What is Countertransference?
Countertransference

Countertransference is simply all of the reactions of the therapist towards the client: the thoughts and emotions that arise in the therapist, during therapy. The reactions could result from patient factors (including the client’s personality or physical characteristics), therapist factors (including the therapist’s personality or personal history), or therapeutic factors (including the process of building rapport and familiarity, information revealed by the client, and way the client responds to the therapist).

Countertransference reactions can powerfully affect the health of the therapeutic alliance. In the past, countertransference was regarded as a barrier to effective therapy, and therapists where taught that they must overcome their reactions to clients. Today, countertransference is generally considered an inevitable and natural reaction by the therapist. Additionally, many clinicians feel that such reactions are crucial for gaining insight into their client’s lives, establishing rapport, and building the therapist-client relationship. These factors are very important predictors of therapy success.

A Brief History of Countertransference

Sigmund Freud

Sigmund Freud felt that countertransference served as a barrier to therapy. Therapists were trained to remain completely neutral, in order and serve as mirrors for their client’s emotional responses. Over time, it became standard for therapists to have to undergo their own intense period of analysis, partially in order to reduce their levels of reactivate to their clients. This view was commonly held by therapists until the 1950s.

Paula Heimann was the first psychoanalyst to look at the benefits of countertransference. She argued that countertransference provided a window into the unconscious mind of the client. She hypothesized that all countertransference reactions are the result of client characteristics, and therefore could be re-conceptualized as originating from the client. While this view is now thought to overstate the role of the patient in countertransference reactions, Heimann was the first therapist to highlight the benefits of observing and understanding such emotional responses.

 Around the same time, D. W. Winnicott wrote that objective countertransference could be especially useful in understanding how a client functions in the world. Winnicott described objective countertransference as occurring when the patient brings out in the therapist the same feelings that the patient brings out in other individuals. In this way, objective countertransference allows the therapist to observe the impact that the client can have on other individuals, which can aid the therapist in understanding the client’s personal experiences and behavior that might be contributing to their mental health.

Heinrich Racker was also instrumental in developing a framework to understand the usefulness of countertransference reactions. Specifically, Racker conceptualized what he termed countertransference neurosis as an inevitable aspect of psychoanalytic therapy. In the early 1950s when Racker was writing, the predominant theory among therapists was that the analyst should remain emotionally neutral and intense emotional reactions to the client were interpreted to be detrimental. Racker dramatically countered this view when he argued countertransference was an inevitable part of psychotherapy.

Racker identified two distinct aspects of countertransference: direct and indirect. Direct countertransference is exemplified by reactions to the patient themselves. Indirect countertransference is reactions to persons outside of the therapeutic frame, such as the patient’s parents, or the clinicians own personal experiences. 

Racker further divided countertransference into concordant and complimentary subtypes. Concordant countertransference can be conceptualized as empathetic reactions to the client. Complementary countertransference is reactions to the patient’s unwanted projections. Projection is an unconscious process whereby the client “splits off” aspects of their self that are unwanted, and “projects” those aspects unto the therapist. In identifying two complimentary subtypes of countertransference, Racker allowed therapists to conceptualize countertransference as sometimes beneficial.

Building on the work of Winnicot, in the 1970s Giovacchi conceptualized countertransference reactions as consisting of objective and idiosyncratic reactions. Objective countertransference is homogenous with reactions that other individuals would have to the client.  Idiosyncratic countertransference reactions are a result of the therapists own personal history. Both of these reactions are common in the course of therapy and can provide valuable insight into the strength of the therapeutic alliance and the impact of the client on society. 

Some contemporary psychoanalytic psychologists feel that it is valuable to share aspects of a countertransference reaction with a client. The decision to disclose such reactions should be carefully considered before action is taken, and the therapist must remember that decisions to disclose should benefit only the client and not be used by the therapist for their own benefit. Even when such discloser is undertaken to assist the client, the therapist must remember that such reactions may not be universally appreciated by clients.

Working With Countertransference

Therapy

How does a therapist work with a client who evokes strong reactions in them during therapy? The therapist is able to overcome barriers that occur through countertransference reactions by remaining introspective and aware of those interpersonal affective reactions. By remaining aware, the therapist can avoid reacting defensively. 

Additionally, the therapist needs to have undergone their own therapy so as to have successfully resolved major areas that might evoke negative countertransference reactions. Therapy for the therapist provides a venue for such conflicts to be resolved and thus reduces the likelihood that the therapist will later be driven to become defensive. Additionally, as in all cases in which the therapist is unsure how to proceed, consultation should be sought with colleagues.

Countertransference Reactions & Dialectical Behavior Therapy

Dialectical Behavior Therapy (DBT) is considered a behavioral therapy, concerned with behaviors we can see and measure; it conceives of thoughts and emotions as behaviors as well. In contrast, countertransference is a concept derived from psychoanalysis, a very different type of therapy. A DBT therapist would not originally use the term countertransference; but, whatever the time, the concept is helpful- how the therapist reacts to the client.

In dialectical behavior therapy (DBT), therapists are supposed to be members of a therapist consultation team. These teams allow DBT therapists get to regular feedback, professional assistance, and emotional support. Providing DBT therapy can demanding, especially when working with suicidal clients, clients with difficult or disturbing trauma histories, and/or clients with borderline personality disorder (BPD). DBT therapy can, at time, get emotional, heated, or combative; at other times, clients can become highly attached to their DBT therapist. In either case, there is a strong potential for DBT therapists to struggle with countertransference which could get in the way of therapy, of they do not remain mindful, and seek regular consultation with other DBT therapists.

The history of how countertransference has been viewed by therapists is long and complex. While most modern therapists regard countertransference as inevitable, this inevitability does not preclude the fact that aspects of such reactions can be harmful to the therapeutic process. In working with adolescent clients, the therapist may be made to feel incompetent or anxious. They must avoid colluding with the client’s projections or responding defensively to them. If the therapist is able to remain aware of their reactions then successful therapy can be undertaken with this population. 

DBT Skills Group
Jenell Effinger
Helping A Loved One Seek Drug or Alcohol Treatment
Substance Abuse Treatment

Family members and close friends of persons who abuse alcohol are in a difficult position- they are often negatively impacted by their loved one’s drinking, while also being in an optimal position to assist behavior change. That is, they can be very helpful in getting their loved when to seek substance abuse treatment, and support their attendance and participation in substance and treatment, while offering loving encouragement.

There is strong evidence that alcohol abuse has a negative impact upon those individuals who are closest to the user. They may experience violence, unpredictable behavior and mood swings, theft of property, verbal aggression, embarrassment, irritability, withdrawal, and damage to their household from the substance user 

On the other hand, evidence shows that loved ones can be highly successful in motivating treatment-resistant clients to both enter alcohol treatment programs and reduce their substance use. How can concerned loved ones best help get their loved one’s into substance abuse treatment, and what variables determines if such attempts will be successful?

There is plenty of research investigating both how concerned loved ones are impacted by alcohol use, and how such persons can impact the treatment outcome of their alcohol abusing friends and family members. There is less research into what factors determine why such loved one’s do takes steps, and what steps are the most helpful.

