Borderline Borderline Personality Personality Disorder Disorder

in Primary Carein Primary CareSherie Ramsgard NPPSherie Ramsgard NPP

Psychiatry @ Psychiatry @ Syracuse University Syracuse University

Health ServicesHealth Services

Borderline Personality Disorder Borderline Personality Disorder (BPD)(BPD) Learning Objectives:Learning Objectives:

1.To understand prevalence and 1.To understand prevalence and related statistics of BPD that arerelated statistics of BPD that are important to primary care.important to primary care.

2.To understand the diagnostic 2.To understand the diagnostic criteria and conceptualization of BPD.criteria and conceptualization of BPD.

3.To discuss the use of structure, 3.To discuss the use of structure, boundary-setting, and constructive boundary-setting, and constructive responses to behavior in the context responses to behavior in the context of primary care treatment. of primary care treatment.

BPD: BPD: A Little Self Reflection…A Little Self Reflection…

What Do You Know?What Do You Know?• • What’s an individual with BPD like?What’s an individual with BPD like?

• • How do you feel when you hear that a How do you feel when you hear that a patient has BPD?patient has BPD?

• • How might you feel after seeing a How might you feel after seeing a patient with BPD?patient with BPD?

BPD: BPD: Prevalence and Related Prevalence and Related StatisticsStatistics

- - Most people have never heard of BPD Most people have never heard of BPD even though it accounts for even though it accounts for 1/4 of all 1/4 of all psychiatric hospital admissionspsychiatric hospital admissions..

- - Affects Affects primarily womenprimarily women..

- - The prevalence rate for the diagnosis The prevalence rate for the diagnosis of Borderline has been found to be of Borderline has been found to be 4 4 times higher in primary care (6.4%)times higher in primary care (6.4%) than in the than in the general population (1.6 general population (1.6 %).%).

BPD: BPD: Prevalence and Related Prevalence and Related StatisticsStatistics

Risky:Risky:- - Suicidal ideation very high in primary care Suicidal ideation very high in primary care

populations (21.4%)populations (21.4%)

- - Up to Up to 10% complete suicide10% complete suicide..

Underidentified in Primary Care:Underidentified in Primary Care:- About half of patients who have BPD were About half of patients who have BPD were

“recognized by their PCPs as having an “recognized by their PCPs as having an ongoing emotional or mental health ongoing emotional or mental health problem or had received mental health problem or had received mental health treatment during the past year”.treatment during the past year”.

Gross et al. (2002)Gross et al. (2002)

BPD Diagnosis: BPD Diagnosis: ControversialControversial

CONS:CONS: May be overdiagnosed by May be overdiagnosed by

clinicians who are frustrated by clinicians who are frustrated by a "difficult patient“.a "difficult patient“.

Stigma does exist. Stigma does exist.

The name Borderline Personality The name Borderline Personality Disorder seems to suggest the Disorder seems to suggest the condition is a personality flaw.  condition is a personality flaw. 

PROS:PROS: Appropriate referral for Appropriate referral for

treatment can be extremely treatment can be extremely helpful.helpful.

Recognizing BPD may enhance Recognizing BPD may enhance understanding patients with understanding patients with challenging behaviors.challenging behaviors.

Physicians may develop Physicians may develop rapport, feel less frustrated, rapport, feel less frustrated, and even have a therapeutic and even have a therapeutic effect by learning about BPD.effect by learning about BPD.

BPD: BPD: Diagnostic CriteriaDiagnostic CriteriaA pervasive pattern of instability of A pervasive pattern of instability of

interpersonal relationships, self- interpersonal relationships, self- image, and affects, and marked image, and affects, and marked impulsivity beginning by early impulsivity beginning by early adulthood and present in a adulthood and present in a variety of contexts.variety of contexts.

Five (or more) criteria Five (or more) criteria must be met for a must be met for a diagnosis of BPD. diagnosis of BPD.

BPD: BPD: Diagnostic CriteriaDiagnostic Criteria

Criteria reflect the individual’sCriteria reflect the individual’ssignificant difficulty significant difficulty

regulating…regulating…1.) 1.) EmotionsEmotions

** Shifts in mood usually lasting Shifts in mood usually lasting only only

a few hours and rarely more a few hours and rarely more than than

a few daysa few days

BPD: BPD: Diagnostic CriteriaDiagnostic Criteria

1.) 1.) Emotions Emotions (cont.)(cont.)

