What We Treat
BPD is characterized by emotion dysregulation, meaning that emotion episodes are frequent, intense, and long-lasting because the person is highly emotionally sensitive and also has considerable difficulty controlling and tolerating their emotions. Many emotions often get dysregulated across a wide range of situations, often leading to impulsive behaviors and relationship problems. Such individuals often feel ashamed to experience basic emotions like sadness or anger, even when they are normal reactions to events. Because they invalidate and suppress their emotions, they alternate between extremes of experiencing and blocking emotions. Many suffer so intensely that they try to end their own lives. Dialectical Behavioral Therapy is recognized as the gold standard psychological treatment for chronically suicidal individuals diagnosed with BPD.
There is considerable overlap between borderline personality disorder (BPD) and bipolar disorder (also known as manic-depressive disorder), and quite a bit of misdiagnosis. The core characteristic of bipolar disorder is mood shifts that swing from extremely low (depression) to extremely high (mania). Manic episodes are periods of extreme energy, euphoria, or irritability that persist continuously for several days to several weeks and lead to extremely erratic or high-risk behaviors. Sometimes individuals with bipolar disorder shift between these extremes within a few days (called “ultra-rapid cycling” or “ultradian” bipolar disorder) and sometimes episodes are separated by many months or years. A person affected by bipolar II disorder has hypomanic episodes (less-intense elevated moods) but not full-blown manic episodes. Individuals with bipolar disorder tend to have high levels of conflict in intimate relationships, and researchers have found that they tend to cope ineffectively with critical and intrusive comments from others, for example by attacking back. People with BPD may also experience large mood swings, emotional sensitivity, and interpersonal conflict, but research suggests that they are more likely to have problems with anger, aggression, and nonsuicidal self-injury, and less likely to have extended periods of extreme euphoric energy. Study have reported that fewer than half the patients previously diagnosed with bipolar disorder by a mental health professional received a diagnosis of bipolar disorder when assessed with a standardized and validated psychiatric diagnostic interview. Most often, patients get a diagnosis of bipolar disorder when a diagnosed of BPD is warranted. This problem is even worse for adolescents because many mental health professionals believe, falsely, that they are not permitted to diagnose adolescents with BPD. Therefore, it is smart to ensure that you receive an accurate diagnosis because the recommended medications sometimes cause serious physical side effects.
A handful of studies have found that adding skills-focused problem-solving Cognitive Behavioral Therapy to standard medication treatment substantially reduces depressive and manic episodes. These treatments are very similar to DBT. One such therapy, Family-Focused Therapy (FFT), utilizes communication skills training and other strategies to improve relationships with family members and relationship partners. In one study, adding FFT to medications reduced 2-year relapse rates to 28%, and reduced psychiatric hospitalization to 12%. In contrast, 60% of the bipolar patients who received medications and minimal psychotherapy relapsed and returned to the hospital in the same 2-year period. All effective psychotherapies for bipolar studies get the patient to maintain consistent times for daily routines for all major activities including sleep, exercise, and eating. Studies have found that manic episodes are often triggered by life events that change sleep-wake habits (e.g., changing time zones due to air travel). Going to bed and waking at the same times, even during weekends, is considered the most important routine, in addition to medications, to reduce biological vulnerability to stress. FFT has many similarities to Dialectical Behavior Therapy. DBT also focus on improving interpersonal skills and problem-solving, and reducing biological vulnerability to stress. There is currently no evidence that bipolar disorders and BPD need different psychotherapies. Although many research studies have confirmed that medications are an effective part of the treatment of bipolar disorder, over the course of a year depressive and manic episodes recur for about half of bipolar I patients on these medications, and only about one-fourth have long periods of minimal symptoms and high functioning.
We utilize these treatment books by David Miklowitz:
- The Bipolar Disorder Survival Guide (2010)
- The Bipolar Teen (2007)
Major depression involves sadness, worry, irritability, shame, low self-esteem, tendencies to assume the worst and “catastrophize” about the future, substantial life stressors/adversities, relationship conflict or loneliness, lack of meaningful and pleasant activities, isolation and disengagement from life, and a tendency to avoid stressful situations.