Deciding to Help A Loved One Seek Substance Abuse Treatment

Substance Abuse Treatment

How and why do people decide to make a change? Why do some people who abuse drugs or alcohol choose to stop, or seek help, while others continue to struggle with addiction? Why, and when, do the loved ones of someone who abuses drugs or alcohol take their own steps to help their loved one enter treatment?

One way of conceptualizing how friends and family respond to their loved one’s drinking is by using Miller and Tonigan’s motivational model (developed from Prochaska and DiClemente’s Transtheoretical Model of Change). 

According to this model, there are stages of motivation that family and close friends moved through when helping their loved one’s change their problematic use of drugs and alcohol. These stages are:

  • Ambivalence: uncertainty about whether a problem exists. Does my loved really have a problem? He/she doesn’t get drunk everyday. He/she only gets high sometimes.

  • Problem Recognition: recognizing that there is a problem. My husband/wife drinks too much, but treatment could be expensive. I don’t think their problem is that serious- we’ll get help if it gets worse. Maybe we should get help, but where do we turn?

  • Taking Steps: taking steps to fix the problem. We need to get your into treatment. Where should we go? What treatment is best? If you don’t reduce your use, there will be consequences for our relationship.

Perhaps you recognize yourself at one of these stages. Are you ambivalent about the issue, sometimes thinking there is a problem, and at other times uncertain if treatment is necessary? Do you recognize there is a problem, but haven’t yet taken steps (perhaps because you don’t know what to do)? Or, are you taking steps, seeking out substance abuse treatment options, or supporting your loved one in treatment?

How to Support Someone Struggling with Substance Abuse

Substance Abuse Treatment

Previous research (such as Love et atl., 1993) has identified fours ways that people tend to respond when a loved one is struggling with drug abuse or problematic drinking:

  • Supporting Sobriety: behaviors that positively reinforce sobriety, such as arranging non-drinking social outings, or spending time with loved one’s when they are not drinking.

  • Supporting Use: Even when they recognize a problem exists, some persons continue to support their loved one’s use.

  • Punishing Use: includes initiating arguments when the loved one is using, threatening them with consequences (e.g., “I’m going to leave you”) for continued use, and attempting to embarrass them by reminding them of their behavior while under the influence.

  • Withdrawing from Use: includes behavior such as leaving the house or refusing to be around their loved one when they are using drugs or alcohol.

What are the most effective ways to respond? Research suggests that substance users are most receptive to supportive and assertive coping styles. The includes:

  • Expressing concern rather than criticism

  • Maintaining hope that treatment will be successful

  • Defending the substance user against criticism

  • Supporting treatment efforts

  • Clearly stating your own opinions on the abuse you perceive

  • Setting firm limits

  • Encouraging regular discussing of the issue

What are ineffective ways of responding? Research suggests such the following methods are less successful:

  • Responding with intense emotion

  • Acting intolerant of your loves ones

  • Being overcritical for failed attempts at sobriety

  • Withdraw, avoidance, or passivity in the face of the issue

  • Being unsupportive or pessimistic about effects to maintain sobriety


Obviously, when persons DO NOT recognize their loved one’s drinking as problematic, they are more likely to support use. Without problem recognition, they are more likely to engage in behaviors that include drinking with the substance user, buying alcohol for the user, and telling the user that they are fun to be around while drinking.

When persons DO recognize problematic drinking AND ARE NOT ready to take steps to help their loved ones, tend to respond by withdrawing from use.

When persons DO recognize problematic drinking AND are ready to take steps to help their loved ones, what steps are they most like to take? In many cases, they respond by punishing use.

Supporting sobriety is more difficult, and requires more information to pull off. However, this is the approach more likely to be successful in leading to sobriety. It is unfortunate that supporting sobriety is underutilized, given that it is an indicator of treatment success.

If you’re ambivalent about whether you or a loved one has an issue with substances and could benefit from treatment, we can help with an assessment.

If you recognize that your loved one has a problem why drugs or alcohol which they don’t acknowledge, we can offer you guidance and support.

If you are ready to take steps and help your loved one by supporting their sobriety, we can offer substance abuse treatment, or support for you as you support your loved one.

Contact us today to speak to a substance abuse therapist, to learn how we can help you reach your goals.

Substance Abuse Treatment
FRTC
Fighting the Stigma of Borderline Personality Disorder
BPD Stigma

As a therapist who specializes in Dialectical Behavior Therapy (DBT), people with Borderline Personality Disorder (BPD) are the focus of my work. Like most therapists I know who also specialize in DBT, I have so much compassion for people who work so hard to improve their lives, achieve their goals and build a life worth living. I am almost daily rendered speechless by my client’s insights, drive and willingness to do whatever it takes to have the life they want.

Because of that, any time a client or even potential client tells me that they have been researching “Borderline Personality Disorder,” I have a very mixed emotional response. On the one hand, when someone who has been struggling, sometimes for years, to find a label or an explanation for their struggles finally discovers BPD, that can be very reassuring for some people. Everything seems to click into place and their struggles start to make sense. And then to find that there is a type of therapy specifically designed to help them- Dialectal Behavior Therapy- can give lots of hope! People allow themselves to begin to have hope that things can actually get better.

One the other hand I often worry about all the frightening, judgmental things they might read online, or the hope-crushing experiences they may have to endure in trying to find an effective BPD therapist. It does not take long for people to run up against the stigma of Borderline Personality Disorder.

Descriptions such as “manipulative,” “attention-seeking,” “unmotivated” and “treatment resistant” are frequently used by professionals and lay people alike (except for perhaps that last one. I don’t know of many lay people who throw around terms like “treatment resistant”).

Mental health professionals often perpetuate this stigma by misdiagnosing clients, by declining to work with people who have BPD, or by using methods of treatment that have no evidence of efficacy for Borderline Personality Disorder. In addition, incorrect information online can easily reinforce the idea that people with Borderline Personality Disorder never get better.

Borderline Personality Disorder Stigma

 All of this rattles around in my head when someone mentions they have looked up Borderline Personality Disorder online as I prepare to refute any of the negative things they may have read or validate their frustrations at trying to find a therapist who gets it and can help them work toward their goals. I keep this information in the front of my mind when doing phone consultation and intakes, reviewing disappointing and sometimes harmful experiences people have had in treatment before. It is not uncommon for people with BPD to come to our practice diagnosed with Bipolar Disorder or Major Depressive Disorder, having done therapeutic work that does not quite seem to address all aspects of their life and the symptoms of BPD they struggle with. It is also not uncommon for people to show up in our offices with little belief or hope that this time will be different, or this type of treatment will work.

As a therapist who specializes in Dialectical Behavior Therapy, who made an active choice to learn this type of therapy and work with people who have Borderline Personality Disorder, I am mindful of this great burden. This burden is shared by all mental health professionals – to work to decrease the stigma associated with BPD. We can do this by educating ourselves thoroughly about what Borderline Personality Disorder really is, how to effectively treat it, and holding other mental health professionals to the same standard. We must be realistic about the barriers our clients will face, not only internally but externally due to a diagnosis, and always be prepared to help gently correct misunderstandings and cultivate hope in the lives of our clients.

If you’re struggling with borderline personality disorder, or wonder if this diagnosis might explain some of the difficulties you are facing, contact us today to learn how DBT can help you reach your goals.