* * Anger that is Anger that is inappropriate, inappropriate, intense or intense or very difficult to control. very difficult to control.

BPD: BPD: Diagnostic CriteriaDiagnostic Criteria2.) 2.) ImpulsivityImpulsivity ** Self-destructive acts, such as self-mutilation or Self-destructive acts, such as self-mutilation or suicidal threats and gestures that happen more suicidal threats and gestures that happen more than once.than once.

BPD: BPD: Diagnostic CriteriaDiagnostic CriteriaSelf-destructive Acts/Self HarmSelf-destructive Acts/Self Harm

Those with BPD frequently feel overwhelmed or Those with BPD frequently feel overwhelmed or anxious and seek ways to reduce their anxious and seek ways to reduce their frustration, stress, or pain. frustration, stress, or pain.

Don’t have an outlet, so Don’t have an outlet, so self-injurious behaviors self-injurious behaviors may be experienced may be experienced as releasing pent-up as releasing pent-up emotions. emotions.

BPD: BPD: Diagnostic CriteriaDiagnostic Criteria2.) 2.) Impulsivity(contd.)Impulsivity(contd.)** Two potentially self-damaging impulsive Two potentially self-damaging impulsive

behavior patterns. behavior patterns. These could include:These could include:

alcohol and other drug abuse, alcohol and other drug abuse, compulsive spending,compulsive spending, eating disorders,eating disorders, gambling, gambling, shoplifting, shoplifting, compulsive sexual behavior,compulsive sexual behavior, reckless drivingreckless driving

BPD: BPD: Diagnostic CriteriaDiagnostic Criteria3.) 3.) Experience of selfExperience of self not knowing who one is or changing what not knowing who one is or changing what

one wants to do on a daily basisone wants to do on a daily basis

** Marked, persistent identity disturbance Marked, persistent identity disturbance shown by uncertainty in: self-image, shown by uncertainty in: self-image, sexual orientation, career choice or sexual orientation, career choice or other long-term goals, friendships, valuesother long-term goals, friendships, values..

BPD: BPD: Diagnostic CriteriaDiagnostic Criteria** Chronic feelings of emptiness or Chronic feelings of emptiness or

boredom.boredom. "I remember describing the feeling of "I remember describing the feeling of

having a deep hole in my stomach. An having a deep hole in my stomach. An emptiness that I didn't know how to fill.” emptiness that I didn't know how to fill.”

BPD: BPD: Diagnostic Criteria Diagnostic Criteria (contd.)(contd.)

4.) 4.) Cognitive experiencesCognitive experiences *transient,stress-related *transient,stress-related paranoid ideation or paranoid ideation or S severe dissociative S severe dissociative symptomssymptoms

(E(Experiencing things as unreal)xperiencing things as unreal)

BPD: BPD: Diagnostic Criteria Diagnostic Criteria (contd.)(contd.)

5.) 5.) Interpersonal relationshipsInterpersonal relationships** frantic efforts to avoid real or frantic efforts to avoid real or

imagined abandonment. imagined abandonment. Note:Note: Do not include Do not include suicidal or self-mutilating suicidal or self-mutilating behavior.behavior.

BPD: BPD: Diagnostic CriteriaDiagnostic Criteria

** a pattern of unstable and intense a pattern of unstable and intense interpersonal relationships characterized by interpersonal relationships characterized by alternating between extremes of idealization alternating between extremes of idealization and devaluation and devaluation (chaotic-love/hate)(chaotic-love/hate)

BPD: BPD: Diagnostic CriteriaDiagnostic CriteriaAdditional examples of dysregulation experiences in the area of Additional examples of dysregulation experiences in the area of relationships… relationships… (Goodwin, 1999)(Goodwin, 1999)

- - Alternating clinging and distancing behaviors (I Hate You, Don't Alternating clinging and distancing behaviors (I Hate You, Don't Leave Me). Leave Me).

- - Great difficulty trusting people and themselves. Great difficulty trusting people and themselves.

- - Sensitivity to criticism or rejection. Sensitivity to criticism or rejection.

- - Feeling of "needing" someone else to survive. Feeling of "needing" someone else to survive.

- - Heavy need for affection and reassurance.Heavy need for affection and reassurance.

- - People with BPD tend to have an unusually high degree of People with BPD tend to have an unusually high degree of interpersonal sensitivity, insight, and empathy.interpersonal sensitivity, insight, and empathy.

