Challenge: Uncontrollability

“Bipolar disorder can feel uncontrollable,” according to Sheri L. Johnson, Ph.D., professor of psychology at the University of California-Berkeley and director of the Cal Mania (CALM) Program. Symptoms, such as mood changes, can seem to appear suddenly and without provocation. And they can diminish daily functioning and ruin relationships, said Sheri Van Dijk, MSW, a psychotherapist and author of The DBT Skills Workbook for Bipolar Disorder.

Strategies: While bipolar disorder can seem unpredictable, there are often patterns and triggers you can watch out for. And even if you can’t prevent symptoms, you can minimize and manage them.

One way to monitor changes is to keep a mood chart, Van Dijk said. Depending on which chart you use, you can record everything from your mood to the number of hours you slept, your anxiety level, medication compliance and menstrual cycle, she said. (This is a good chart, she said.) For instance, you can anticipate a potential depressive episode if you see that your mood has been progressively sinking in the last few days, Van Dijk said.

Practicing healthy habits is an effective way to lessen the hold emotions have on you. Make it a priority to get enough sleep, going to bed at the same time and waking up at the same time, Van Dijk said. Create a calm bedtime routine, avoid substances such as alcohol – which disrupts sleep – and don’t exercise in the evenings, said Johnson, also co-author of Bipolar Disorder: A Guide for the Newly Diagnosed.

Sleep deprivation can trigger mania, and “it makes you more susceptible to being controlled by your emotions, such as irritability,” Van Dijk said. On the other hand, sleeping too much can cause lethargy and also reduce your ability to manage emotions, she said.

Exercise helps to reduce depressive symptoms. Eliminating caffeine can reduce irritability and anxiety and improve sleep, Van Dijk said. She suggested cutting out caffeine for two weeks and paying attention to any changes. Some people also find that certain foods exacerbate their mood swings. You can check by cutting out specific foods from your diet, and watching the results, she said.

You also can use a variety of strategies to stave off the negative consequences from your symptoms. For instance, if impulsive spending is a problem, gain control by having a low limit on your credit cards, Johnson said. When you’re experiencing early signs of mania, have someone else hold onto your checks and cards, Johnson said. If you do overspend, return your purchases, she said. You can even ask a friend to go with you, she added.

Challenge: Medication

“There is no ‘one size fits all’ medication that helps everyone with bipolar disorder,” Johnson said. Lithium is typically the first line of treatment. But for some people the side effects are especially troublesome, she said. Finding the right medication (or combination of medications) can seem like a daunting process.

Strategies: Learn as much as you can about mood-stabilizing medications, Johnson said, including their potential side effects. “Find a doctor who will work with you to make adjustments based on your experiences with the different medications,” she said. Expect that it might take several tries to figure out the best medications for you.

Many of the side effects dissipate after the first two weeks, Johnson said. Changing the dose schedule helps to minimize side effects. For instance, if you feel groggy, your doctor might suggest taking your medication in the evening, she said.

Support groups are another valuable tool, Johnson said. (She suggested looking at the Depression and Bipolar Support Alliance website for a group.) For instance, individuals in these groups are usually familiar with compassionate doctors in the area, she said.

Challenge: Relationships

Bipolar disorder is hard on relationships. The very symptoms – swinging moods, risky behaviors – often leave loved ones feeling confused, exhausted and like they’re walking on eggshells, Van Dijk said.

She also sees loved ones have difficulty distinguishing between the illness and the person. They might invalidate the person’s feelings and either blame everything on the illness or believe the person is making conscious choices when it is the illness.

Strategies: Bipolar disorder is difficult to understand, Van Dijk said. “Different affective episodes, [such as] depression versus hypomania, result in different symptoms, and one episode of depression or hypomania can be different from the next within the same person,” she said.

So it’s incredibly important for loved ones to get educated about the illness and how it functions. Individual therapy, family therapy and support groups can help. Refer loved ones to self-help resources and biographies or memoirs of people with bipolar disorder, Johnson said.

Getting a handle on your emotions also improves relationships, she said. Working on assertiveness is key, too, she said. Individuals with bipolar disorder tend to have a tough time being assertive. Therapy is a good place to learn assertiveness skills. But if you’d like to practice on your own, Van Dijk suggested using “I statements”: “ I feel _____ when you ______.” She gave the following example: “I feel scared and hurt when you threaten to leave me.”

Challenge: Anxiety

According to Johnson, about two-thirds of people with bipolar disorder also have a diagnosable anxiety disorder.

Strategies: Johnson stressed the importance of using relaxation techniques and not using avoidance behaviors. As Van Dijk explained, “the more you avoid things because of your anxiety, the more your anxiety will actually increase, because you never allow your brain to learn that there’s nothing to be anxious about.”

Psychotherapy is tremendously helpful for managing bipolar disorder and the above challenges. If you’ve been prescribed medication, never stop taking it abruptly – this boosts the risk for relapse – and communicate regularly with your doctor.

Cyclothymia affects up to 1 percent of the population. However, at a hospital’s psychiatric department, it’s anywhere from 3 to 5 percent, according to Dr. Stephen B. Stokl, MD, Chief of Psychiatry at Southlake Regional Health Centre in Ontario.

Cyclothymia is marked by bouts of low-grade depression and hypomania, which includes elevated or irritable mood, decreased need for sleep and racing thoughts for at least four days. Adults are diagnosed after symptoms persist for two years. (Kids and teens are diagnosed after one year.) “Cyclothymia has an insidious onset that starts in late adolescence or early adulthood, and has a chronic nature,” Stokl said. It’s milder than bipolar I and bipolar II.