Cognitive Behavioral Therapy (CBT) for depression includes Behavioral Activation Therapy (BA) and Cognitive Therapy (CT). Behavioral activation treatment for depression focuses on the problems you are experiencing in your life rather than on a problem with your thinking or your biology. While depression itself is not considered a “normal condition” that is in any way desirable, the depressive reactions to a life that brings few rewards are considered understandable and not the “fault” of the sufferer. Behavioral activation first targets the inertia that occurs in depression, helping you to begin to take steps to re-engage in life despite the lack of motivation or the negative feelings, including solving real-life problems and engaging in regular pleasant activities and those that promote social connection, a sense of mastery, and meaning in life. The client pursuing relationships and a meaningful life even what the behaviors require acting opposite to hopeless thinking and depression feelings, which involves applying mindfulness skills to see the depression thoughts as thoughts rather than facts CT involves the therapist helps the client to reverse their tendencies to assume the worst and to “catastrophize” by fully incorporating relevant information about hope and effectiveness, and problem-solving options.
CBT, BA, and antidepressant medications effectively treat depression. One study compared CBT to Behavioral Activation and found that there were no differences in treatment outcome. Another major study compared BA, Cognitive Therapy, and Antidepressant Medication and found that Behavioral Activation was as effective as antidepressant medications and slightly more effective than Cognitive Therapy in the treatment of moderate to severe depression. Medications often work but they do so only for so long as you keep taking them, whereas CBT and BA reduce risk for subsequent symptom return long after treatment is over.
We utilize these books that describe the treatments:
- Depression in Context: Strategies for Guided Action (by Martell, Addis, & Jacobson)
- The Mindful Way Through Depression (by Zindel Segal)
Cognitive Behavioral Therapy provides a self-control program to teach clients to anticipate and cope with the the events that trigger anger. Core skills include strategies to identify and effectively diffuse high-risk situations, gentle assertiveness and communication skills, the time-out skill, relaxation, and slow breathing. Cognitive techniques provide clients with ways to reinterpret the behaviors of others. Behavioral strategies include skillful avoidance balanced with repeatedly practicing facing the anger-eliciting situations instead of always avoiding or escaping them, which allows them to desensitize to the situations. In addition, slow breathing strategies train the client to stay calm and relaxed as they hold anger-eliciting thoughts and images in mind, and with repeated practice they gain the ability to tolerate their anger-elicting thoughts and images.
We utilize this book that describes the treatments:
- Anger Management for Everyone (by Kassinove & Tafrate)
Anxiety disorders often need treatment when the person faces frequent high levels of distress, especially if the fear prevents the person from pursuing relationships and important life goals. When this occurs, the perceptions of danger are out of proportion to the facts of the situations, and the person assumes the worst, “catastrophizes” about the future and does not incorporate relevant information about safety, effective coping strategies, and problem-solving options, and the person tends to avoid feared situations and suppress fearful thoughts. Many research studies show that thought suppression and avoidant behaviors provide immediate relief, but ensure that the anxiety disorder stays intact.
Cognitive Behavioral Therapy is extremely effective at reducing fear by helping clients face the challenging situations and thoughts that trigger their anxiety and panic. The first step is for the therapist to help the client accurately evaluate the dangers. We will work with your medical doctor to rule out true risks to your physical health and help you apply problem solving skills to reduce the true threats to your life goals, for example, if you are truly likely to lose your relationship or your job. For fears that are out of proportion to the facts of the situations, the therapist helps the client to reverse their tendencies to assume the worst and to “catastrophize” by fully incorporating relevant information about safety and effective and problem-solving options. Clients also practice repeatedly facing the fear-eliciting situations instead of avoiding or escaping them, which allows them to desensitize to the situations that trigger their fears and to see that the actual outcomes are not as bad as they expect. In addition, slow breathing strategies train the client to stay calm and relaxed as they hold fearful thoughts and images in mind, and with repeated practice they gain the ability to tolerate their fear-elicting thoughts and images, and pursue relationships and a meaningful life without being deterred by fear.