Jamie Thompson
The Biosocial Theory of Borderline Personality Disorder, Part I
Borderline Personality Disorder 1

As a psychologist who specializes in Dialectical Behavior Therapy (DBT), I am frequently asked by clients and families about how Borderline Personality Disorder (BPD) develops. We think BPD is caused by a combination of factors, so the answer is a bit complicated! The Biosocial Theory reflects our current understanding in how BPD develops. The theory states that BPD is a disorder of emotion dysregulation, and that emotion dysregulation is the result of emotional vulnerability as well as a lack of emotion modulation skills. Moreover, the Biosocial Theory postulates that these difficulties are rooted in biological predispositions that are exacerbated by the environment. 

Emotional Vulnerability

 When we discuss emotional vulnerability, we are specifically referring to three things: sensitivity, reactivity, & slow return to baseline. When an individual is “sensitive,” it means that person has a low threshold for an emotional reaction. What may not be bothersome to most is bothersome to the emotionally sensitive person. If a child is sensitive, they may react to even the slightest frustration or annoyance. Emotional sensitivity is often what causes friends and family members of those with BPD to “walk on eggshells.” Furthermore, the emotionally sensitive individual may also be able to detect subtle emotional information in their environment that others don’t notice (hint: many therapists are sensitive). They experience emotions much more frequently than others, and sometimes for seemingly no reason and out of the blue. 

Emotional reactivity refers to the intensity of emotions and reactions. I’ve had clients tell me that their emotions hit them like a ton of bricks and last forever. What may be disappointing or annoying to many, may cause an emotionally reactive person to feel overwhelming sadness or rage. On the other hand, emotionally reactive individuals are like to experience joy more easily and fall in love faster, so it isn’t limited to emotions that we don’t like to experience!

Slow return to emotional baseline means that reactions to emotional stimuli are long lasting; therefore, once upset or dysregulated, the body takes a long time to return to baseline. This doesn’t mean that the person is holding a grudge, but it is their body’s physiological response to stress. Also, as they return to baseline, they are even more vulnerable and susceptible to other emotionally laden events and hardly ever do they get a “break.” Those who have experienced invalidation or trauma, or identify as emotionally reactive, tend to have higher baselines. A higher baseline can be difficult to sustain long term and can lead to self-harm and suicidal behaviors.

 Emotional vulnerability is not a lack of self-control. We now know from a scientific perspective that emotionally vulnerable isn’t a matter of choice. Studies have shown that newborn babies have varying degrees of emotional responses before they even learn what emotions are. In one study, newborns were tickled on their nose with a feather. Some babies did absolutely nothing while being tickled, others had a mild response in that they moved around a bit, and others began crying and were difficult to console. The babies who were difficult to console were viewed as being more sensitive to emotional stimuli.

 Neurobiology

Borderline Personality Disorder 2

There has been modest research support for the neurobiology of BPD, particularly within the limbic system and prefrontal cortex. The limbic system is the primary processing center for emotions and memory within the brain, whereas the prefrontal cortex is implicated in planning, personality, decision making, and behavioral control. A meta-analysis in 2009 reported structural changes within the limbic system in those with BPD, which may contribute to emotional dysregulation.

When researchers had participants diagnosed with BPD undergo brain imaging while completing an assessment, it was found that negative emotional words caused the participants to have more difficulty with the task and act more impulsively. Moreover, the brain imaging showed that there was less activity in the part of the brain that is responsible for behavioral control, reflecting the mood dependent behavioral dysregulation that occurs in BPD.

There has also been consistent research support demonstrating that those with BPD tend to misclassify and misinterpret neutral faces as negative, which may contribute to interpersonal sensitivity. Another study revealed that those with BPD demonstrated a lower resting parasympathetic tone, the part of our nervous system responsible for slowing heart rate and relaxing muscles, suggesting that individuals diagnosed with BPD have to work even harder to regulate their emotions from a biological perspective. However, there is good news! Small scale studies have reported findings that Dialectical Behavior Therapy (DBT) targets amygdala hyperactivity, which is a part of the emotional processing center in the brain.

Impulsivity

 Impulsivity also has a biological basis in that regulating action is harder for some than others and it can feel nearly impossible to control impulsive behaviors. My clients often, without thinking, can do things that get them into trouble and sometimes the behavior appears to come out of nowhere. People with BPD can find it really hard to be effective and their moods can get in the way of organizing behavior to achieve their goals. They also have difficulty controlling behaviors that are linked to their moods, like lashing out at others when angry, or drinking when sad. 

Invalidating Environments

Borderline Personality Disorder 3

The social part of the theory refers to an invalidating social environment, particularly caregivers. If you are a parent whose child has BPD, take a deep breath, I will explain! An invalidating environment is one that doesn’t seem to understand your emotions, which is problematic if you are an emotionally vulnerable person. The environment may communicate that your emotions are wrong, weird, or bad. It can ignore emotional reactions and does nothing to help with appropriate emotional expression. Children who grow up in invalidating environments learn that they cannot trust themselves- that their interpretations of their behaviors, emotions, thoughts, and perspectives cannot be trusted. 

Here are some examples of invalidation:

Comments such as:

  • “Don’t be such a baby” 

  • “Quit your crying” 

  • “Pull yourself up by the bootstraps” 

  • “Stop crying, this isn’t that big of a deal, it’s okay”

  • “Talking about problems just makes them worse”

Parents who punish emotional expression:

  • “We don’t talk about emotions in this house”

  • “Leave your bad mood at the front door”

  • “If you’re going to cry, go to your room”

Oversimplification of problem solving, which does not teach the child to tolerate distress or form realistic goals or expectations about life:

  • “You just need to try harder to stop drinking”

  • “If you really cared, you’d be able to change”

  • “Maybe if you got out of the house more often, you wouldn’t be so depressed”

  • “You just have to CHOOSE to be happy”

  • “Everything happens for a reason”

Confusing one’s own emotions with the emotions of others:

  • “I’m exhausted, let’s all go to bed”

 When kids don’t get their needs met, they may increase the intensity of emotional expression, but that doesn’t actually help. What they need is for a parent to validate them. Instead, the child unconsciously escalates their level of emotional intensity and behaviors. They eventually get to a level that forces the environment to respond (screaming children in Target, anyone?). When the caregiver sees that the child truly needs help and does something, that interaction reinforces (strengthening the behavior through reward) high level emotions and behaviors. The child then unconsciously learns that people respond to them and meet their needs when they react in an intense manner.

 DBT therapists use the “Tulip in the Rose Garden” metaphor to demonstrate the Goodness of Fit principle, which talks about how an award-winning rose gardener decides to plant tulips in his rose garden. He doesn’t realize that tulips and roses have very different requirements in order to grow. If he treats the tulip like his roses, the tulips won’t be able to flourish! Emotionally vulnerable people in invalidating environments are the tulips in this metaphor. If the conditions aren’t right, they are going to struggle. Goodness of fit results when the child’s environment, expectations, and demands match the child’s emotional sensitivity, capacities, and characteristics.

Trauma and Abuse

Sexual or physical abuse is an extreme form of invalidation and is often a precursor for BPD. Abuse communicates to the individual that they do not deserve basic respect or safety, and can make the victim feel worthless, rejected, and devoid of human value. The rates for co-occurring PTSD in individuals with BPD vary, ranging from 30% to 68% depending on the study; although, other studies have reported rates of childhood physical abuse in BPD of 71% and rates of childhood sexual abuse up to 86%. Regardless, sexual abuse predicts a more severe and chronic presentation. However, not everyone with BPD has experienced a significant traumatic event in their life.

Info for Parents

Borderline Personality Disorder 4

 If you are a parent or caregiver to someone with BPD, know that it is our assumption as DBT therapists that people who invalidate are often doing the best they can! Normal parenting includes periods of ineffectiveness, and life can certainly interfere with one’s ability to parent. There are many reasons why this occurs:

  • Some kids are so emotionally vulnerable that even our best efforts to validate are ineffective 

  • You think you’re validating, but notice it just makes your kids more upset

  • You may not know how to validate or maybe your parents never taught you

  • You aren’t aware of how important validation is or even what it is

  • Fear that if you validate the emotion, your child may become more emotional and not less

  • You believe that by validating your child’s emotions, you will make them weak

  • High stress and pressure at home or work

  • Having too few resources

  • The ways in which you learned to regulate your emotions are not as helpful to your child

  • Validation may seem like agreeing or approval 

  • Your child is super great at pushing your buttons and pushing you into emotional dysregulation

  • You’re emotionally vulnerable, or experience mental health symptoms that impact your ability to understand your child’s emotions

 The development of BPD is clearly complicated and likely looks very different for each individual. If you, or someone you love has BPD, contact us to make an appointment today!

Ashley Allen
Using Operant Conditioning to Understand Self-Harm
Self-Harm

Self-harm occurs when someone hurts or injures themselves on purpose, without intending to cause death. Common forms of self-harm include cutting, burning, scratching, hitting, and ingesting toxic substances. Self-harm is also known as self-injury, or non-suicidal self-injury (NSSI).

Self-harm is a serious and growing phenomenon, yet little is known about the function of this behavior. For many, these behaviors can seem baffling. Why do people hurt themselves on person? One model that describes why people commit self-harm describes the behavior using the principles of operant conditioning

What is Operant Conditioning?

The famous behavior science B.F. Skinner first defined the idea of operant conditioning. He described the interaction of people and animals with their environment as consisting of three factors:

  • The antecedent. This is the triggering or prompting event or circumstances that leads to the response.

  • The behavior. The response to the antecedent is the behavior we are interested in.

  • The consequences. This occurs after the behavior, and it makes the behavior more or less likely to occur again.

There are two recognized processes through which consequences can impact future behavior: reinforcement and punishment. Reinforcement is at work when the consequences of behavior maintain or increase the prevalence of that behavior. Punishment is at work when the consequences of behavior result in the reduction of future incidents of that behavior. Reinforcement and punishment can be either negative or positive. A consequence is negative when it results in the removal of something from the environment. A consequence is positive when it results in the addition of something to the environment.

Positive reinforcement: the addition of something that results in a behavior being maintained or increased (such as when a child cleans his room and his mother gives him a cookie).

  • Negative reinforcement: the removal of something negative that results in a behavior being maintained or increased (drinking makes a socially anxious individual feel more relaxed).

  • Positive punishment: the addition of something that results in a behavior decreasing (a child disobeys their parent and gets a spanking).

  • Negative punishment: the removal of something positive that results in a behavior decreasing (a person’s is caught speeding and has their license suspended). 

If the consequences of self-harm were only negative, the operant conditioning model would expect the behaviors to become stop. However, research indicates that self-harm behaviors tend to persist. According to a model of self-harm based upon operant conditioning, persons who harm themselves must be receiving some benefit from the behavior. It is in some way rewarding or reinforcing, which explains why they keep doing it.

Antecedents: The Reasons People Self-Harm

Why do people hurt themselves?

So, why do people self-harm?

The reasons vary, but researchers and clinicians have suggested many possible reasons why someone might hurt themselves. Commonly cited reasons include:

  • Feeling dissociated or numb.

  • Feeling overwhelmed with negative emotions (such as anger, sadness, or anxiety).

  • Feeling neglected, abandoned, or lonely.

  • Feeling ashamed after engaging in behavior or having thoughts believed to be “bad.”

These are certainly very broad and general categories. The reasons people self-harm are complex, and may change over time. However, understanding these basic reasons can help to illustrate the fact that there are some potential “benefits” for persons who commit self-harm. If there were not, it would be a much rarer problem.

Clearly, self-harm is a complex behavior with many possible prompting conditions.

Self-Harm as a Behavior

Many people who commit self-harmer report daily urges to hurt themselves; however, few act on these urges with that frequency (Nixon, Cloutier & Aggarwal, 2002). About 80% of individuals who repetitively self-harm do so a maximum of once a week (Nixon, Cloutier & Aggarwal, 2002).

Additional research between the relationship of self-harm urges and self-harm incidents could be important for developing better treatment. Why don’t self-harmers act on every urge or at least act more frequently? By what mechanism are they able to resist the urge to self-harm? Also, is there something unique to the antecedent condition that precedes actual self-harm incidents?

While these issues remain largely uninvestigated, there is preliminary evidence that self-harm behavior takes different forms depending on the behaviors antecedent condition. 

For example, individuals who engaged in self-harm for social reasons (because they were faced with an undesirable task or felt lonely) contemplated injuring themselves for more time before engaging in the behavior. These individuals also endorsed experiencing more pain during self-harm episodes.

In contrast, individuals who self-harmed in an attempt to stop feeling bad or in order to feel something (stop dissociation), reported they thought only a few minutes before self-harming and experienced no pain during their episodes (Nock and Prinstein, 2005). Interestingly, Nixon et. al. (2002) found that a history of child-abuse was most associated with individuals who indicated that self-harm was motivated by an attempt to stop dissociation.

Consequences: Rewards and Reinforcement From Self-Harming

If the antecedents above lead persons to commit self-harm, what do they get out of it? Why do so many people keep doing it, often with increasing intensity? Here are some of the theorized rewards for each of the antecedents discussed above.

  • Feeling dissociated or numb —> self-harm results in feeling something.

  • Feeling overwhelmed with negative emotions (such as anger, sadness, or anxiety) —> self-harm results in those emotions being masked (through distraction, or an endorphin release)

  • Feeling neglected, abandoned, or lonely —> self-harm results in attention and/or sympathy.

  • Feeling ashamed after engaging in behavior or having thoughts believed to be “bad” —> self-harm acts as self-punishment.

Due to the neglect of the role that specific antecedents play in the development of self-harming behavior, it is difficult to assess what categories of consequences are related to which categories of antecedents. The only consequence that seems to have been empirically tested by researchers is the emotional consequences of self-harm. Even so, most frequently these emotion consequences are lumped together as “bad” emotions.

Anecdotally, the reinforcement that occurs by the removal of negative emotions appears to be very powerful. One young woman described the process as “feel(ing) like a pressure cooker that’s going to explode. Cutting and bleeding sufficiently is like letting out the steam. If I do this to my satisfaction, I feel immediate relief, as if injected with Valium or something. It helps stop the inner turmoil for a while” (As cited in Magnall and Yurcovich, 2008).

The experience of self-harm as a powerful negative reinforcer has an addictive quality (Nixon, Cloutier & Aggarwal, 2002).  Of the 42 self-harmers surveyed by Nixon, Cloutier & Aggarwal, 90% stated that the frequency and severity of their self-harm has increased despite the realization that their behavior is harmful. Additionally, 85% of the participants in this study noticed that their tension levels reoccurred when the stopped engaging in self-harming behavior. From an operational conditioning standpoint, if tension levels were reduced by self-harming on previous occasions, then the learned consequences of that action will make it more likely that an individual will reengage in the behavior. 

Additionally, Nock and Prinstein (2005) hypothesize that while the first episode of self-harm may be well thought-out, as the behavior is reinforced through its consequences it is undertaken in a more impulsive manner. The impulsivity, or lack of forethought, that develops as self-harm behavior becomes more habitual could make it more resistant to treatment.

Interestingly, there is little evidence to indicate how self-harm works to relieve emotional distress. Current research hypothesizes that self-harm functions to reduce negative affect by either serving as a distraction or by triggering a biological mechanism such as an endorphin release (Klonsky, 2007). Clinically, all that is known is that for many individuals, self-harm is an effective emotional regulation strategy. 

How do we treat self-harm?

Treatment of self-harm could theoretically occur at any of the three levels:

Treating self-harm
  • Antecedent intervention would treat self-harm through changes to the environment in which the behavior occurs, and reducing or removing the reasons for committing self-harm.

  • Behavioral intervention would involve restricting, or making it difficult to engage in the behavior at all.

  • Consequential intervention would require changing the reinforcing effects of the behavior, it make it less rewarding or more “punishing” to commit self-harm.

For self-harm, it is difficult to intervene at the behavioral or consequential level. Intervening at the behavioral level would require preventing self-harm through heightened security or bodily restraint. While this may occur in some hospital or correctional settings, this is obviously not a feasible treatment, or realistic long-term approach. Additionally, the consequences of self-harm are not well understood and seem to vary from person to person, making intervention at this level difficult. Therefore, the most likely intervention point in the treatment of self-harm is at the antecedent condition. 

While it is important to acknowledge that self-harm is a complex behavior, research does support the idea that the most common antecedent in self-harm is the experience of some form of negative emotion. Therefore, interceding at the antecedent level of self-harm involves changing the way the client either perceives or reacts to their emotional experiences.

According to Dialectical Behavioral Therapy, poor emotion regulation skills contribute to self-harm (and other misguided attempts to escape negative emotion). DBT attempts to teach people emotion regulation skills, which includes replacing maladaptive methods of emotion regulation (such as self-injury) with healthy ways of regulating emotion. In fact, many research studies have shown DBT to be highly effective at reducing suicidality and self-harm.

At FRTC, our Dialectical Behavioral Therapy clinicians are intensively trained in DBT and the treatment of self-harm. If you or someone you love is struggling with self-harm, contact us to learn how DBT can help.

Jenell Effinger
Cognitive Theory in the Treatment of Depression
Depression

What is depression? Depression is characterized by depressed mood, a loss of pleasure, difficulty concentrating, and feelings of worthlessness or guilt. Negative thoughts, or cognitions, are an important part of the symptoms of depression. 

What causes depression? There are many different theories from different schools of thought about what causes depression and other mental illnesses. According to cognitive theory, thoughts and beliefs are the primary cause of depression.

Cognitive theory offers a model to explain human behavior and mental illness. Aaron Beck, a pioneer in cognitive theory, thought that childhood experiences lead to the creation of “cognitive structures” that guide our interpretation of future events. 

According to cognitive theory, people take in and process information from the environment, which results in stored representations of our experiences and related beliefs. In cognitive theory, these mental models are referred to as schemas.

Schemas are cognitive shortcuts for navigating the world, shaping perceptions and interpretations. They are “a network of beliefs, assumptions, formulas, and rules… connected to memories relevant to the development and formation of such beliefs” (Beck, 1991).

Theses schemas are then reactivated in similar situations, and act as interpretive shortcuts. One benefit of this is our brain doesn’t have to work as hard, and it can fill in missing information. Most of the time, this is helpful, and doesn’t cause many problems. But, sometimes, relying on these cognitive shortcuts can result in errors.

According to this theory, early experiences are especially important because these cognitive models guide how all future information is processed. If one’s early experiences are adverse or extreme, the individual may develop biased schemas.

For example, according to this theory, depression is the result of early adverse experiences leading to the creation of a negative information processing bias. This guides the perception and interpretation of information though a negative, pessimistic, and distorted filter.

Depression is a consequence of a negative schematic bias across three domains, concerning the self, the world, and the future (Allen, 2005; Beck & Alford, 2009). Negative thoughts about the self include beliefs that one is “worthless, unlovable, and deficient.” Such persons consider themselves “deficient, inadequate, or unworthy.” Negative thoughts about the world include beliefs that the world is scary and overwhelming. Such persons view their life as a “succession of burdens, obstacles, or traumatic situations.” Negative thoughts about the future include beliefs that failure is assured, happiness is unattainable, and there is no use trying to change things. As such persons look ahead, they see a life of “unremitting hardship, frustration, and deprivation.”

When early experiences lead to the development of negative schemas and depression later in life, the individual may have poor insight into the source of their difficulty. Since schemas are pervasive, the depressed person is often unaware of their influence, or that his or her experiences are out of the norm. As such, the presenting problem of the depressed individual is sometimes somatic, such as a loss of appetite, fatigue, or difficulty sleeping.

Depression therapy

Schemas tend to be strengthened over time, unless challenged. As schemas filter perceptions, the mind continues to build “biased “memories. These biased memories are then incorporated into further biased schemas. Schemas are then further strengthened by exposure to congruent experiences, as people seek out environments that conform to their view of the world.

Research has examined other specific schemas which may be important for the development and maintenance of depression. Persons who score high on measures of depression also tend to endorse statements suggesting the presence of enduring beliefs related to shame, inferiority, and expectations of abandonment and social isolation (Calvete, Estévez, López de Arroyabe & Ruiz, 2005).

Negative interpersonal schemas may be especially important for, and specific to, the development of depression (Dozois et al., 2009). Negative beliefs about emotions (such as their legitimacy, comprehensibility, and controllability) may also be important in the maintenance of depression, since such beliefs are related to poor emotional regulation skills and unhealthy coping methods. (Leahy, Tirch, & Melwani, 2012).

Schemas exist at a deep and enduring level, and are difficult to change. When navigating the world, the individual makes sense of every situation through an interaction between their schemas and their perception of the current circumstances. Beck called the results of the product of these interactions automatic thoughts. According to Beck, schemes relevant to the current situation “interact with the symbolic situation to produce the automatic thoughts” (Beck, 1991). Automatic thoughts are produced quickly, with few cognitive resources. Information is broadly categorized, and errors in perception and interpretation are likely (Beck & Haigh, 2014; Beck, 1991).

The depressed person is unable to assess a situation with accuracy, and is prone to jumping to negative conclusions even when the evidence does not support such a conclusion. For example, a person with strong negative schemas about the self may respond to challenging situations with automatic thoughts such as “I will fail,” or “This is hopeless.” When left out by peers, such a person may think “I am worthless,” or “I am unloveable.” A person with strong negative schemas about the world may respond to a setback with such automatic thoughts as “Life is too difficult,” or “No one will help me.”