Most people never get treatment, according to John Preston, PsyD, professor at Alliant International University and author of three books on bipolar disorder, including Taking Charge of Bipolar Disorder. That’s because the depressions typically aren’t incapacitating, and people do feel OK for periods of time, he said. (But these periods don’t last longer than two months, which DSM-IV stipulates for the diagnosis.)

In other words, because symptoms tend to be less debilitating, people just don’t realize they have an illness, said Sheri Van Dijk, MSW, a psychotherapist and author of The DBT Skills Workbook for Bipolar Disorder. It’s usually loved ones who notice a problem, finding it hard to live with someone who has unstable moods, Preston said.

In fact, the toll on relationships can be dramatic. “Cyclothymia usually comes with a high morbidity in terms of breakdown in relationships both personal and at work,” Stokl said.

Also, if untreated, cyclothymia can get worse. “At least half of the people with cyclothymia, over a period of time, will start developing increasingly severe mood episodes,” and will be diagnosed with bipolar disorder, Preston said.

Diagnosing Cyclothymia

Diagnosing cyclothymia can be tricky. It may be misdiagnosed as bipolar NOS, bipolar II or borderline personality disorder, Van Dijk said. But individuals with bipolar II tend to struggle with more severe depression.

As Preston explained, there also are important differences between cyclothymia and borderline personality disorder. A person with borderline personality disorder may appear to be experiencing a hypomanic episode by acting upbeat and animated. But their elevated mood doesn’t last long and it always happens after becoming infatuated with someone new, he said. (Once the infatuation fades, they’re back to feeling dejected.)

The hallmark sign of hypomania is a decreased need for sleep, Preston said. People with hypomania only sleep for four or five hours. But they feel no fatigue, while those with borderline personality disorder become exhausted, he said.

Also, “People with borderline personality disorder are exquisitely sensitive to feeling rejected and abandoned,” he added.

The best way to diagnose cyclothymia – and bipolar disorders in general – is to get a comprehensive history of the person’s mood, which requires talking to both the person and a loved one who knows them very well, Preston said. Loved ones are usually better able to spot the mood changes, he said.

As Shari Y. Manning, Ph.D, writes in her excellent book Loving Someone with Borderline Personality Disorder, “People with BPD have an exquisite vulnerability to emotions.” And this susceptibility is hardwired.

For instance, Manning cites one interesting study where researchers tickled infants on their noses with a feather. Their responses ranged widely: Some infants didn’t react at all, others moved around and still others started crying and it was tough to calm them down. These babies were seen as “sensitive to emotional stimuli.”

Like other disorders, BPD also involves an environmental component. (Not everyone who’s emotionally sensitive goes on to have BPD.) Individuals with BPD aren’t just genetically vulnerable to emotions; they’ve also grown up in an “invalidating environment.” So they might’ve never learned how to regulate their emotions, or their emotions were continuously ignored or dismissed.

What It Means To Be “Emotional”

According to Manning, being emotional isn’t a lack of control; it has more to do with “three separate tendencies that cause emotional arousal in different ways.” These are:

• “Emotional Sensitivity.” Loved ones aren’t the only ones confused when someone with BPD has an emotional reaction seemingly out of nowhere. People with BPD may be unaware of the trigger, too. But they still have a strong reaction. “Emotional sensitivity wires people to react to cues and to react to their reactions.” Manning explains that: “To understand emotional sensitivity, think of the person with BPD as being ‘raw.’ His emotional nerve endings are exposed, and so he is acutely affected by anything emotional.”
• “Emotional Reactivity.” A person with BPD not only reacts with extreme emotion (“what would be sadness in most becomes overwhelming despair. What would be anger becomes rage”), but their behavior also is intense and doesn’t fit the situation. They might sleep for days, scream in public or self-harm. Manning points out that emotional reactivity isn’t self-indulgent or manipulative, which is an unfortunate myth attached to BPD. Instead, research has suggested that people with BPD have a higher emotional baseline. If most people’s emotional baseline is 20 on a 0 to 100 scale, then people with BPD are continuously at 80. What can intensify their reactions are the secondary emotions of shame and guilt because they know “their emotions are out of control,” Manning writes. Let’s say your loved one is angry. “On top of the original anger, these secondary emotions feel intolerable, and their fear of all this emotion, ironically, tends to fire off another series of emotions—perhaps anger that is now shifted to you, for ‘not helping’ your loved one or for some unexpressed reason.”
• “Slow Return to Baseline.” People with BPD also have a hard time calming down and stay upset longer than others without the disorder. And there’s interesting evidence to back this up. “In a person with average emotional intensity, an emotion fires in the brain for around 12 seconds. There is evidence that in people with BPD emotions fire for 20 percent longer.”

An Exercise in Understanding

In Loving Someone with Borderline Personality Disorder, Manning also helps readers better understand what it’s like to be emotionally vulnerable. She suggests thinking about an extended period of time when you were very emotional.

For Manning her emotional explosion happened when the company she’d worked for was going bankrupt. Not only was everyone upset and Manning barely sleeping but then her friend passed away. “At that point I felt like every emotion that I had was at the surface of my skin. I physically felt like I would explode with emotion if one more thing happened.” She notes that she was “an emotional sponge.” She didn’t even want sympathy because she felt like this would put her over the edge.

When thinking about your own highly emotional experience, Manning writes:

…Remember what it felt like emotionally and physically. Remember how it felt like emotions were just building on each other. Remember the experience of no one understanding how bad the situation was and how emotional you were. Now tell yourself that this is the experience of your loved one every moment of every day.

