather have a treatment delivered with moderate fidelity and available to lots of people than insist on perfect fidelity and make it available only to a tiny number.
But there is a critically important distinction between using DBT skills or DBT-informed treatment and providing comprehensive, adherent DBT. The primary issue is truth in advertising. Because DBT is not just a collection of coping skills.
DBT is a full, highly relational, treatment model and a theoretical orientation. It includes individual DBT therapy, DBT skills training, between-session phone coaching, and a therapist consultation team. Those pieces are not incidental. They are crucial to treatment success (Linehan et al., 2015).
And when we are talking about clients with severe emotion dysregulation, chronic suicidality, self-harm, and multiple interacting problems, that distinction really matters.
There are so many insurance companies out there that genuinely believe they are checking the box of providing access to "DBT,“ when what is available actually bears little to no resemblance to the high fidelity, evidence-based intervention.
A secondary result is that so many clients and families think they have had DBT when they've actually had nothing of the sort. These clients often walk away with the idea that DBT isn't for them. When these families come to our program and get comprehensive DBT, they reflect to us how much they didn't understand what DBT actually was and what a disservice that was to them and their treatment trajectories.
Incorporating DBT skills into other treatments is often a reasonable, helpful thing to do.
I just wish everyone – and especially insurance companies – would stop calling that DBT. This is particularly important when an insurer says, we have someone in network who does DBT, and that provider isn’t actually providing anything beyond a handful of the skills.
4. Comprehensive DBT requires more than an introductory training.
This is closely related to the previous point. Again, this is not about gatekeeping who gets to use DBT.
But comprehensive DBT is a complicated treatment for complex, multi-problem presentations. It takes a tremendous amount of training, supervision, and ongoing consultation to deliver the model well and with high fidelity. Foundational training is an excellent beginning. It is not the end (Harned et al., 2022).
5. DBT was specifically developed to treat serious suicidality and self-harm.
This is probably the piece that baffles me most when it comes to insurance reviews.
DBT was originally developed specifically for people with severe, chronic suicidal behavior and BPD. Reducing life-threatening behavior is the top treatment target in standard DBT.
And the evidence is not limited to suicidal ideation. Randomized trials have specifically studied people with histories of suicide attempts and nonsuicidal self-injury and demonstrated reductions in suicidal and self-harming behaviors. DBT is associated with fewer suicide attempts, fewer psychiatric hospitalizations, and lower treatment dropout than treatment delivered by expert community therapists. (Linehan et al., 2006).
So it is genuinely strange to encounter the argument that someone is somehow too suicidal for DBT or that another, non-evidence based treatment is available in network and is expected to be sufficient for a client with suicidality.
DBT is the evidence-based treatment of choice for suicidality and self-harm.
6. DBT keeps people out of higher levels of care.
One of the things DBT does especially well is to help people stay safe at lower levels of care and stay out higher levels of care when that’s not what they need (De cous et al., 2019; Linehan et al., 2006). This enables people to keep working towards their goals, build skills in their real lives, and prevent the hopelessness and isolation that can come from repeated hospitalizations. Repeated psychiatric emergency-service use can have negative effects for some clients with BPD (Coyle et al., 2018).
None of this means that hospitalization is never appropriate. It’s often essential. It means that risk level and level of care are not interchangeable concepts.
A client can be at significant chronic risk and still be appropriately treated in a well-designed DBT program capable of assessing, monitoring, and responding to that risk. And, while DBT might be somewhat more expensive than other treatments at the same level of care, it’s generally cheaper than a higher level of care – and a better investment in the long-term.
7. Another treatment at the same “level of care” is not necessarily an equivalent alternative.
This comes up constantly in insurance decisions.
An insurer may say: We have an outpatient therapist in network. Or, There is another partial hospitalization program available.
But that is not necessarily an apples-to-apples comparison.
For many clients seeking comprehensive DBT—especially intensive DBT—the alternative is not:
Comprehensive DBT vs. another basically equivalent treatment.
Often the real comparison is:
Comprehensive DBT vs. needing a higher level of care.
Comprehensive DBT costs more to provide than a once-weekly individual therapy session because it contains more treatment. There are multiple modes, multiple clinicians, 24/7 clinician support via skills coaching, and an entire consultation structure supporting the providers. And still, it generally costs less than a higher level of care or repeated acute care use, which are the real alternatives.
TLDR; What I wish insurers understood
I understand why insurance companies need need to evaluate medical necessity, level of care, and whether less expensive alternatives exist.
But those decisions only make sense when the criteria are being applied to an accurate understanding of the treatment and the population.
Clients with BPD do get better.
DBT is an evidence-based treatment specifically designed for people with severe emotion dysregulation, multiple problems, suicidality, and self-harm.
Comprehensive DBT is not synonymous with learning DBT skills.
And treating high-risk clients effectively does not always mean moving them to the most restrictive setting available.
References
American Psychiatric Association. (2024). The American Psychiatric Association Practice Guideline for the Treatment of Patients With Borderline Personality Disorder. American Journal of Psychiatry, 181(11).
Coyle, T.N., Shaver, J.A., & Linehan, M.M. (2018). On the potential for iatrogenic effects of psychiatric crisis services: The example of dialectical behavior therapy for adult women with borderline personality disorder. Journal of Consulting and Clinical Psychology, 86(2), 116-124.
De Cou, C.R., Comtois, K.A., & Landes, S.J. (2019). Dialectical behavior therapy is effective for the treatment of suicidal behavior: A meta-analysis. Behavior Therapy, 50(1), 60-72.
Gunderson, J. G., Stout, R. L., McGlashan, T. H., et al. (2011). Ten-year course of borderline personality disorder: Psychopathology and function from the Collaborative Longitudinal Personality Disorders Study. Archives of General Psychiatry, 68(8), 827–837.
Harned, M.S., Gallop, R.J., Schmidt, S.C., & Korslund, K.E. (2022). The temporal relationships between therapist adherence and patient outcomes in dialectical behavior therapy. Journal of Consulting and Clinical Psychology, 90(3), 272–281.
Linehan, M. M., Comtois, K. A., Murray, A. M., et al. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757–766.
Linehan, M. M., Korslund, K. E., Harned, M. S., et al. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: A randomized clinical trial and component analysis. JAMA Psychiatry, 72(5), 475–482.
Storebo, O. J., Stoffers-Winterling, J. M., Völlm, B. A., et al. (2020). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews.