Viewing entries tagged
treatment

Understanding Borderline Personality Disorder: Part 2—BPD Treatment and How to Use It

Understanding Borderline Personality Disorder: Part 2—BPD Treatment and How to Use It

Photography by      Joanna Rosciszewska

Photography by Joanna Rosciszewska

In part I, I wrote about receiving a BPD diagnosis. A diagnosis opens the door to treatments that fit. This is an important first step, but what’s next? What do we know about treatments and how can they be helpful?

What we know about working with BPD

At its heart, BPD is pattern of strained relationships. This means that people with BPD have difficulty with relationships within themselves, with others, and with the world. At the root of these problems is a troubled relationship with emotions. People with BPD experience their feelings as more intense, urgent, and often unbearable. It is common for these individuals to experience a lot of distress, and come to mental health professionals feeling desperate for some relief.

As mentioned in Part 1, the intensity of the distress can have an impact on the relationship with health care professionals, leaving the parties involved feeling frustrated and helpless. As a result, and in an attempt to reduce the suffering, the person seeking help may end up being prescribed lots of different medications—many with unpleasant side effects. Although in some cases, certain medications might help with some of the symptoms, we have more recently learned that the best approach for treating BPD is not pharmacological, but rather involves effective psychotherapy (Paris, 2017).

In the 1990s, Marsha Linehan developed a treatment specifically to help individuals with BPD understand and change their relationship with themselves and the emotions they experience as mixed and intense. She called it Dialectical Behaviour Therapy (DBT), to highlight the importance of the “dialectical”, or “the plaid” which refers to working with opposite forces. For example, this can mean accepting one’s emotions and experiences as valid, while simultaneously working to change behaviours that have negative consequences (to read more about the “Plaid” and DBT, check out Michelle’s Blog post). With robust research support, DBT has gained significant recognition. It is effective, accessible, and popular, which has led many health care professionals and people seeking therapy to equate BPD treatment with DBT.

Although DBT has virtually become synonymous with BPD treatment, it is not the only psychological treatment available and appropriate for BPD. Many other approaches to therapy use other lenses to address BPD difficulties and have been shown to be effective. Mentalization-based therapy (MBT) is a particularly good fit because it aims to help people understand their internal experiences in order to change their relationships with themselves, with others, and the world. Similarly, approaches that focus on emotions (e.g., Emotion-Focused Therapy-EFT) or relationships (e.g., Transference-Focused Psychotherapy-TFP) have also garnered research support as effective in addressing the challenges that arise with BPD (Paris, 2017).

While there are lots of 3-letter treatment options, each with its own angle, there is not much evidence to suggest that one unique type of therapy addressing personality-related difficulties is actually superior than others for BPD (Livesley, Dimaggio & Clarkin, 2015). Among many researchers and clinicians specializing in BPD, there is some consensus that the best approach is to offer therapy that integrates relevant ideas from all approaches (Livesley, 2017; Nelson et al., 2017). When it comes to therapies addressing personality disorders, no one “brand name” does better than others (Paris, 2017). This is good news, because it means most therapy approaches for BPD work, and integrating more than one is even better.

Photography by      Joanna Rosciszewska

Photography by Joanna Rosciszewska

What’s important in BPD treatment

Knowing that integrating relevant ideas from different approaches is what seems to work best, how do we know which ideas to integrate?

First, since an intense experience of emotions is often what drives a lot of the difficulties, working to identify, understand and manage emotions is critical. Managing emotions might mean learning to take a step back, observe, and experience—survive the emotion without reacting. This process also helps reduce impulsivity by creating a space to be purposeful rather than immediately acting on urge. I like to think of it as having conversations with emotions. With time, these conversations shift the relationship with one’s internal experience and reduce the chaos.

Another piece of the puzzle is shifting one’s relationship with other people. This may involve learning about other people’s emotions and intentions, and about the subtleties of relationships more broadly. It often involves understanding physical, personal, and emotional boundaries (For more on boundaries, check out this blog post) as well as what makes a relationship sustainable.