We utilize these books that describe the treatments:
- Face Your Fears: A Proven Plan to Beat Anxiety, Panic, Phobias, and Obsessions (by David Tolin)
- Anxiety and Avoidance: A Universal Treatment for Anxiety, Panic, and Fear (by Michael Tompkins)
- Stop Obsessing (by Foa & Wilson)
- Panic Attacks Workbook: A Guided Program for Beating the Panic Trick
- The Mindfulness and Acceptance Workbook for Anxiety: A Guide to Breaking Free from Anxiety, Phobias, and Worry Using Acceptance and Commitment Therapy
PTSD is a condition when the person frequently feels high levels of distress stemming from motor vehicle accidents, combat service, abuse, and other traumatic events, and fear prevents the person from pursuing relationships and important life goals. People diagnosed with PTSD often avoid situations that remind them of their traumatic events, avoid talking about the events, and actively suppress trauma thoughts and memories. Many research studies show that these coping strategies provide immediate relief, but ensure that the PTSD stays intact.
Cognitive Behavioral Therapy is an effective treatment for PTSD. Two forms of CBT, Prolonged Exposure Therapy (PE) and Cognitive Processing Therapy (CPT) are well-established treatments that have been found to be extremely effective in treating PTSD by helping clients face their trauma memories while processing their emotions about the event. Instead of avoiding or escaping situations that provoke anxiety, clients learn how to confront these situations and begin to reevaluate what happened. Prolonged Exposure helps the clients to gradually face the memories of their trauma, and desensitize to the real-life situations that trigger their PTSD reactions. Slow breathing strategies train the client to stay calm and relaxed as the traumatic events are remembered, and with repeated practice they gain the ability to tolerate their memories, and pursue relationships and a meaningful life without being deterred by fear.
We utilize this book that describes the treatments:
- Reclaiming Your Life from a Traumatic Experience: A Prolonged Exposure Treatment Program Workbook (by Rothbaum, Foa, & Hembree)
SAD is diagnosed when the person faces high levels of distress in social situations, especially if the fear prevents the person from pursuing relationships and important life goals. People with this struggle have highly exaggerated perceptions risk of rejection and embarrassment/humiliation, are highly biased in assuming that they are negatively evaluated by others, and tend to avoid their feared social situations.
Cognitive Behavioral Therapy (CBT) effectively reduces excessive social anxiety. The first step is for the therapist to help the client accurately evaluate his or her social skills, and teach the client social skills as needed. Most fear in social anxiety disorder is out of proportion to the facts of the situations, in which case the therapist helps the client to reverse their tendencies to assume the worst about what others think of them, and to “catastrophize” minor social mishaps (e.g., others seeing their anxiety) by fully incorporating relevant information about acceptable social behaviors and options for interacting with others skillfully. Clients also practice repeatedly facing their feared social situations instead of avoiding or escaping them, which allows them to desensitize to their feared situations and to see that actual social rejection is much less frequent and less severe than they expect. With repeated practice they gain the ability to tolerate their fear-elicting thoughts and situations, and pursue relationships and a meaningful life without being deterred by their social fears.
We utilize these books that describe the treatments:
Individuals with OCD struggle with repetitive behaviors that neutralize fears or discomforts. They face frequent high levels of distress, and their repetitive behaviors often create serious obstacles to employment or interpersonal relationship. They expect extreme danger if they were to resist their repetitive behaviors, although at some level they often realize that their fears are unrealistic. Many research studies show that engaging in the repetitive behaviors provides immediate relief, but ensures that the fears stays intact.
Cognitive Behavioral Therapy is extremely effective at treating OCD by helping clients face the situations and thoughts that trigger their OCD. Clients practice repeatedly facing the fear-eliciting situations instead of avoiding or escaping them, which allows them to desensitize to the situations that trigger their OCD fears and to see that the outcomes they fear do not actually occur. In addition, slow breathing strategies train the client to stay calm and relaxed as they hold fearful thoughts and images in mind, and with repeated practice they gain the ability to tolerate their fear-elicting thoughts and images, and pursue relationships and a meaningful life without being deterred by fear.