How Loved Ones Can Help

Manning shared her insight on how family and friends can help in a two-part interview on Psych Central (Part 1 and Part 2). And loved ones can do a lot, especially when it comes to helping the person when they’re upset.

In her book, Manning provides readers with step-by-step strategies and detailed examples. Below is a brief list of suggestions from her book:

1. Assess: ask what has happened.
2. Listen actively; don’t contradict, judge, or say your loved one is overreacting.
3. Validate: find something in what happened that makes sense and is understandable, that you can relate to; say what that is.
4. Ask if you can help, not to solve the problem but to get through the moment.
5. If your loved one says no, give him or her space and remember the emotions of emotionally vulnerable people last longer.

Also, it’s important to remember that people with BPD do get better and simply need to learn the skills of managing their emotions. While this requires hard work and effort, treatments such as dialectical behavior therapy (DBT) have been shown to be highly effective. You can learn more about DBT here and here.

“You go from one extreme to the other, from trying to make sure nothing upsets the person you love to trying to get away from the person at all costs. You may feel like you’re caught in a riptide, unsure when the behaviors that upset you are going to stop and where you’re going to be dropped off at the end.”

However, you can take steps to become “unlost,” as Manning puts it, and improve your relationship.

In Part 2 of our interview, Manning reveals how to help defuse your loved one’s intense emotions, how to handle a crisis, what to do if your loved one refuses treatment and much more. (You can read Part 1 here.)

Manning also is Chief Executive Officer of the Treatment Implementation Collaborative, LLC, which offers consultations, training and supervision in Dialectical Behavior Therapy (DBT).

Q: You suggest using a technique called validation to help defuse a loved one’s intense emotions. What is validation, and how is it different from simply agreeing with what someone says?

Validation is a way of acknowledging some small piece of what the person says as understandable, sensible, “valid.” An important piece of validation that people miss is that we don’t validate the invalid. For example, if your loved one is 5’7,” weighs 80 pounds and says “I’m fat,” you wouldn’t validate that by saying, “Yes, you are fat.” That would be validating the invalid.

You can validate some part of what she is saying by saying “I know you feel fat (or bloated, or full)”, whatever is appropriate to the context of what she is saying. Try to find some small kernel of validity. Remember that tone and manner can be invalidating when words are validating. “I know you FEEL fat” can be invalidating because it communicates that the feeling is wrong.

Q: In your book, you talk about an emotional whirlpool where a person with BPD is triggered by some event that’s unpleasant or scary for them. Then they struggle with a torrent of emotions, which can lead to impulsive behavior. Loved ones can feel especially helpless in these moments. What can loved ones do?

The first thing that loved ones should do is regulate their own emotions. It is so difficult to watch someone you love who is in agony and behaviorally out of control. Loved ones can become fearful, angry, judgmental, guilty, a whole gamut of emotions and thoughts. When family members regulate their own emotions, they are better able to think about how to help their loved one.

Q: What’s the difference between self-harm and suicidal behavior?

Suicidal behavior is behavior with the intention of being dead. Many people with BPD engage in behaviors that inflict physical harm that aren’t about killing themselves. Self-harm behaviors often function to bring down (relieve) painful, extreme emotions. People with BPD can have suicidal behaviors only, self-harm behaviors only or a combination of both.

Q: What should you do if your loved one is suicidal?

There are many reasons for suicidal behavior. Studies have shown that some people feel emotional relief by picturing themselves dying. Thinking, talking, planning suicide may work to relieve emotions, at least for a little while. Some people are planful about how they will kill themselves and meet all of the warning signs that are on suicide prevention websites.

However, about 30 percent of suicide attempts are impulsive, meaning that the person thought about it for just a few minutes. One problem is that people with BPD often fall into the impulsive suicide attempts. So, it is important to remember that if your loved one says that she is going to commit suicide, you have to take it seriously.

That being said, our responses to suicidal behavior can reinforce the behavior. If every time your loved one gets suicidal, you go get her, bring her to your house, feed her and tuck her into bed, you could be inadvertently reinforcing her behavior, especially if you don’t do the same thing when she is doing well.

Figuring out the reinforcers for suicidal behavior is complicated work and the consequences for being wrong can be catastrophic. If you think you are reinforcing suicidal behavior, go talk to a behavioral or cognitive behavioral therapist. Create an alternative plan with your loved one that reinforces non-suicidal behavior. If your loved one is suicidal in the moment, here are a few steps to take with him:

• It may sound strange, but the first thing to do is to tell him not to kill himself.
• Focus on tolerating the moment. Don’t drag up old issues.
• Ask what emotions your loved one is having.
• Validate his emotions and his experience.
• Ask how you can help (if you are willing to help).
• Communicate your faith in your loved one’s ability to get through the crisis.
• If you are ever in doubt, call a professional.

Q: BPD is highly treatable. But what can family or friends do if their loved one refuses to get treatment or there’s no professional in their area who treats people with BPD?

Access to effective treatment for BPD remains an issue. Twenty years ago, clinicians considered BPD untreatable and it takes time to change perception, even when we have data that say that there are effective treatments. If there is no treatment available, start a grassroots campaign with the local community mental health center, NAMI (National Alliance for the Mentally Ill) Chapter or other advocacy groups. I have encouraged people to find a cognitive-behavioral therapist in their area if there is no one who specializes in treating BPD.

If your loved one refuses to get treatment, the key is to support her and take care of yourself. Make sure you are regulating your emotions and communicating limits about what behaviors you can tolerate and which you can’t tolerate. Be supportive when possible but try not to reinforce out of control behaviors. Validate, validate, validate while encouraging your loved one to get treatment.

Often people with BPD have had negative experiences in therapy. They have been fired by therapists, gotten worse, thought they were getting worse or were left with thoughts that they cannot be helped. Have honest, nonjudgmental conversations with your loved one about her reasons for refusing treatment and problemsolve if possible.

Remember that changing behavior is often like water over rocks: gently, consistently and in a validating way, continue to encourage her to go to therapy while communicating your belief in your loved one’s ability to have a life worth living.

Finally, find help for yourself. Many Dialectical Behavior Therapy programs have Friends and Family groups. Join a support program for family members of people with BPD. NEA-BPD and TARA and the Treatment Implementation Collaborative and others have distance programs for family members that provide support while teaching family members about BPD and how to help their loved one and themselves.

Q: Anything else you’d like readers to know about BPD and what loved ones can do to help themselves and the person with BPD?

At the end of the day, compassion is effective. If you are compassionate, you will try to help your loved one without judging or condemning him. If you are compassionate, you will care for your own physical and emotional health.

When in doubt about what to do, I always ask myself what the most humane response is that I can have. Then, I do it.

(You can also read Part 1 of How to Help a Loved One with Borderline Personality Disorder.)

Fortunately, there are specific strategies you can use to support your loved one, improve your relationship and feel better yourself.

In Part 1 of our interview, Shari Manning, Ph.D, a licensed professional counselor in private practice who specializes in treating BPD, shares these effective strategies and helps readers gain a deeper understanding of the disorder.

Specifically, she reveals the many myths and facts behind BPD, how the disorder manifests and what mistakes loved ones make when trying to help.

Manning also is Chief Executive Officer of the Treatment Implementation Collaborative, LLC, and author of the recently published book Loving Someone with Borderline Personality Disorder. (It’s a must-read!)

Q: What are the most common myths about borderline personality disorder (BPD) and how it manifests?

• People with BPD are manipulative. We have found that it is not effective to be judgmental of clients or each other. If you think you are being manipulated, you will be defensive in your responses to the person whom you think is manipulating you. You will act to protect yourself and not out of wisdom. Besides, as we tell our clients, the problem is that people with BPD are not artful at manipulating. Really skillfully manipulative people get what they want from others without them knowing they are being manipulated. People with BPD get caught.

• People with BPD do not really want to die when they attempt suicide. Depending on the research, and the severity of the disorder 8 to 11 percent of people with BPD die by suicide. Their lives are agony and they often want to escape the pain of their lives. Sometimes they do so by trying to completely end the pain with suicide; other times, they get temporary relief with other behaviors, e.g. cutting, burning, substance abuse, binging/purging, shoplifting.
• People with BPD are stalkers (like the character from Fatal Attraction). People with BPD often don’t have interpersonal skills. Their learning history has been one of losing relationships, often because of their extreme behaviors. There have been several studies done and it appears that four to 15 percent of stalkers were diagnosed with BPD. It is important to remember that some percent of stalkers may meet criteria for BPD but stalking is not a characteristic of BPD. Very few people with BPD become stalkers.
• People with BPD just don’t want to change (or they would do so). I have never met a person with BPD who wanted to be emotionally and behaviorally out of control. If there were a magic wand that “cured” BPD, I am certain all of my clients would have me wave it at them. The problem is that change is really hard for all of us and doubly (maybe triply) hard for people who are emotionally sensitive. Think of a behavior that you wanted to change (quitting smoking, exercising, dieting). Think of all of the times you failed. Did you fail because you didn’t really want to change or because you failed?
• People with BPD are uncaring and only think of themselves. In my experience (and I don’t really have studies to back this up), people with BPD are extremely caring. They get a reputation for only thinking of themselves when they get distressed and engage in behaviors that cause harm to their relationships (overcalling, over-texting, showing up when not invited). In the heat of the crisis, people with BPD are often so physiologically/emotionally aroused, that they cannot be mindful to others. However, they feel an extreme amount of guilt and shame about the effects of their behavior on others.
• BPD develops from childhood sexual abuse. Not all people who have suffered childhood sexual abuse develop BPD and not all people with BPD suffered childhood sexual abuse. Depending on the study, 28% to 40% of people with BPD had sexual abuse in their childhood. We used to think that the incidence was higher but as the diagnostic criteria for BPD have been more effectively used, we are finding that the incidence is lower than we initially believed.
• BPD develops from poor parenting. As I said above, some people with borderline personality disorder are sexually or physically abused as children. Some people with BPD had distant or invalidating families. However, some people came from completely “normal” families. People with BPD are born with an innate, biological sensitivity to emotions, e.g. they have quick to fire, strong, reactive emotions. Children who are emotionally sensitive take special parenting. Sometimes, the parents of the person who develops BPD just aren’t as emotional and cannot teach their child how to regulate intense emotions. We tell clients that they are like swans born into a family full of ducks. The duck parents only know how to teach the swan how to be a duck.

Q: What mistakes do you see loved ones make when trying to deal with someone with BPD?

Family members often try to encourage their loved one but inadvertently invalidate them and increase their emotional arousal. For example: the person with BPD says, “I am a terrible person” after seeing hospital bills from a suicide attempt. The family member responds, “No, you’re not a bad person.” The contradiction makes the person with borderline personality disorder more distressed.

Instead, try acknowledging the feelings/thoughts behind the statement then moving into something else. Say instead, “I know that you feel badly about how you acted and that makes you think you are a bad person.”

Another error is that family members give the person with BPD more care and attention when they are in crisis and then withdraw when they are not. This may inadvertently reinforce the crisis behavior and punish non-crisis behavior.