There are other elements that we know contribute to progress in therapy for BPD regardless of the content of therapy or approach. This list includes having a consistent and predictable structure (e.g., regular, weekly therapy sessions), building motivation for change, and working toward self-reflection (Livesley, 2017).

Beyond all these factors, if you are looking for therapy that works, good fit with a therapist and investment in the journey itself are crucial to making therapy work. What does this therapeutic effort look like and what does this all mean about being in therapy when you have BPD?

How to be in therapy when you have BPD

  1. Give the process a chance. Lots of big feelings might come up as you begin, challenge yourself to get started even when it’s a substantial effort that feels uncomfortable at first.

  2. Once you’ve found a fit, stick to it and be consistent in order to build momentum. At the beginning, go weekly—even when you don’t feel like it, or if you have some other reason not to go. Therapy is a big investment of time, money, and emotional energy. If you allow yourself to build momentum and persevere, you will make it a valuable (and cost-effective) experience of personal growth.

  3. Tolerate difficult emotions as they come up: Showing yourself you can survive intense and difficult emotions is an important part of the process.

  4. Trust your gut, yet still challenge yourself. Ask yourself what your emotion is telling you, and whether rolling with the discomfort could possibly be beneficial to you. For example, it might look like facing your fear, giving a person a chance even if you’re angry, or getting out of bed even though you’re sad.

  5. Focus less on the what and more on the how. Listen to the words of your stories and take a step back to understand the big picture in what’s going on. Use this often in your therapy.

  6. Open up to talking about your emotions in therapy, especially when they have to do with your therapist. Tell them if you’re scared to talk about something, if you’ve felt sad or hurt after they said something, if you’re angry with them, etc. Lots of old and new feelings can come up in the therapeutic relationship. It’s your opportunity to work out the messy parts with someone who is qualified to help you.


Danit Nitka received her PhD from the Clinical and Research Psychology program at Concordia University in Montreal, Quebec, and is a psychologist at Connecte Montreal Psychology Group. The team at Connecte loves writing about ways to boost our mental health and bring psychology into our everyday lives. For more helpful tips, check out Connecte’s blogspodcast, follow @connectepsychology on Instagram or like us on Facebook.


References

Livesley, W. J., Dimaggio, G., & Clarkin, J. F. (Eds.). (2015). Integrated treatment for personality disorder: A modular approach. Guilford Publications.

Livesley, W. J. (2017). Integrated modular treatment for borderline personality disorder: A practical guide to combining effective treatment methods. Cambridge University Press.

Nelson, D. L., Beutler, L. E., & Castonguay, L. G. (2012). Psychotherapy integration in the treatment of personality disorders: A commentary. Journal of personality disorders, 26(1), 7-16.

Paris, J. (2017). Stepped care for borderline personality disorder: making treatment brief, effective, and accessible. Academic Press.



WANT TO CHANGE THE WORLD? START BY CONNECTING TO YOU: PART 2

WANT TO CHANGE THE WORLD? START BY CONNECTING TO YOU: PART 2

This post is a continuation of my last post, which can be summed up nicely by this quote my colleague Andrea recently posted on Instagram:

“You can’t pour from an empty cup. Take care of yourself first.”

In that post I asked you to get in touch with all of the reasons WHY you want to keep your cup full. These are your WHYs for taking care of you: the values and people you want to nourish in your life. If you haven’t read it, it’s short, please take a moment to do so: Want to Change the World? Start by Connecting to You.

In this post I’d like to talk about WHAT self-care is for you? I think a common misconception is that self-care is all about tea and massages. These are great ways to recharge if they work for you! But personally I find going for a run or sitting around a dinner table with my friends just as nourishing as going to the spa. Last post I also suggested that you should not start with what other people tell you you should do to take care of yourself or what your inner bully tells you your “lazy butt” should do to take care of you. I think the most nourishing self-care moments are actually when we connect our actions with our values (our WHYs). So, let’s look back at those lists we created last time. Here’s my short list:

My WHYs

Who is important to me? (1)

  • My family

  • My friends

  • My colleagues

What is important to me? (1)

  • Growth

  • Hard work

  • Authenticity

  • Creativity

  • Connecting with people

  • Feeling part of something bigger than me

  • Taking care of my body

  • Being in nature

  • Freedom

  • Fun

I’ll try to give you an example of how you might try to connect your self-care actions with your WHYs in the area of health. Most of us know that exercise is an important piece of self-care, but for many of us it feels like a chore. I was in this boat for a long time. When I was a kid I played many sports, mostly just for fun, because my friends were doing them. But as I got older my friends did fewer team sports and by the age of 18 I was left sport-less. My husband is a professional athlete and when we met at the age of 20 I was inspired to get back into exercise. So, I tried to jump on the gym bandwagon. My husband spent his days at the gym, there must be something good about it right? And so I would go to the gym a few hours a week to work out and it was fine. But then slowly but surely the gym would creep down my priority list and ooops I would find myself months without going to the gym at all. Anyone recognize this pattern? And the pattern continued for years and years until near the end of my 20s when I decided I was tired of feeling bad about not going to the gym and gave up on exercise altogether. Phew what a relief! But then months later, feeling sluggish and unfit, I asked myself “is there another way?” Can I personalize this exercise thing so that I actually like it and it might stick? So I looked back and asked myself what I used to like about exercise? For many sports it was just the social aspect but there were no sports that all of my friends were doing anymore (and I’m not that good at making new friends) so that might not work. But then I realized the two sports I really loved, just for me, were horseback riding and cross-country skiing (neither of which is done in a gym, Aha!) So why did I like them? 1) Because they were both done outside, often in the forest (which connected me to nature), and 2) taking off for hours of trail riding or skiing totally disconnected me from “real life” and rejuvenated me (which gave me a sense of freedom). And so, with less time in the schedule as an adult I decided to try out something similar but more practical: running. I loved it and haven’t looked back since. What I learned is that if you turn exercise into something is meaningful to you, the motivation will come much easier.

Since then I have tried this with different aspects of my life. I’ve broken down self-care into 4 domains for myself: Health, Leisure, Work, and Relationships (1). And asked myself in each of these domains what is a meaningful self-care activity for me? Remember we can find meaning by looking to our WHYs.

Here are some of the self-care activities that work for me (my self-care WHATs):

Domain: Health
Self-care WHAT: Running
WHY: Connection to nature; feeling of freedom

Domain: Leisure
Self-care WHAT: Dinners with friends (especially outside)
WHY: Connection with people; feeling part of something bigger than myself; fun

Domain: Work
Self-care WHAT: Blocking off hours in the morning once a week for writing
WHY: Freedom; creativity

Domain: Relationships
Self-care WHAT: Long weekends up north with my husband
WHY: Connection; nature; growth as a couple, as parents; authenticity; (and freedom from the children!)

If you like the idea try it out and see how it works for you!

“Make a chore into a meaningful decision, and self-motivation will emerge.”
From the book Smarter Faster Better, by Charles Duhigg

I know I promised to talk about finding your lead domino (2) and making daily commitments to action. I did not forget. So stay tuned for part 3 of Want to change the world, start by connecting to you!


Jodie Richardson is a clinical psychologist in Westmount, Montreal, Quebec, at Connecte Montreal Psychology Group. The team at Connecte loves writing about ways to boost our mental health and bring psychology into our everyday lives. For more helpful tips, check out Connecte’s blogspodcast, follow @connectepsychology on Instagram or @ConnecteMTL on Twitter, or like us on Facebook.


References

Great book by Charles Duhigg, Smarter Faster Better: The Secrets of Being Productive in Life and Business

Check out this fun video by Dr. Russ Harris: Values vs Goals     

Intrinsic motivation is proven to help us reach our goals long-term. See: Koestner, R. (2008). Reaching One’s Personal Goals: A Motivational Perspective Focused on Autonomy. Canadian Psychology, 49(1), 60-67. 

Also see: Why We Do What We Do: Understanding Self-Motivation, Edward L. Deci

1. These are really great questions that Benjamin Schoendorff asks in his ACT matrix training to get at what’s truly important to people and to break down life into important domains. You can find out more about the ACT matrix here. Clinicians can check out his book: The Essential Guide to the ACT matrix.

2. Borrowing this term from Tim Ferriss and The 4 Hour Workweek