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People with the same BPD diagnosis can have symptoms driven by different processes.

Current evidence-based BPD treatments target different mechanisms of change.

Matching treatment to the person may improve outcomes and shorten recovery.

A few years ago, I took on two new clients within a few weeks of each other. I remember being struck by how similar they were. Both were diagnosed with borderline personality disorder (BPD) and both struggled with alcohol use and over-spending.

But as we started talking about what happened in the moments before they used, it became clear they weren't actually struggling with the same problem at all.

One patient reached for alcohol or her credit card whenever her negative emotions became overwhelming. Drinking and shopping offered temporary relief from shame, sadness, and anxiety. My other patient described these behaviors as something that happened automatically whenever the opportunity presented itself. Instead of numbing emotional pain, she was saying yes to whatever felt exciting in the moment.

Seeing these patients side-by-side changed the way I think about treating BPD. If two people can arrive at the diagnosis—and even the same symptoms (risky substance use and reckless spending)—through different psychological pathways, why would we assume they need exactly the same intervention?

One Diagnosis, Many Pathways

One of the biggest misconceptions about mental health conditions is that all people with the same disorder........

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