Q: In your book, you discuss the importance of gaining a deeper understanding of how BPD manifests so loved ones know what to expect and don’t feel so lost. You also note that Dr. Marsha Linehan, the founder of dialectical-behavior therapy, classified the disorder into five areas of dysregulation. Can you briefly describe these categories?

• Emotional dysregulation — extreme emotional responses, especially with shame, sadness and anger.
• Behavioral dysregulation — impulsive behaviors like suicide, self-harm, alcohol/drugs, binging/purging, gambling, shoplifting, etc.
• Interpersonal dysregulation — relationships that are chaotic, fearfulness of losing relationships coupled with extreme behaviors to keep the relationship
• Self-dysregulation — not knowing who a person is, what their role is, being unclear on values, goals, sexuality
• Cognitive dysregulation — problems with attentional control, dissociation, sometimes even brief episodes of paranoia

Q: You say that BPD, at its core, is an emotional problem. Why are people with BPD so much more emotional than others?

Our emotional sensitivity is something that is hardwired into us. Some people are more emotional than others. People with BPD are usually among the most emotionally sensitive people. Anyone who is emotionally sensitive must have skills to regulate those intense emotions. Skills are learned not hardwired.

In Part 2 of How to Help a Loved One with Borderline Personality Disorder, Manning discusses how to help defuse your loved one’s intense emotions, how to handle a crisis, what to do if your loved one refuses treatment and much more.

Below two seasoned psychologists debunk common myths about psychotherapy and offer pointers on making the most out of therapy.

Misconceptions and Concerns About Psychotherapy

According to Ryan Howes, Ph.D, psychologist, writer and professor in Pasadena, California, “Some clients expect their therapists to give them direct advice, telling them who to date and what to study and when to break up.” It’s easy to think this way considering that TV therapists dole out advice without hesitation. “But most therapists resist giving advice because they believe it’s better for the client to learn to solve their own problems,” he says.

Clients also worry about what others will think. They wonder what’ll happen if their co-workers or friends find out they’re going to therapy. They might automatically assume others will think they’re “weak, flawed [or] crazy,” comments Chicago psychologist and life coach John Duffy, Ph.D. In reality, though, “More often than not, people tend to be very supportive,” he says. Plus, it’s up to you who you tell about your therapy, and confidentiality laws protect your privacy.

The therapy process itself can get confusing. According to Duffy, people might have questions like: “Is it brainwashing? Will it change my personality? What if focusing on my problems will make them worse, not better?”

These myths and concerns stem from various sources, including therapists themselves. Howes says: “…no two therapies/therapists are alike, the media does a lousy job of portraying realistic therapy, many people are still too ashamed to talk about it and therapists don’t always do a good job of teaching clients the best ways to get the most from their therapy.”

How to Make the Most of Therapy

1. Do your homework.

Be a discerning consumer by doing your research. Therapists “have different approaches, and come from different schools of thought,” Duffy says. For instance, you might learn the differences between treatment approaches, such as cognitive-behavioral therapy and psychodynamic therapy, he says.

2. Ask for referrals.

“It is difficult to determine on paper or via a website who will work for you,” Duffy says, “So ask around.”

3. Consider expertise.

“If you are seeking a therapist for a teenager, for instance, you probably want to avoid the therapist who focuses on couples work,” Duffy explains. Similarly, if you know your diagnosis, see someone who specializes in that disorder.

4. Be open to change and the process.

Change is hard. And it’s a pivotal part of therapy. As Duffy says, “By definition, therapy is a change process, and it will and should foster a bit of discomfort. This is not a bad thing.”

Engaging fully in therapy increases the chances of its effectiveness, he says. Think of it this way: “In order to get a different result, you’ll probably need to try a different approach,” Howes says.

So trust the process. “Some of the techniques therapists use — like the empty chair, reflective listening and thought stopping — can seem corny at first, but many people find them effective.” And keep in mind that some issues will require bigger changes than you initially thought, he adds.

5. Limit the process.

Another way to foster change is to remember that the therapeutic process doesn’t go on forever. “That is, if we think therapy has no end, we may put off the changes we want and need to make. If we know we’re working together for about 6, or 12 or even 20 weeks, that timing provides a context for us to think about and enact change,” Duffy says.

6. Make therapy part of your life.

Many people expect change to happen from an hour a week at the therapist’s office, Duffy points out. But “…in order for the process to foster real change, a great deal of the work has to take place outside of the therapy room.”

This “might range from a simple meditation to a significant change in work habits to ending a dysfunctional relationship.”

In other words, “Therapy is one of those ‘you get out of it what you put into it’ activities,” Howes says. He suggests “Keep a journal, show up to appointments on time, read books about your issue, do your homework and dive in.”

The key, Duffy says, is to hold yourself accountable for this outside work.

7. Be brutally honest.

For instance, whether you have positive or negative feelings about your therapist, don’t be afraid to bring them up, Howes says. In fact, “…this sort of discussion can provide some of the best results therapy has to offer.”

Consequently, he says, “Whether you’re talking about yourself, your past, your ‘craziest’ thoughts or the relationship with the therapist, brutal honesty is the quickest route to results.”

8. Realize that “things can get worse before they get better,” Howes says.

“After a few sessions of poking around in a person’s psyche, we’ve opened several cans of worms and it can feel overwhelming,” he says. It’s not uncommon that “…people come in to work on one problem and soon realize they have four.”

9. Talk about challenges regarding therapy.

Therapy requires resources, namely time and money, which as Howes says, “are increasingly hard to come by.” Also, some people might not have access to community resources or a good support system. Then there are also what Howes refers to as “backseat drivers,” “well-meaning loved ones who try to tell [clients] what to talk about in therapy, ask a million questions about it or even poke fun at them for being in therapy.”