We utilize these books that describe the treatments:
- OCD: A Guide for the Newly Diagnosed (by Michael Tompkins)
- Stop Obsessing (by Foa & Wilson)
A form of Cognitive Behavioral Therapy called Relapse Prevention Therapy (RPT) has been found to be effective for treating alcohol and drug abuse. RPT is a behavioral self-control program that teaches individuals with substance addiction how to anticipate and cope with the potential for relapse. Coping skills training is core of RPT, teaching clients strategies to identify and cope effectively with high-risk situations such as negative emotional states, social pressure, and interpersonal conflict, cope with urges and craving, implement strategies to minimize negative consequences during a lapse, and learn how to create a more balanced lifestyle. Cognitive techniques provide clients with ways to reframe the habit change process as a learning experience with errors and setbacks expected as mastery develops. Behavioral strategies include skillful avoidance and lifestyle modifications such as meditation, exercise, and spiritual practices to strengthen a client’s overall coping capacity.
We utilize these books that describe the treatments:
Cognitive Behavioral Therapy (CBT) has been found to be effective for treating eating disorders. It helps clients maintain regular eating habits, distract themselves from cravings, stop emotional eating, and address body image issues.
A description of this CBT approach was published in the books:
- Overcoming Binge Eating (by Christopher Fairburn)
- The Dialectical Behavior Therapy Skills Workbook For Bulimia (by Astrachan-Fletcher & Maslar)
- End Emotional Eating: Using Dialectical Behavior Therapy Skills to Cope with Difficult Emotions and Develop a Healthy Relationship to Food (by Taitz & Safer)
- Feeling Good about the Way You Look: A Program for Overcoming Body Image Problems (by Sabine Wilhelm)
Many disorders involve emotion dysregulation, meaning that emotion episodes are frequent, intense, and long-lasting because the person is highly emotionally reactive and also has considerable difficulty controlling and tolerating their emotions. The dysregulation can involve sadness, anxiety, anger, or shame/guilt, or combinations of those emotions, which sometimes leads to impulsive or destructive behaviors. Often these struggles with emotion are components of various disorders, though some people do not qualify for a formal diagnosis. Because the emotions are painful these individuals often try to suppress their emotions, which causes them to alternate between extremes of experiencing and blocking emotions.
Dialectical Behavioral Therapy (DBT) and Cognitive Behavioral Therapy (CBT) are effective for improving emotion regulation. DBT skills and biofeedback help clients regulate their emotions after they get triggered. Healthy diet, exercise, consistent sleep, and regular practice of relaxation or slow breathing are broad interventions to increase emotional resiliency (reduce emotional sensitivities). Emotional resiliency is also strengthened when the client engages in regular pleasant activities and those that promote social connection, a sense of mastery, and meaning in life. In addition, CBT exposure therapy strategies reduce sensitivities to specific internal and external emotion triggers, for example distressing thoughts and behaviors of others that make you upset.
DBT utilizes effective strategies for strong and persistent self-hatred and shame. Validation helps clients counteract negative judgments and unrealistic standards of acceptable behavior (i.e., perfectionistic “shoulds”). The therapist thoroughly explain how the client’s behaviors are caused or normal. The client then practices thoroughly explaining how his or her emotions and behaviors make sense until the client achieves mastery of self-validation. When shame is due to the patient behaviors that truly contradict their moral values or to behaviors that would likely lead to rejection from an important individual or social group if revealed or known, the therapist helps the client improve his or her shame through repair, which generally involves reducing the future risk of social rejection by mending the relationship (including, but not limited to a sincere apology to those who were harmed), restoring the well-being of the individual who was harmed by the behaviors, showing strong evidence of strategies and effort being applied to ensure the problem behaviors are unlikely to recur (e.g., anger management therapy), and accepting consequences. When shame is based on the client falsely feeling as if their behaviors have contradicted their moral values or will lead to others rejecting them when this outcome is unlikely, the therapist helps the client reduce his or her shame through opposite action. Opposite action for unjustified shame involves the patient repeatedly engaging in actions that are incompatible to their shame-congruent hiding and self-punishment rather than avoiding shame-inducing behaviors.
Some relevant books are:
- The Mindful Path to Self-Compassion: Freeing Yourself from Destructive Thoughts and Emotions(by Germer & Salzberg)
- Self-Compassion: The Proven Power of Being Kind to Yourself Paperback (by Kristin Neff)
- Feeling Good about the Way You Look: A Program for Overcoming Body Image Problems (by Sabine Wilhelm)