Your Questions

A Diagnosis of BPD: What Does That Mean?
The DSM Five is the Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition. It “rules” that the BPD diagnosis is given to people who meet five or more of the following nine criteria (or symptoms) – although let’s be clear: that label does not need to be given for there to be much pain and dysfunction; in fact, frequently the diagnosis given is inaccurate; and life can be quite hard for anyone who has just two or three of these symptoms.

We have re-organized the symptoms in two categories: those that might be at the source of intense emotions, and those that are the outcomes of such strong feelings; although of course there is overlap.

Symptoms That Cause Strong Emotions

  • Frantic efforts to avoid real or imagined abandonment
  • Identity disturbance: markedly and persistently unstable self-image or sense of self
  • Chronic feelings of emptiness
  • Affective instability due to a marked reactivity of mood

Symptoms That Are The Result Of Strong Emotions

  • Pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
  • Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, substance abuse, reckless driving, binge eating)
  • Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior
  • Inappropriate, intense anger or difficulty controlling anger
  • Transient, stress, related paranoid ideation or severe dissociative symptoms
What Does BPD Look Like In Families?
Family life holds many challenging moments, whether in keeping a healthy connection with other family members. building a marriage, raising children.

When a member of the family is extremely sensitive, appears to over-react frequently in anger or sadness, engages in impulsive behaviors or substance use, family life can become overwhelming – putting the health and integrity of the whole family on the line.


What Does BPD Look Like To Others?
I described people who suffer with symptoms of BPD in a congressional briefing in Washington a few years ago, as individuals who might be “really cool and talented and full of promise, … and yet out there , … cutting or burning or using way too much or on their own; someone whose reactions are quite intense, who loves you one day and hates you the next, or is really hard to read; someone who changes their mind a lot and makes life decisions that make little sense to you…”

People who suffer from BPD or severe, chronic emotional dysregulation are often described as so sensitive, very kind and empathetic in moments; but hard to understand, with extremely unexpected reactions at times, and a great deal of intensity in those reactions. Sometimes very down, depressed and sometimes very activated, their sadness or their anger is rarely moderate. They are often very adept at finding short term solutions to the difficult situations they might find themselves in, but they seem to live chaotic lives where another difficulty arises as soon as one is resolved.

Is There Hope?
People with BPD often have unstable interpersonal relationships, self-image and emotions. They are also often very impulsive. They live in a great deal of pain. And their families do too. Life with someone who has this illness is shown to be among the most difficult in terms of stress, burden and grief.

There are treatments and courses of action for this illness, and while it can in fact be lethal, the rates of recovery are high.

What Is Dialectical Behavior Therapy?

The effectiveness of Dialectical Behavior Therapy (DBT) among people who suffer from BPD symptoms has been proven by many research studies conducted over the past two decades. It is rooted in Dialectics (the D) as well as in Behavior theory (the B), with a healthy dose of Zen influence too.

Dialectics is a method of discourse and disagreement resolution. The dialectical method consists in looking for the truth by actively searching for and examining with an open mind different, sometimes opposing viewpoints and holding that even though apparently opposed, both sides can be true.

Behaviorism explores how people’s behaviors are shaped by their environment and suggests how to reinforce positive behaviors while trying to reduce or extinguish maladaptive ones.

DBT is an effective and intensive treatment. It requires an emotional investment. Together we will be looking to change deeply held ineffective thought or behavior patterns, and this is not easy. We are truly in awe of the bravery of our clients.

DBT also requires an investment of time: in addition to individual therapy once weekly, we will ask you to participate with great regularity in a weekly 90 minutes DBT skills group and to engage in telephone coaching (more on this in the treatment overview below). Treatment often lasts 6 months to a year.

And finally DBT is an intensive treatment that requires a financial investment. We are aware of the difficulty this can represent and attempt to offer some relief from this by keeping our group cost low, as well as by offering sliding scale and different individual session costs based on clinician experience and qualifications.

What Are The Components Of DBT Treatment?
The formal DBT protocol for patients includes individual therapy as well as skills groups; rendered by clinicians who are intensively trained, who offer phone coaching and who participate in team consultation.

We also strongly encourage family therapy or education because research shows that helping families interact in more effective ways with their loved one is helpful regardless of whether their loved one is in treatment or not.