Many clients don’t bring up these issues to their therapists. Instead, they might suddenly stop therapy or keep getting stressed out. Howes emphasizes the importance of talking to your therapist about these concerns, because together you can brainstorm solutions.

In general, therapy offers many benefits, whether you’re struggling with mental illness, a difficult life transition or other concerns. According to Howes, therapy is an opportunity “to try new things. It’s a place for thinkers to try feeling, busy people to practice slowing down, non-confrontational people to be assertive, people pleasers to practice thinking only about themselves, and cut-and-run people to learn the art of a healthy goodbye.”

He concludes, “It’s like taking a college course where you are the topic. Make the most of it!”

Photo by Code Pink, available under a Creative Commons attribution license.

Porr then wrote this book, which encompasses her investigation and research into the family experience of loving a member suffering from BPD.  It teaches DBT skills training and mentalization, a highly useful treatment for families who want to learn how to decrease collective stress, increase effective communication, rebuild trust, introduce better coping methods, process and debrief argument aftermaths and reduce challenging conduct that maintains BPD actions and behaviors.  The purpose of this book is to feel, deal, heal and change the family system in a holistic manner, focusing on all members rather than the individual sufferer.  It is not about blaming the “victim” and it gives much hope that transformation and reconciliation is possible.

BPD does not have many fine moments in history.  Think Glenn Close in Fatal Attraction, Winona Ryder in Girl, Interrupted, Jessica Walter in Play Misty for Me and Robert De Niro in Raging Bull to name but a few.  BPD is characterized by mood instability, efforts to avoid real or imagined abandonment, black and white thinking, idealization and devaluation of significant others, splitting into good and bad, impulsive behavior, a history of unstable relationships, a distorted and wavering sense of identity and image with chronic feelings of emptiness, a tendency toward paranoia, self-harm and suicide ideation as well as completed suicide in 10 percent of people diagnosed.  Borderline personality disorder is like emotional dyslexia because there is a disconnection between actual words spoken and interpretation of these words.  It is these conversations and behaviors that undermine relationships with family, friends and colleagues and generally make life a misery for the sufferer and their loved ones.

While there have been many clinical and technical books written by professionals for professionals about BPD, recently there has been an influx of books written specifically for family members who need specific tools and strategies to help cope with these distorted and disturbing behaviors.  A good book for a layperson about a psychiatric condition needs to be simply but elegantly written with minimal use of technical words, terms and psychobabble, resonate fully and responsibly with the reader, be helpful and hopeful and above all capture and engage the heart.  Porr’s text fulfills those criteria superbly with some very unique and creative metaphors.  The book demystifies a syndrome that is believed to affect nearly six out of 100 people, and it is both thorough and comprehensive.

Porr states, “As many as 5.9 percent of the general population meet the criteria for BPD.  Professionals do not talk much about this disorder on TV, your friends may not believe it exists; even Oprah does not discuss it.  There is no poster person for BPD rallying support [and] no telethon to help raise money.”  It goes on to say that “Many people with BPD are able to control their behavior in public situations or among strangers.  They have the ability to appear calm and competent to outsiders, to act “as if” they are “okay;” but they seem unable to maintain this behavior within intimate relationships, with partners or close family members.”  This is frustrating for family members who feel they will be disbelieved and closed down by others if they mention this discrepancy.

This is also why a family approach is needed. There is a whole chapter devoted to BPD sufferers’ siblings and how these people have been neglected by the mental health community.  The BPD sufferer absorbs so much of the family’s emotional and physical attention and concern that the siblings’ needs and achievements are overlooked.  Siblings, spouses and other members are more likely to have an empathic approach if they understand the genetic component and neurological structures involved in BPD.

The section on the science of BPD discusses how changing the brain can change the behavior.  This chapter states that “The scientific findings brought together here will help you reframe BPD as a mental disorder with real, tangible biological underpinnings rather than a “character flaw” or a matter of “bad” personality.”

DBT is considered the treatment with the most randomly controlled clinical trials showing its effectiveness.  One small quibble, I feel, is that the DBT process itself can be somewhat directive, rigid and inflexible which, ironically enough, are the very same disturbing traits one is trying to eliminate in BPD itself.  It is stated by Marsha Linehan that “If your patient isn’t better in a year, you should find another therapist for your patient.”  She also states that it is the therapy that is 100 percent effective and that it is the therapist who is failing the patient.  My thoughts are that any therapy that claims such a high success rate needs to have long term follow-up (2, 5, 10 or 20 years) to see if that success has any subsequent longevity.

The last section deals with mentalization and understanding interpersonal misunderstandings.  Mentalization Based Therapy treatment for BPD, developed in England by Anthony Bateman and Peter Fonagy, is evidence-based and a reasonably new method of treatment for BPD. Peter Fonagy is a prominent contemporary psychoanalyst and clinical psychologist and his clinical interests center on issues of borderline psychopathology, violence and early attachment relationships.  He has also written extensively on attachment theory and psychoanalysis.

If DBT focuses on controlling emotions and changing behavior, MBT focuses more on understanding the misunderstandings that occur in relationships by changing perceptions, interpersonal situations and experiences.  Mentalization is defined as making use of mental representations of one’s own and another’s emotional state.  Lack of effective parenting can leave children unable to modulate and interpret their own feelings, as well as those of others. It explores the separation and merging of the minds of two people in a significant relationship and how they perceive each other.  It focuses on awareness and acknowledgement, explores alternative interpretations and intentions from both points of view.