BPD: BPD: Conceptually Conceptually Speaking…Speaking…

Characteristics stem from the intensity of emotional Characteristics stem from the intensity of emotional instability: instability: Intensity of emotions leads to a tendency to perceive…Intensity of emotions leads to a tendency to perceive… others’ behavior as malevolent (related to inappropriate, others’ behavior as malevolent (related to inappropriate,

angry outbursts)angry outbursts) abandonment (even minor loss may be experienced as panic)abandonment (even minor loss may be experienced as panic) extreme emotional responses to intimacy (manifested in extreme emotional responses to intimacy (manifested in

splitting and idealization/devaluing)splitting and idealization/devaluing) dissociation (helps the patient separate from the intensity of dissociation (helps the patient separate from the intensity of

his/her emotions) his/her emotions)

BPD: BPD: Conceptually Speaking…Conceptually Speaking…Intensity of emotions leads to: Primitive Defense Intensity of emotions leads to: Primitive Defense

MechanismsMechanisms desperate, impulsive, often unhealthy attempts to make desperate, impulsive, often unhealthy attempts to make

themselves feel better or essentially, manage their emotions. themselves feel better or essentially, manage their emotions. What’s seen as manipulative or impulsive behaviors are What’s seen as manipulative or impulsive behaviors are

desperate attempts to obtain a response from their desperate attempts to obtain a response from their environment.environment.

The outcome of these behaviors may be soothing and The outcome of these behaviors may be soothing and empowering initially, but behaviors are often self-damaging empowering initially, but behaviors are often self-damaging in the long run.in the long run.

BPD: BPD: Conceptually Speaking…Conceptually Speaking… Difficult to have good relationships if you Difficult to have good relationships if you

can’t regulate emotionscan’t regulate emotionsbut…but…

without good relationships it’s also difficult without good relationships it’s also difficult to regulate emotions because much more to regulate emotions because much more emotionally vulnerable. emotionally vulnerable.

Cyclic problemCyclic problem

BPD: BPD: Conceptually Speaking…Conceptually Speaking… Individuals with BPD are born with anIndividuals with BPD are born with an innate innate biological tendencybiological tendency to react to react

more intensely to lower levels of stress more intensely to lower levels of stress than others and to take longer to than others and to take longer to recover. (Linehan, M.)recover. (Linehan, M.)

They were raised in environments in which their They were raised in environments in which their beliefs about themselves and their environment were continually beliefs about themselves and their environment were continually

devalueddevalued and invalidatedand invalidated These factors combine to create adults who are uncertain of the truth of These factors combine to create adults who are uncertain of the truth of

their own feelings and who are confronted by three basic dialectics they their own feelings and who are confronted by three basic dialectics they have failed to master (and thus rush frantically from pole to pole of):have failed to master (and thus rush frantically from pole to pole of):

vulnerability vs invalidationvulnerability vs invalidation

active passivity (tendency to be passive when confronted with a problem active passivity (tendency to be passive when confronted with a problem and actively seek a rescuer) vs apparent competence (appearing to be and actively seek a rescuer) vs apparent competence (appearing to be capable when in reality internally things are falling apart)capable when in reality internally things are falling apart)

unremitting crises vs inhibited grief. unremitting crises vs inhibited grief.

EFFECTS OF BPD ON HEALTHCARE EFFECTS OF BPD ON HEALTHCARE UTILIZATION for Primary Care:UTILIZATION for Primary Care:

Greater number of office visitsGreater number of office visits Greater number of prescriptionsGreater number of prescriptions Greater number of phone callsGreater number of phone calls More frequent specialist referralsMore frequent specialist referrals

BPD & SOMATIC PREOCCUPATIONBPD & SOMATIC PREOCCUPATION BPD affects immunity to medical illness?BPD affects immunity to medical illness?