Treating Depression with Cognitive Therapy

Depression treatment

If schemes, and the automatic thoughts they generate, are responsible for depression, how do you go about treating depression? According to cognitive theory, treatment will involve:

  • Learning to recognize these automatic thoughts.

  • Challenging automatic thoughts by generating alternative explanations.

Some forms of cognitive therapy involve addressing the relevant core schemas driving the directly. Other forms emphasize other skills, such as:

  • Increasing mindfulness of emotion

  • Increasing toleration of negative emotions (through exposure to uncomfortable physical sensations, negative emotions, and emotional situations)

  • Decreasing avoidance of situations which might result in emotion

  • Decreasing unhealthy emotion-driven behaviors

  • Accumulating and/or scheduling positive experiences

In some cases of depression, the role of schemas and automatic thoughts may be less clear. According to cognitive theory, those issues are always at the core of depression, whether or not the client has sufficient awareness of these issues to be able to discuss them in therapy.

Therapists who subscribe to other schools of thought may disagree. Even amongst therapists who find cognitive theories and techniques helpful, however, the crucial questions is: what approach will bring relief to the client? 

At FRTC, our therapists use cognitive techniques when treating depression and other issues, but we always choose and tailor our treatments for the unique needs of the clients.

Front Range Treatment Center
Why is Mindfulness Helpful?
Mindfulness+and+DBT

Mindfulness is one of the core skills of dialectical behavior therapy (DBT). DBT has been shown to be an effective treatment for borderline personality disorder (BPD), self-harm, suicidal thoughts and attempts, depression, and other issues of intense emotion. In DBT, clients spend the first two weeks of every module of skills classes focused on the practice of mindfulness.

How does mindfulness contribute to the great effectiveness of DBT? How does practicing mindfulness lead to symptom reduction? One recent study considered what facets of mindfulness contribute to symptom reduction in persons with borderline personality disorder (BPD).

The researchers used a tool called the Five Facet Mindfulness Questionnaire. This measure breaks down mindfulness into five different attributes. These attributes are:

  • observing

  • describing

  • acting with awareness

  • nonjudging of inner experience

  • nonreactivity to inner experience

In DBT skills classes, participants practice mindfulness in an attempt to develop these skills. The learn to observe their surroundings, and their internal emotional and cognitive world. They learn to describe what is going on around and within themselves, in a non-judgmental way, without a strong reaction. In turns they learn to act with awareness, making more intentional, purposeful decisions.

These mindfulness subskills all go together but are some of them more related to the reduction in BPD symptoms that comes from learning DBT skills?  It turns out,

Acting with awareness and nonjudging of inner experience seems to be especially important. By acting with increased awareness, persons with BPD take more control and are able to make more effective, less emotion-driven decisions. By judging one’s inner experiences less, including one’s thoughts and emotions, persons with BPD are able to experience negative thoughts and emotions without it resulting in a cascade of self-judgement and further negative emotion. Participants improving in these mindfulness skills also showed lover levels of depression and overall distress.

Fall and Winter 2019 DBT Course Dates

Our fall session starts August 26th!

We will cover the DBT skill of Emotion Regulation. During the upcoming winter session, we will discuss Interpersonal Effectiveness.

Fall Session: Emotion Regulation

  • 8/26-10/14 (9 weeks)

Winter Session: Interpersonal Effectiveness

  • 10/28-12/16 (7 weeks, no group the week of Thanksgiving)

Contact us at FRTC to learn how DBT can help you build a life worth living.

Why do people cut themselves?
Cutting

Non-suicidal self-injury (NSSI), also called self-harm, is someone hurts themselves on purpose. When most people think of NSSI, they think of cutting, as when people use knives or razors to cut themselves. Other ways people commit self-harm include burning, hitting, consuming chemicals, scratching, hair-pulling, and overdosing (on OTC, prescription, or illegal drugs). Self-harm is more common in people with histories of depression, suicidality, or a diagnosis of borderline personality disorder.

Why do people commit self-harm? According to one theory, self-harm is motivated by emotional dysregulation. Emotional dysregulation is a key characteristic of borderline personality disorder, and is a problem for many people suffering from emotional disorders. People with emotion regulation difficulties tend to feel their emotions more strongly, stay upset longer, and have difficulty calming down. These people will often turn to unhealthy ways of coping with strong, negative emotions. One such method: self-harm.

A recent study examined the relationship between emotional dysregulation and self-harm. The result? A significant relationship between levels of emotional dysregulation and self-harm behavior. According to the authors:

Emotion dysregulation subscales most strongly associated with NSSI included limited access to regulation strategies, non-acceptance of emotional responses, impulse control difficulties, and difficulties engaging goal-directed behavior.

Dialectical Behavior Therapy is designed to address issues of emotional dysregulation, through skills such as distress tolerance (accepting strong negative emotions) and emotional regulation (ways to reduce strong emotions).

DBT skills groups begin this week!
Summer DBT. Better than a beach pineapple.

Summer DBT. Better than a beach pineapple.

Dialectical Behavior Therapy (DBT) skills groups begin this week! There's still time to sign up. This summer, we'll be learning about Distress Tolerance: how to weather those difficult moments and strong emotions.

Our DBT groups meet once a week for an hour and a half. In a classroom like setting, clients learn and practice a variety of DBT skills to improve their quality of life.

Skills learned in DBT group therapy sessions are then discussed in individual therapy, where the client practices applying those skills to the issues they are facing in their life.

Here are the available class times this summer:

  • Tuesday evenings, from 4:00-5:30 pm

  • Wednesday mornings, from 10:00-11:30 am

  • Thursday afternoons, from 11:30-1:00 pm

Contact us for more info, or to sign up!

Borderline Personality Disorder and Physical Health
BPD and Health

There has long been a noted link between borderline personality disorder (BPD) and poor physical health consequences. BPD certainly does not impact physical health for everyone, but for many, BPD drives behaviors that are known to be detrimental, or even dangerous.

Since BPD is a characterized by a deficit of emotion regulation skills, people with BPD sometimes engage in disparate attempts to feel better which can have long term negative consequences. A recent study examined some of these behaviors. They include:

  • alcohol and drug abuse

  • self-harm

  • chronic use of opioid, benzodiazepine, and anti-psychotic medications

  • smoking

  • poor diet

  • poor sexual health

  • poor adherence to medical treatments

There is also a relationship between BPD and binge-eating and sleep issues.

DBT is a treatment for BPD, and it used to target specific, problematic behaviors. While the focus is on emotional health, DBT could also target behaviors that have a negative effect on physical health.

May is Borderline Personality Disorder Awareness Month
BPD Awareness Month

May is Borderline Personality Disorder Awareness Month.

In 2007, the House of Representatives passed a resolution supporting efforts to educate the public about BPD, and in support of BPS Awareness Month. The text of that resolution, recognizing the severity of BPD and the importance of raising awareness about, is included below.

Also, learn more about BPD: its causes, symptoms, and treatment.