The chapter explains that an inability or failure to mentalize seems to be at the core of BPD.  It deals with helping the non-BPD family members with the BPD sufferer and gives much accurate and detailed explanation on how to take the high road in order to make a difference; on being supportive, empathic and compassionate, how to ask lots of questions, be a detective, to listen, observe and validate, to be humble, to take responsibility and if necessary apologize, be consistent, do not get sidetracked, be careful of the use of language, do not be dogmatic and inflexible, always label feelings, find alternative perspectives, be vulnerable, radically honest and authentic.

I found this book managed to encompass the entire family experience, offered much supportive and constructive advice, demystified effective evidenced-based therapy and gave not just hope and reassurance but concrete and anecdotal evidence that there is a cure for a personality disorder once considered untreatable.  It was riveting to read and easy to understand.  It placed familial love, compassion, respect and empathy as the secret ingredients to complete the therapeutic recipe, important ingredients which were lacking from so many previous modalities and treatments.

Overcoming Borderline Personality Disorder: A Family Guide for Healing and Change
By Valerie Porr, M.A.
Oxford University Press USA: August 2010
Paperback, 424 pages
$24.95

If you’re someone with BPD or a loved one of someone with BPD, you probably already know this. The devastation this disorder causes is immense but the misunderstanding and lack of treatment may be just as heavy. With The Buddha & The Borderline, I believe that you’ll find relief, reputable information and hope. It’s far from an easy read. But it’s real, authentic and truly valuable.

In this memoir, Van Gelder documents her diagnosis, treatment and recovery from BPD. She begins the book when she’s 30 years old, when she’s already attempted several times to take her own life, gone through a handful of hospitalizations, been diagnosed with depression, anxiety and post-traumatic stress disorder and recovered from alcohol and drug addiction. She is in the arms of yet another boyfriend, attaching herself to him in such a way that she loses herself completely. (She writes later in the book: “If Taylor were gone, it would be like pulling the plug in a basin that holds all the shapeless, turbulent liquid of my life. I would drain away.”) This is a pattern: With every boyfriend, her identity, her musical tastes, how she dresses, what she believes tend to change. Yet she doesn’t know why. After each relationship ends, she starts searching for another savior.

Van Gelder desperately wants to find out what is wrong because as she writes, “…despite being clean and sober for almost a decade, I’m still a mess.” For almost two decades, she’s been in therapy. She has tried various types of treatments, medications and 12-step programs, but yet nothing seems to be working.

When she’s finally diagnosed at a local hospital, Van Gelder witnesses firsthand the stigma, shame, myths, insurance woes and unavailability of treatment. Yet even as she’s struggling with out-of-control symptoms and suicidal urges and grappling with such a stigmatized diagnosis, Van Gelder continues fighting. Her initial motivator? Rage. She writes:

Ultimately rage, not hope, hurls me into recovery when I finally understand that it’s not simply my illness, but incompetence and avoidance from the mental health system that has created my ‘incurable and hopeless’ condition.

This book is a must-read for several reasons. One of the main reasons is that Van Gelder demystifies BPD, clearly defining the symptoms both from a scientific level and a personal one. She writes about deeply intimate slices from her life so readers receive an inside look into what it’s like to have BPD. This is very uncommon, as BPD is largely marred in mystery in our society. The public gets very little solid information about what this disorder really looks like.

Van Gelder also addresses her loved one’s denials of her diagnosis — also common. In the beginning, her mom repeatedly questions her being “mentally ill.” In a therapy session with her mother, Van Gelder says:

But why can’t you take my mental illness seriously? I feel like I’ve been set up, over and over. Like I’m a cripple without a wheelchair, and everyone keeps signing me up for marathons, then shaming me for not winning the race.

She also faces similar frustrations as she tries to share information about BPD with her grandparents:

Indeed, I discover that the less I say, the happier everyone seems to be with me. I sometimes wonder if I wouldn’t have been better off as a paraplegic or afflicted by some tragic form of cancer.

Secondly, she demystifies dialectical behavior therapy (DBT) — a treatment developed by Marsha Linehan, Ph.D., which has scores of research studies to back up its effectiveness — and informs the reader in great detail about this treatment. So while this is a memoir, it also serves as a valuable teaching tool. Loved ones and individuals with BPD will benefit from learning about their options and the nitty-gritty of DBT, which like BPD itself, many people have no clue about. Therapists and graduate students also will learn a lot.

Relying on research studies and books on DBT, Van Gelder quotes Dr. Linehan (and other experts) and describes the theories, goals and techniques of the treatment in layman’s terms throughout the book. As she gives readers the theory behind each step, she illustrates this in relation to herself and her therapy.

For instance, DBT focuses on the concept of dialectics, which on a practical level is, according to Van Gelder, “…what happens when opposites combine to create something new…On a deeper level, dialectics is a viewpoint that recognizes reality and human behavior as fundamentally relational.”

Throughout the book, Van Gelder tries to reconcile the opposing parts of herself. Can she really resist something and long for it at the same time? Can she be healthy in some ways but still lack a secure sense of self? Interestingly, the book, too, mirrors this dialectical nature. It’s painful, frustrating and potentially triggering while being uplifting, soothing and hopeful.

In the last part of the book, Van Gelder discovers Buddhism and explores how it applies to BPD and her life (dialectical behavior therapy is actually based on Buddhist philosophies). Just as she does throughout the book, in the end, she provides several profound insights.

In addition to the perceptive content, Van Gelder’s writing is beautiful and heartbreaking. Van Gelder is a gifted and eloquent writer, and readers will instantly get pulled into her story.