In individual therapy, patients explore their maladaptive behaviors and with their clinician’s help, look to replace them with skillful ones. They practice these skills and role play them to be sure they not simply know them but can implement them.

In skills groups, group members learn four broad types of skills to deal more effectively with their emotions. All four areas are equally important to the success of the therapy, and they include Core Mindfulness Skills, Distress Tolerance Skills,  Emotion Regulation Skills and Interpersonal Effectiveness Skills. Our patients learn a large number of competencies in each category in order to identify those trusted, go-to skills that will ease their struggles.

Through telephone coaching, patients learn to generalize the skills – to apply them in distress, dysregulated moments — when they need them the most.

Similarly, family members can effect profound change in the family and for their loved one by using just a few skillful behaviors: in family therapy they learn how to better identify and understand emotions (mindfulness), to regulate these emotions (emotion regulation) and to navigate the middle path and validate (interpersonal effectiveness).

Why Would Someone Who Has "Done DBT Skills Groups" Not Be Getting Better?
Fully learning a new set of skills requires going through four stages:

– First someone must explain the skill so the student understands it.
– Then the student must be encouraged to try it out to make sure they are doing it right, and the teacher must be attentive to any small or big mistakes.
– Next, the student must be encouraged to practice it in a variety of environments so they become fluent in it.
– Only then will that skill become a natural go-to, ready to replace prior maladaptive responses.

Although class content is the same, all DBT skills groups are not created equal. The knowledge and attentiveness of group leaders as well as their ability to generate interest, curiosity, commitment and sustained skill use is imperative. This is how our clients not only learn the skills, but practice, implement and eventually generalize them to their lives.

Do you Take Insurance?
DBT is a time intensive therapy and insurance doesn’t cover its various components adequately. We are therefore not paneled with any insurance company.

To make things financially easier, we offer skills groups at a very low monthly cost, and we also offer a variety of individual session fees based on clinician’s length of experience. We supply all our clients with “superbills”, and most have submitted these successfully to their insurance companies. And finally we offer a limited amount of openings on a sliding scale basis.

How Can I Educate Myself Further On This Topic?
See our Resources section for suggested books, links and videos.

Marie-Paule De Valdivia, Founder & Clinician Families On The Line

My experience is unique and multi-faceted. I am the relative of a family member who manages her BPD symptoms and with whom I enjoy a loving relationship.

As part of my MSW curriculum, I trained extensively in the DBT program of Yale New Haven Psychiatric Hospital. I have worked extensively with family members via phone or Skype; as well as in-person with clients who suffer from the symptoms of BPD and their families.

I have volunteered on the board of the National Education Alliance for Borderline Personality Disorder for 10 years, believing passionately in that mission and developing the Family Connections program in the US and around the world, as well as teaching it at home and overseas to hundreds of families and colleagues.

I am frequently invited to speak on the topic of families’ experience and treatment at conferences in the US and worldwide.

My Journey

When our child’s illness became evident a decade ago, we, her family, were very much overwhelmed and had no sense of where to turn. Despite the fact that they had been in intensive therapy; for about a year we floundered about, while their life which had been full of promise came to an abrupt stop, filled as it was with impulsive and dangerous behaviors. Yet no one brought up with us the diagnosis of BPD. And when they turned 18, of course no one discussed anything with us at all anymore. It is only when I discovered the description of BPD symptoms on the website of a well known psychiatric hospital, that all became clear.

Our child went into treatment. We took the NEABPD Family Connections class. Things improved vastly, both at home and for them. There were bumps in the road, but the progress was marked.

I started teaching Family Connections, I could see the profound effect on families and loved it. So I went back to school and earned an MSW. I was given the extraordinary opportunity to complete my second year practicum in the DBT program of the Yale-New Haven Psychiatric Hospital. This gave me a well-rounded view of BPD, from a parent’s as well as from a clinician’s perspective.

I have helped patients and continue to do so; I have been helping families for many years; and perhaps most importantly, our family is solid and our adult child has a kind of hope and a life journey we could not have imagined.

My DBT Experience

Founder & Therapist
Families On The Line

Assistant Clinical Professor of Social Work in Psychiatry (2015-present)
Yale University, School of Medicine
Along with supervising doctoral students in psychology, I also co-directed the Annual Yale –NEABPD conference in 2015 and 2016.