Whereas borderline personality disorder (BPD) affects the regulation of emotion and afflicts approximately 2 percent of the general population;

Whereas BPD is a leading cause of suicide, as an estimated 10 percent of individuals with this disorder take their own lives;

Whereas BPD usually manifests itself in adolescence and early adulthood;

Whereas symptoms of BPD include self-injury; rage; substance abuse; destructive impulsiveness; a pattern of unstable emotions, self-image, and relationships; and may result in suicide;

Whereas BPD is inheritable and is exacerbated by environmental factors;

Whereas official recognition of BPD is relatively new, and diagnosing it is often impeded by lack of awareness and frequent co-occurrence with other conditions, such as depression, bipolar disorder, substance abuse, anxiety, and eating disorders;

Whereas despite its prevalence, enormous public health costs, and the devastating toll it takes on individuals, families, and communities, BPD only recently has begun to command the attention it requires;

Whereas it is essential to increase awareness of BPD among people suffering from this disorder, their families, mental health professionals, and the general public by promoting education, research, funding, early detection, and effective treatments; and

Whereas the National Education Alliance for Borderline Personality Disorder and the National Alliance on Mental Illness have requested that Congress designate May as Borderline Personality Disorder Awareness Month as a means of educating our Nation about this disorder, the needs of those suffering from it, and its consequences: Now, therefore, be it

Resolved, That the House of Representatives supports the goals and ideals of Borderline Personality Disorder Awareness Month.

Parental Validation: Tips for Dealing with Your Teen
Teen DBT Validation

When someone else is upset, it isn’t always easy to be sympathetic. This is especially true when it seems like they are upset for little or no reason, or they are overreacting. For parents, this can be a constant struggle. All children do this, though it usually settles down with time. Some people, though, struggle with strong emotions all their life. It can be especially difficult living with a high-emotion teenager.

The truth is, some people get upset easier than others, and have a hard time calming down. We call the ability to calm oneself down an emotion regulation skill. Some people, because of their biology, have a hard time with emotional regulation. (Though it can be learned- teaching these skills is a key component of DBT).

For the parent of a teen with poor emotion regulation skills, life can be difficult, and your relationship with your child can suffer. During times of high emotion, it is only natural to think, or to say:

“Get over it”

“You are overreacting”

“Act your age”

We call these responses invalidating. The problem? These responses are usually not effective. By effective, we mean helping you get what you want. When your teen is upset, the thing you probably want most from your interaction with them is for them to feel better and calm down. These types of responses tends to not calm people down, but instead lead to more negative emotion. Only now the negative emotion is about both the original issue and your response to it.

These responses are probably not effective even if they are true. Someone may be “overreacting,” in the sense that they are over estimating the significance of an event. Teens often overestimate the importance of events, because they lack the perspective of experience. For example, the end of a romantic relationship tends to be much more painful during adolescence, because of unrealistic expectations about the relationship.

When people are upset, they usually can’t be argued or berated into feeling better. Often, people cannot be convinced to feel better, even with a rational argument. Emotions often have to be felt, and take time to run their course.

Even more crucially, invalidating responses can result in confusion and greater negative emotion. Over years, these responses can be damaging. If children constantly receive the message that their emotions are “wrong,” their emotion regulation skills tend to suffer: they never become skilled at recognizing, labeling, or controlling their emotions.

So, if your teen is really upset, and you don’t agree with their reaction or beliefs driving the reaction, how do you respond? 

Effective responses tend to begin with validation. Validation requires recognizing the emotions the other person is experiencing.

“You seem to be feeling X”

“I’m sorry you feel so sad/angry/upset”

“That is very sad when X happens”

It can be very difficult to be validating sometimes. It can be helpful to remember that validation does not require you to agree with the reasons behind emotion, or the intensity of the emotion, or the poor coping skills being used. It is simple a recognition of the reality of what the other person is feeling. 

When dealing with someone who is highly emotional, practice working from how things are, rather than how you wish them to be. Maybe you don’t think someone should be upset, but if they are, that is what you have to work with. Here are some tips on how to be validating:

  • Give the person your full attention

  • Observe and reflect what the other person is feeling (“ You seem very upset”)

  • Demonstrate acceptance and understanding (“It can be very hard when x happens”)

  • Avoid being judgmental (“You’re overreacting”), insincere (saying things you don’t really mean),

Give these tips a try, and you may find it helps when dealing with your high-emotion teen, calming them down faster, and strengthening your relationship.

Announcing our Summer Intensive DBT Program for Teens
Teen DBT Program

Summer 2019 we will be offering an intensive teen DBT program, for high schoolers and college freshman.

The schedule is condensed and accelerated, designed to fit an entire year’s worth of topics over summer break. Participants will meet twice a week for 90 minutes for DBT skills group, where they will cover all the same material taught in our regular courses. The course lasts 8 weeks.

They also have the option of meeting for 50 minutes weekly with an individual therapist. If your teen already has a therapist, they may be able to join us for just DBT skills group, and we will work with their therapist to ensure they are making progress.

Learn more about our DBT program to see what participants learn.

Components

Our Teen Summer Intensive DBT program has several components:

  • Twice weekly, 90 minute DBT Skills Groups (for 8 weeks).

  • Two, 2-hour Parent Groups. In Parent Group, we provide an overview of everything your teen is learning about. This will help you understand their new skills, and support them in applying them. This isn’t group therapy, and no sharing is required. We can accommodate 1 or 2 parents or guardians per teen. Parents groups meet on two Saturdays.

  • A custom program workbook with handouts and worksheets.

  • Optional: Weekly 50 minute individual therapy. Usually, you must have an individual therapist to participate in DBT Skills Group. For those that want or need it, we can offer individual therapy as well. If your teen is local, we can work around their schedule so they can continue to see their therapist after the program ends and the school year begins.

  • Optional: Therapist transition assistance. If your teen is a graduating senior going off to college, or a college freshman home for the summer, we can help them find a therapist to see during the next school year. We will also connect with their new therapist, and help with the transition.

Program Schedule & Cost

Our teen summer intensive DBT program for the summer of 2019 will be on Tuesdays and Thursdays, from 1:30-3:00. The first class meets on June 4th, and the last on July 25th. Parents classes are from 10:00-12:00 on Saturday June 8th, and Saturday July 13th.

Early-Bird Pricing is available until May, at $1500. The regular price is $2000. This includes 28-hours of DBT skills instruction, therapist location and transition assistance (for those leaving for college), and all materials. Your insurance may cover part of the cost, and we can provide you with a statement to seek reimbursement.

Can Your DNA Predict Therapy Success?
Borderline Personality Disorder and BPD

Research has identified several genes that may be important for the development of borderline personality disorder (BPD). Of special interest are epigenetic mechanisms: genes that may turn on or off depending on one’s experience.

What kind of experiences? Intense, early childhood experiences are no doubt important for the development of BPD. This includes different forms of maltreatment, abuse, and neglect. Those experiences contribute to the development of BPD, possibly through the activation or deactivation of certain genes.

A recent study examined three such genes and therapy outcome. The researchers examined 44 patients with BPD undergoing Dialectical Behavior Therapy (DBT). The results? They found a relationship between repression in two of the genes and therapy success. Two of the genes (APBA3 and MCF2) showed higher levels of “DNA methylation” on those persons for whom DBT was successful.

Why does this matter? In the future, it may be possible to predict whether or not DBT will be successful based on a genetic test. Eventually, it may be possible to tailor treatment for BPD (and other disorders) based upon one’s genetic makeup.