As mentioned briefly above, parts of the book may be triggering to some readers. Van Gelder writes poignantly and often in-depth about painful experiences, including her cutting, suicidal urges and sexual abuse. So while this level of detail may be necessary for readers to gain a better grasp of BPD’s desperation, confusion and grief, it can have a negative effect on someone who’s vulnerable.

As much as this book is about seeking the correct diagnosis and the struggles of recovery, The Buddha & The Borderline is also about Van Gelder’s journey to find herself and lead a life worth living — the ultimate goal of DBT. Even though this is a memoir, it’ll no doubt echo the stories of other sufferers and help readers better understand BPD and its treatment.

The Buddha and the Borderline: My Recovery from Borderline Personality Disorder Through Dialectical Behavioral Therapy, Buddhism and Online Dating
By Kiera van Gelder
New Harbinger Publications: August 2010
Paperback, 246 pages
$17.95

Dialectical behavior therapy (DBT) is a specific form of cognitive-behavioral therapy. DBT seeks to build upon the foundation of CBT, to help enhance its effectiveness and address specific concerns that the founder of DBT, psychologist Marsha Linehan, saw as deficits in CBT.

DBT emphasizes the psychosocial aspects of treatment — how a person interacts with others in different environments and relationships. The theory behind the approach is that some people are prone to react in a more intense and out-of-the-ordinary manner toward certain emotional situations, primarily those found in romantic, family and friend relationships. DBT was originally designed to help treat people with borderline personality disorder, but is now used to treat a wide range of concerns.

DBT theory suggests that some people’s arousal levels in certain situations can increase far more quickly than the average person’s. This leads a person to attain a much higher level of emotional stimulation than normal, and it may take a significant amount of time to return to normal emotional arousal levels.

DBT differs in practice in one important way. In addition to individual, weekly psychotherapy sessions, most DBT treatment also features a weekly group therapy component. In these group sessions, people learn skills from one of four different modules: interpersonal effectiveness, distress tolerance/reality acceptance skills, emotion regulation, and mindfulness skills. A group setting is an ideal place to learn and practice these skills, because it offers a safe and supportive environment.

Both CBT and DBT can incorporate exploring an individual’s past or history, to help an individual better understand how it may have impacted their current situation. However, discussion of one’s past is not a focus in either form of therapy, nor is it a differentiation between the two forms (it is completely dependent upon the individual psychotherapist).

Whether cognitive-behavior therapy or dialectical behavior therapy is right for you is a determination best made in conjunction with an experienced therapist. Both types of psychotherapy have strong research backing and have been proven to help a person with a wide range of mental health concerns.

Want to learn more about DBT? Follow our blog, Dialectical Behavior Therapy Understood or read our overview of dialectical behavior therapy.

What is DBT?

Dialectical behavior therapy (DBT) treatment is a cognitive-behavioral approach that emphasizes the psychosocial aspects of treatment. The theory behind the approach is that some people are prone to react in a more intense and out-of-the-ordinary manner toward certain emotional situations, primarily those found in romantic, family and friend relationships. DBT theory suggests that some people’s arousal levels in such situations can increase far more quickly than the average person’s, attain a higher level of emotional stimulation, and take a significant amount of time to return to baseline arousal levels.

People who are sometimes diagnosed with borderline personality disorder experience extreme swings in their emotions, see the world in black-and-white shades, and seem to always be jumping from one crisis to another. Because few people understand such reactions — most of all their own family and a childhood that emphasized invalidation — they don’t have any methods for coping with these sudden, intense surges of emotion. DBT is a method for teaching skills that will help in this task.

Characteristics of DBT

• Support-oriented: It helps a person identify their strengths and builds on them so that the person can feel better about him/herself and their life.
• Cognitive-based: DBT helps identify thoughts, beliefs, and assumptions that make life harder: “I have to be perfect at everything.” “If I get angry, I’m a terrible person” & helps people to learn different ways of thinking that will make life more bearable: “I don’t need to be perfect at things for people to care about me”, “Everyone gets angry, it’s a normal emotion.
• Collaborative: It requires constant attention to relationships between clients and staff. In DBT people are encouraged to work out problems in their relationships with their therapist and the therapists to do the same with them. DBT asks people to complete homework assignments, to role-play new ways of interacting with others, and to practice skills such as soothing yourself when upset. These skills, a crucial part of DBT, are taught in weekly lectures, reviewed in weekly homework groups, and referred to in nearly every group. The individual therapist helps the person to learn, apply and master the DBT skills.

Generally, dialectical behavior therapy (DBT) may be seen as having two main components:

1. Individual weekly psychotherapy sessions that emphasize problem-solving behavior for the past week’s issues and troubles that arose in the person’s life. Self-injurious and suicidal behaviors take first priority, followed by behaviors that may interfere with the therapy process. Quality of life issues and working toward improving life in general may also be discussed. Individual sessions in DBT also focus on decreasing and dealing with post-traumatic stress responses (from previous trauma in the person’s life) and helping enhance their own self-respect and self-image.

Both between and during sessions, the therapist actively teaches and reinforces adaptive behaviors, especially as they occur within the therapeutic relationship. . . The emphasis is on teaching patients how to manage emotional trauma rather than reducing or taking them out of crises. . . . Telephone contact with the individual therapist between sessions is part of DBT procedures.
(Linehan, 1993)

During individual therapy sessions, the therapist and client work toward learning and improving many basic social skills.

2. Weekly group therapy sessions, generally 2 1/2 hours a session and led by a trained DBT therapist, where people learn skills from one of four different modules: interpersonal effectiveness, distress tolerance/reality acceptance skills, emotion regulation, and mindfulness skills are taught.