BPD manifests first or BPD manifests first or only as somatic preoccupationonly as somatic preoccupation

BPD co-exists with genuine BPD co-exists with genuine medical medical

conditionsconditions

Classic BPD symptoms with Primary Care Classic BPD symptoms with Primary Care NuancesNuances

Medically Self Sabotaging Medically Self Sabotaging BehaviorBehavior - - Intentional self Intentional self harming behaviorsharming behaviors

Perceptions of Illness - Perceptions of Illness - BPD perceive themselves as more BPD perceive themselves as more disableddisabled

Pain Syndromes - Pain Syndromes - Disturbances in regulation of pain Disturbances in regulation of pain sensations & statesensations & statess

Prescription Misuse/Abuse - Prescription Misuse/Abuse - 64% have co-morbid 64% have co-morbid substance abuse problems. Self dysregulationsubstance abuse problems. Self dysregulation

HIV - HIV - Self regulation issues of substances abuse & promiscuitySelf regulation issues of substances abuse & promiscuity Skin Picking/Excoriation - Skin Picking/Excoriation - Self harm/mutilation of any kindSelf harm/mutilation of any kind Facticious Illness - Facticious Illness - the need to have a medical sxs. to elicit the need to have a medical sxs. to elicit

emotional involvement of othersemotional involvement of others

Other Medical Phenomena Associated Other Medical Phenomena Associated with BPDwith BPD

Plastic SurgeryPlastic Surgery BPD PS pts. requested higher number of areas for surgery, BPD PS pts. requested higher number of areas for surgery,

perceived PS as more serious, and had least satisfaction post op perceived PS as more serious, and had least satisfaction post op (body image issues)(body image issues)

Rheumatoid ArthritisRheumatoid Arthritis Rather than direct relationship, more likely mediated by early Rather than direct relationship, more likely mediated by early

developmental trauma & subsequent effects on immunitydevelopmental trauma & subsequent effects on immunity ObesityObesity

Associated difficulties with self regulation. Binge eating disorderAssociated difficulties with self regulation. Binge eating disorder DisabilityDisability

As BPD is often r/t childhood victimization, this theme often As BPD is often r/t childhood victimization, this theme often perpetuates itself in adulthood as medical disabilityperpetuates itself in adulthood as medical disability

BPD: BPD: Office ManagementOffice Management

1.) Structure, structure, structure1.) Structure, structure, structureActively structure the interviewActively structure the interview

Respond to repeated office calls by voicing Respond to repeated office calls by voicing commitment to the relationship within the context commitment to the relationship within the context of negotiated boundary setting.of negotiated boundary setting.

Schedule brief, frequent visits and give verbal Schedule brief, frequent visits and give verbal outline of the territory to be addressed in future outline of the territory to be addressed in future visits, when a long list of issues or new last-visits, when a long list of issues or new last-second issues are brought up.second issues are brought up.

LaForge, E. (2007)LaForge, E. (2007)

BPD: BPD: Office ManagementOffice Management2.) Remain calm and empathetic to diffuse hostility.2.) Remain calm and empathetic to diffuse hostility.

EEMPATHY MPATHY AATTENTION TTENTION RRESPECTESPECT

Respond to emotional outbursts by:Respond to emotional outbursts by: recognizing feelings while requesting appropriate behavior.recognizing feelings while requesting appropriate behavior.““I can see how you might be angry about this, and I’d like to I can see how you might be angry about this, and I’d like to

talk with you about it if you can lower your voice”.talk with you about it if you can lower your voice”.

If the patient does not respond:If the patient does not respond: voice awareness of the heightened emotion at present and voice awareness of the heightened emotion at present and

the need for a break until this is reduced, when the the need for a break until this is reduced, when the conversation will resume.conversation will resume.

BPD: BPD: Office ManagementOffice Management3.) Beware of Splitting3.) Beware of Splitting

Beware that agreeing with an a devalued view of Beware that agreeing with an a devalued view of another provider, may be a form of splitting, another provider, may be a form of splitting, unhelpful to the patient’s treatment.unhelpful to the patient’s treatment.

or that…or that…Being overly protective of another treater’s Being overly protective of another treater’s goodness, may invalidate the perceptions of the goodness, may invalidate the perceptions of the individual with BPD.individual with BPD.

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BPD: BPD: Office ManagementOffice Management4.) Look out for counter-transference4.) Look out for counter-transference

Positive counter-transference:Positive counter-transference: Clinician unconsciously respondsClinician unconsciously responds to idealization in a manner so as to idealization in a manner so as to continue extracting accolades from the patient. to continue extracting accolades from the patient.

((Ex. “giving in” to excessive special requests, responding to Ex. “giving in” to excessive special requests, responding to requests for medications that are not medically warranted.)requests for medications that are not medically warranted.)

Negative counter-transference:Negative counter-transference: Clinician unconsciously responds to devaluation by Clinician unconsciously responds to devaluation by

ignoring, avoiding, or devaluing complaints.ignoring, avoiding, or devaluing complaints.

