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.