DBT Clinician
Yale-New Haven Psychiatric Intensive Outpatient Hospital
During my tenure at YNHH, I delivered group and DBT therapy to adults, adolescents and their families. During a part of that time I also co-directed the DBT program of the Yale New Haven Psychiatric Day Hospital.

Board member and (c) Family Connections Leader (2009-2018)
Executive Vice President (2017-2018)

National Education Alliance for Borderline Personalitydisorder
As part of this all-volunteer organization, I helped grow the Family Connections program from serving a few hundred families annually to serving thousands of families in over 20 countries. I facilitated classes for about 400 families; and trained class leaders internationally. I chaired the Family Connections committee on the board from its inception and for 7 years.

Julia Cardone M.ed, LMSW

Julia is a Licensed Master of Social Work who enjoys working with children, adolescents, and adults. She has extensive training in Dialectical Behavior Therapy and brings her experience in Motivational Interviewing and Cognitive Behavior Therapy to her work with individuals and families.

Prior to joining Families on the Line, Julia served as a practicum clinician within the Yale New Haven Hospital Intensive Outpatient Program, leading DBT skills groups, conducting mindfulness practices with groups, and providing therapy targeting emotional dysregulation. Julia also has experience working with children and adolescents and their families as a behavioral health clinician at Wellmore Behavioral Health in Waterbury, CT, where she engaged in both individual and family work. In addition, Julia has a strong interest in supporting those who grieve, and has received advanced training in providing Complicated Grief Treatment.

She is a Family Connections leader for the National Education Alliance for Borderline Personality Disorder and is passionate about bringing skills and support to families via NEA-BPD weekend intensive workshops and classes for family members of those with emotional dysregulation difficulties.

Julia received her undergraduate degree in Psychology from Brown University, followed by a Master’s in Counseling and Consulting Psychology from Harvard University’s Graduate School of Education. She received her Masters of Science in Social Work from Columbia University.

Alli Kalpakci, PhD

Alli has an expertise in working with individuals who experience intense emotions that often lead to problems in interpersonal relationships, risky or impulsive behaviors, self-harm and suicide, and intense self-criticism and hopelessness. She is passionate about working with individuals who have not previously found therapy helpful, and she is committed to genuinely and radically accepting her clients in order to help them experience real and measurable changes in their life.

Alli received her Ph.D. in Clinical Psychology at the University of Houston and completed pre- and post-doctoral fellowships at Yale University School of Medicine, specializing in using Dialectical Behavior Therapy (DBT) in her work with adults and adolescents with borderline personality disorder and their families. Her relevant clinical training includes intensive fellowships at Yale New Haven Hospital Intensive Outpatient DBT Program, The Menninger Clinic, The DBT Center of Houston, the Adolescent Diagnosis Assessment Prevention Treatment Center, and the West Haven VA Outpatient Addiction and Recovery Services program. Alli also has an extensive research background and is a published author in peer-reviewed journals and books on borderline personality disorder, social cognition, emotional sensitivity, and the development of personality disorders.

In addition to DBT, Alli is trained in multiple therapeutic interventions including Cognitive Behavioral Therapy, Prolonged Exposure [PE], DBT-PE, Cognitive Processing Therapy, Motivational Interviewing, CBT-SUD, and Mentalization-Based Therapy.

Hedy Kober

Hedy completed her doctoral degree in psychology at Columbia University, with a focus on cognitive and affective neuroscience. She is currently completing her respecialization in clinical psychology. Before Hedy joined Families on the Line, she trained at Yale’s Intensive Outpatient DBT program and at Shoreline Psychological Services. Hedy is also an Associate Professor of Psychiatry and Psychology at Yale, where she is the Director of the Clinical & Affective Neuroscience Lab.

Hedy’s research work focuses on the cognitive and neural mechanisms underlying emotion regulation strategies, and treatments for psychopathology more broadly (e.g., substance use disorders, eating disorders, mood disorders, and borderline personality disorder). Additional research focuses on the effects and neural mechanisms underlying mindfulness meditation and acceptance-based practices. In both areas, she has published extensively and has given national and international talks.

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