BPD: BPD: Office ManagementOffice Management 5)Open honest discussion 5)Open honest discussion of the role of emotions/life of the role of emotions/life stressors in medical concerns.stressors in medical concerns.

Chronic rotating physical Chronic rotating physical complaints: attempt to focus complaints: attempt to focus on a specific complaint with on a specific complaint with brief discussion of patient’s brief discussion of patient’s psychosocial concerns.psychosocial concerns.LaForge, E. (2007) LaForge, E. (2007)

BPD: BPD: Office ManagementOffice Management6.) Partner-up for physical 6.) Partner-up for physical

examinations.examinations.

LaForge, E. (2007)LaForge, E. (2007)

BPD: BPD: Office ManagementOffice Management 7.) Educate about BPD if appropriate7.) Educate about BPD if appropriate

Reviewing the diagnostic criteria for BPD Reviewing the diagnostic criteria for BPD with the patient may lead the patient with the patient may lead the patient to feel to feel more understood by themore understood by the provider. This may help theprovider. This may help the patient accept patient accept treatment treatment efforts in general. efforts in general. LaForge, E. (2007)LaForge, E. (2007)

BPD: BPD: Office ManagementOffice Management8.) Know that suicide and self-harm will be issues.8.) Know that suicide and self-harm will be issues.

Patients with BPD are likely Patients with BPD are likely to acknowledge suicidal to acknowledge suicidal thoughts very commonly.thoughts very commonly.

Take these behaviors seriously, Take these behaviors seriously, assess and document consistently, assess and document consistently, consider options if needed, but also consider options if needed, but also know that suicidal ideation and self harm are ways in know that suicidal ideation and self harm are ways in which patients with BPD cope with their disorder.which patients with BPD cope with their disorder.If you are too uncomfortable with this, refer to If you are too uncomfortable with this, refer to

someone else.someone else. LaForge, E. (2007)LaForge, E. (2007)

- Drugs that enhance brain serotonin Drugs that enhance brain serotonin function may improve emotional function may improve emotional symptoms in BPD. symptoms in BPD. - Mood-stabilizing drugs that are known Mood-stabilizing drugs that are known to enhance the activity of GABA, the brain’s to enhance the activity of GABA, the brain’s major inhibitory neurotransmitter.major inhibitory neurotransmitter.

Psychopharmacological treatment of BPD is Psychopharmacological treatment of BPD is complex complex

and not expected to solve the problem. and not expected to solve the problem.

MedsMeds for Borderline? for Borderline?

Therapy is the primary mode for treating BPD, Therapy is the primary mode for treating BPD, so always consider this option as a primary so always consider this option as a primary

step.step. Dialectical Behavior TherapyDialectical Behavior Therapy

Is a cognitive-behavioral treatment program Is a cognitive-behavioral treatment program developed by Marsha Linehan, Ph.D. in the developed by Marsha Linehan, Ph.D. in the early 1980searly 1980s

5 CORE STRATEGIES:5 CORE STRATEGIES:1. Dialectics1. Dialectics2. Problem solving (2. Problem solving (behavior therapybehavior therapy))3. Acceptance (3. Acceptance (validationvalidation))4. Case management strategies4. Case management strategies5. Communication strategies 5. Communication strategies

Therapy for BPDTherapy for BPD

The Four Stages of DBT Individual The Four Stages of DBT Individual TherapyTherapy

Stage I: Moving From Being Out of

Control ofOne’s Behavior

to Being in Control

Stage II: Moving From

Being Emotionally Shut

Down to Experiencing

Emotions Fully

Stage III: Building an

Ordinary Life, Solving

Ordinary Life Problems

Stage IV: Moving From

Incompletenessto Completeness/

Connection

Goal:1.Keep client alive &2.Improve functioning

Targets1. Address life -threatening behaviorsand those thatinterfere with effectivetreatment and maydestroy quality of life2.Increase behavioral skills

Goal: 1. Help clientexperience emotions

Target:1. Increase emotionalExperiencing2. decrease emotional suffering

Goal:1. Help client dealwith problems ofeverydayliving

Target: 1.Focus onmanagement of aspects of daily living (e.g.,marital conflict, job dissatisfaction)

Goal: 1.Help client movetoward a life thatinvolves an ongoingcapacity for experiences of joy and freedom

Target: 1.Focus on helping client reach a sense ofconnectedness to agreater whole