Improvement of Mindfulness Skills After Attending Dialectical Behavior Therapy Skills Group
DBT Mindfulness

A recent study examined 35 adults diagnosed with borderline personality disorder (BPD), attending a 20-week dialectical behavior therapy (DBT) skills group. The researchers were interested in improvements in mindfulness skills. They measured improvements in:

  • observing: noticing one’s surroundings and inner experiences

  • describing: labeling one’s sensations, observations, thoughts and feelings

  • acting with awareness: acting with attention

  • nonjudging of inner experience: experiencing thoughts and feelings without judgement

  • nonreactivity to inner experience: experiencing thoughts and feelings without emotionally reacting to them

They discovered increases in some facets of mindfulness. They discovered a relationship between acting with awareness and nonjudging of inner experience and reductions in BPD and depression symptoms.

In DBT skills classes, about every two months participants spend two weeks focusing just on mindfulness skills. Could it be beneficial to focus on acting with awareness and nonjudging of inner experience during those two weeks? Perhaps, if more research shows those factors contribute more to symptom improvement.

The Biological Basis of Borderline Personality Disorder (BPD)

According to the biosocial model of borderline personality disorder, BPD is the result of a complex interaction between biological vulnerabilities and the environment, which results in the development of the disorder. Of special interest are invalidating environments- those in which children’s emotional experiences are ignored, belittled, otherwise invalidated by caretakers. In some cases, this emotional mistreatment occurs along with verbal, physical or sexual abuse.

The biological vulnerabilities of interest are related to hyperreactivity (sensitive to cues, especially to negative stimuli) and hyperarousal (a higher baseline level of emotion, with a slower return to baseline). Research on borderline personality disorder in the biological sciences attempts to identify the genetic source of these vulnerabilities.

One current focus of research are genes governing the stress response, located in the the hypothalamic-pituitary-adrenal (HPA) axis. These region of the brain determines how people respond to stress, from interpersonal conflict to encountering a wild animal.

Future research will continue to identity relevant genes, while also examining epigenetic effects- the switching on or off of genes in response to the environment. That is, events such as child abuse can “activate” certain genes implicated in BPD. Eventually, it may be possible to “deactivate” those genes through medical intervention (gene therapy). It is also possible implicated genes do “turn off” over time in response to corrective environmental experiences (which can include therapy, such as DBT).

Reducing the Negative Consequences of Drinking

A recent study examined the use of "alcohol protective behaviors" used by college students experiencing PTSD symptoms. The authors explored the relationship between the negative consequences of alcohol use and PTSD symptoms. They noted that those symptoms were less in people who use "alcohol protective behaviors." This was especially true for women. What are these helpful behaviors?

First are "manner of drinking" strategies. These are ways to avoid the negative consequences of drinking, related to the method of drinking. For example, someone might choose to avoid drinking games, avoid hard liquor, or avoid taking shots.

Second are limiting strategies. These are ways to help to prevent the negative consequences of drinking by setting a limit on the number of drinks consumed. Before drinking, for example, someone may decide to limit themselves to three beers, or two glasses of wine.

Third are "serious harm reduction strategies," or attempts to directly prevent serious negative consequences. For example, one might intentionally not drive to an event with drinking, so there will be no chance to drive later while under the influence.

Studies have shown persons with certain mental health issues, such as PTSD, tend to use alcohol protective behaviors less often. A helpful intervention, therefore, might be to teach persons in therapy who are also experiencing negative consequences from alcohol use about the benefits of such strategies, and encourage their use. Such persons may or may not also be struggling with alcohol addiction. If they are, they may not be ready to reduce or stop their use. In either situation, alcohol protective behaviors could be a helpful addition to treatment.

alcohol consequences
Involving Significant Others in Borderline Personality Disorder Treatment
Family DBT

Most therapy is independent, conducted one-on-one, with the client and therapist working together. When couples are having relationship trouble they may seek couples counseling. Families may seek out family counseling to reduce interpersonal conflict and improve relationships. But, when there is one patient seeking treatment for a specific mental health issue, romantic partner involvement is usually neglected.

When someone with borderline personality disorder (BPD) seeks treatment, should romantic partners be included in treatment? BPD greatly impacts the ability to have stable, rewarding relationships. In addition, it can be very stressful for those who love someone diagnosed with BPD. It can be difficult to live with a partner who displays unpredicted shifts in mood, high levels of anger and conflict, self-harm, suicide attempts, and other risky behaviors.

There are many ways for those who love someone with BPD to get help. Persons can seek outside support and information. Persons can receive supportive therapy for themselves, ideally from a therapist experienced in treating borderline personality disorder. Or, such persons can be included in their loved one’s treatment. A recent study examined the inclusion of significant others in BPD treatment, and examined whether that lead to better outcomes for the persons with BPD.

The authors examined a number of previous studies that involved significant others in BPD treatment, including dialectical behavior therapy (DBT). One of the most promising techniques involved bringing in the client’s partners for a 2-hour training, on the CBT or DBT techniques the client was learning. This allowed the partners to better support the BPD client. For example, a partner could assist an upset client unable to remember which skill to apply… “Did you try X?”

Partner involvement is no doubt valuable, though there is a lack of systematic ways to accomplish this. Many DBT clinicians who do include significant others likely do so in an informal, case by case basis, and would likely benefit from a manualized approach.

Front Range Treatment Center
Treating Anxiety and Depression with "Transdiagnostic" Methods
Anxiety and Depression Treatment

At Front Range Treatment Center, we often use the Unified Protocol when treating clients with mixed depression and anxiety. The UP is a transdiagnostic treatment. What does this mean?

There is an ongoing debate amongst mental health researchers whether it is better to focus on developing ever more precise distinctions between disorders and disorder sub-types, or to focus on diagnostic groupings and emphasize common underlying processes that cut across multiple diagnoses and diagnostic categories (Norton & Paulus, 2016). The widespread use of the DSM encourages clinicians to make fine diagnostic distinctions, and thereby encourages the use of highly focused and diagnosis-specific treatments. However, some clinicians and researchers argue in favor of a diagnostic and treatment philosophy grounded in commonalities rather than distinctions. This debate of “splitting” versus “lumping” is especially lively amongst those who treat and research the mood disorders, with a growing number of persons emphasizing the consistent similarities amongst those with anxiety and depressive disorders.

One of the most popular transdiagnostic interventions is the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP). The UP was designed to address vulnerabilities common to persons with anxiety and depressive disorders, such as negative affect, negative attribution bias, and avoidant tendencies (Barlow et al., 2017). The UP has been found effective in reducing the symptoms of PTSD, as well as generalized anxiety disorder, panic disorder, phobias, major depressive disorder, borderline personality disorder, eating disorders, and substance abuse. The UP has been shown to reduce symptoms severity, improve affect, and improve daily functioning (Farchione et al., 2012).

There is also some evidence the UP has a lower attrition rate than single-diagnosis treatments. Barlow (2017) compared the efficacy of the Unified Protocol with diagnosis specific, single-disorder protocols (SDPs). They discovered the UP and SDPs were statistically equivalent in their efficacy. However, the UP group was significantly more likely to complete treatment than the SDP group.

Front Range Treatment Center