CORE CORE MINDFULNESSMINDFULNESS

SKILLSSKILLS

1. What Skills? Observing Describing Participating

2. How Skills? Non

Judgementally One Mindfully Effectively

INTERPERSONAL EFFECTIVENESSINTERPERSONAL EFFECTIVENESSSKILLSSKILLS

Using Objectiveness Effectiveness: (DEARMAN)Using Objectiveness Effectiveness: (DEARMAN) D DescribeD Describe E ExpressE Express A AssertA Assert R ReinforceR Reinforce M MindfulM Mindful A Appear ConfidentA Appear Confident N NegotiateN Negotiate

Using Relationship Effectiveness: (GIVE)Using Relationship Effectiveness: (GIVE) G GentleG Gentle I InterestedI Interested V ValidateV Validate E Easy MannerE Easy Manner

Self Respect Effectiveness Self Respect Effectiveness (FAST)(FAST)

F Fair A Apologies (no Apologies) S Stick to value T Truthful

DISTRESS TOLERANCE SKILLS DISTRESS TOLERANCE SKILLS surviving without making surviving without making it worseit worse Distract – Wise Mind Distract – Wise Mind ACCEPTSACCEPTS

AActivities,ctivities,CContributing,ontributing,CComparisons omparisons ,opposite,oppositeEEmotions,motions,PPushing away,ushing away,TThoughts,houghts,SSensationsensations

Self Soothe – Use the Five SensesSelf Soothe – Use the Five Senses IMPROVE IMPROVE the moment the moment

IImagery, magery, MMeaning, eaning, PPrayer, rayer, RRelaxation, elaxation, OOne thing ne thing in the moment, in the moment, VVacation, acation, EEncouragedmentncouragedment

Pros and ConsPros and ConsMaking it worse by?/tolerating distress by?Making it worse by?/tolerating distress by?

Emotion RegulationEmotion Regulation* Teaches clients how to manage negative and* Teaches clients how to manage negative and overwhelming emotions while increasing their overwhelming emotions while increasing their positive experiencespositive experiences. . Three goalsThree goals::

1. Understand one’s emotions1. Understand one’s emotions Recognizing & naming emotions/Primary vs. secondary Recognizing & naming emotions/Primary vs. secondary

emotions/emotion Mythsemotions/emotion Myths 2. Reduce emotional vulnerability 2. Reduce emotional vulnerability ((PLEASE MASTERPLEASE MASTER))

PLPL – represents taking care of our physical health and treating pain – represents taking care of our physical health and treating pain and/or illness. and/or illness. EE – is for eating a balanced diet and avoiding excess – is for eating a balanced diet and avoiding excess sugar, fat, and caffeine. sugar, fat, and caffeine. AA – stands for avoiding alcohol and drugs, – stands for avoiding alcohol and drugs, which only exacerbate emotional instability. which only exacerbate emotional instability. SS – represents getting – represents getting regular and adequate sleepregular and adequate sleep.. EE – is for getting regular exercise. – is for getting regular exercise. MASTERMASTER – refers to doing daily activities that build confidence and competency.– refers to doing daily activities that build confidence and competency.

3. Decrease emotional suffering3. Decrease emotional suffering Letting Go & Opposite ActionLetting Go & Opposite Action

The primary care clinician is likely The primary care clinician is likely to have the to have the

essential role in essential role in initiating initiating

psychotherapy treatmentpsychotherapy treatment. . (Present as an adjunct, not a (Present as an adjunct, not a

replacement, for replacement, for primary care) – abandonment primary care) – abandonment

sensitivitysensitivity

If the patient hasn’t considered therapy, or has If the patient hasn’t considered therapy, or has previously resisted, the PCP is well-positioned to previously resisted, the PCP is well-positioned to create a functional and stable working relationship, create a functional and stable working relationship, that can facilitate the referral and embracing of that can facilitate the referral and embracing of therapy, possibly initiating a lifetime of change. therapy, possibly initiating a lifetime of change. (LaForge, 2007)(LaForge, 2007)

DBT RESOURCESDBT RESOURCES Individual & Group TherapyIndividual & Group Therapy Psychological HealthCare AssociatesPsychological HealthCare Associates Upstate Outpatient Psych. ServicesUpstate Outpatient Psych. Services

SELF HELP Skills training manuals SELF HELP Skills training manuals

On-Line – Apps. / Blogs / Forums / On-Line – Apps. / Blogs / Forums /