How much therapy/DBT is enough? Also, a ChatGPT pro tip

[pantherpanther]

Has anyone seen a spouse with BPD make real recovery?  Bonus points if they cheated and recovered to the point that you can focus productively on the relationship together.  If so, what level of commitment and intensity of therapy did it require?

My BPDw sees a therapist for 30 minutes every other week.  To his credit, he was quickly able to diagnose her, as  I suspected BPD for at least a decade.  Regardless, I feel like this is the equivalent of training for a marathon by going for a brisk walk on Sunday morning.

Their sessions have no apparent structure.  They seem to be along the lines of, "How are things, lately?"  She has gotten some coping advice, but there doesn't seem to be any structured approach toward DBT progress or even for her to really understand what BPD is.

Over the course of 6 months, she independently worked through a DBT workbook and has used techniques with a little bit of success.  She has some degree of self-motivation to improve, but doesn't grasp how critically important full transformation is.  The motivation may simply be to do enough to prevent me from leaving, as she's mortally afraid of abandonment.  When I suggest she do more, the reaction is textbook BPD, "I'll never be good enough for you," as if my desire to have a wife who is unlikely cheat on me again (intimately and financially) is the problem.  Sometimes this triggers a category 5 splitting episode, so I hesitate to even raise the concern.

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Separately, I've found this board + ChatGPT combined to be very useful for both BPD and infidelity assistance.  It's worth a try if you haven't already.  It will cite studies and stats.  It can help you find providers in your area.  Most importantly, you can ask follow up questions and dig deep.  It's given better advice than any therapist I've seen.  In the example below, I asked why studies say DBT is reputed for having such a high success rate, yet most anecdotal stories indicate it never really gets better.  The last line is key:

1. Long-Term Remission Is Statistically Likely — But Misleading 
Several long-term studies show high remission rates for BPD:

The McLean Study of Adult Development (MSAD) – the most cited longitudinal study:

88% of patients met criteria for remission at 10 years.

However, only 50% achieved sustained remission, and many still had significant symptoms (like emotional dysregulation, manipulation, and identity disturbance).

Relapse rates were around 30% after 2 years of remission.

Caveat: These statistics only apply to people who received intensive treatment (often inpatient and long-term DBT), which is rare outside of research settings.

[kells76]

Lot of great questions and stuff to discuss in your post.

My BPDw sees a therapist for 30 minutes every other week.  To his credit, he was quickly able to diagnose her, as  I suspected BPD for at least a decade.  Regardless, I feel like this is the equivalent of training for a marathon by going for a brisk walk on Sunday morning.

I'm looking at a career change and while unlikely, there is a small chance that I may need to pass a physical fitness test. My baseline is good but many others would be starting from zero. I Googled around to see what people going into this field typically do for training to pass the test, and many replies were "do the Couch To 5K program". This takes you from a "couch potato" (unable to run, or never have run) on day 1 to jogging for 30 minutes straight in week 9... but for all of week 1, you spend most of your time walking.

So, while it's not what we'd want, 30 min of therapy EOW is a start. We get to marathons by walking.

That's not to say that she's committed to change; only time will tell what her overall trajectory is, and what her motivation is. Just to say that if she's been essentially untreated for nearly 2 decades, she can't run a marathon right out of the gates, and she might not even have the skills (that you and I have) to tolerate the discomfort of therapy for an hour once a week. If her T really "has her number" then he may be being very deliberate in not overwhelming her, and laying a strong foundation of trust before pushing. He can't help her if she isn't there.

Hard to know -- I'm not there, and you know her better than anyone else -- but not impossible that that's what's going on.

Also important to know that unless you're in the session, you don't really know what they're talking about, either. She may come back and tell you "he just asks me how things have been" but unless you are in person hearing that, it could be anything else. They could be working on some shame stuff but she can't pull herself together to tell you. Recall that pwBPD lack even basic emotional management skills -- stuff you and I may take for granted. Trustbuilding and basic skillbuilding often have to happen in therapy before the pwBPD has the tools to address bigger behaviors.

Their sessions have no apparent structure.  They seem to be along the lines of, "How are things, lately?"  She has gotten some coping advice, but there doesn't seem to be any structured approach toward DBT progress or even for her to really understand what BPD is.

Again, hard to say based on this point in time how things will go. It's possible she found a "yes-man" therapist who doesn't want to rock the boat... it's possible she found a really canny T who absolutely understands what the deal is, and knows to go slowly.

Either way, there's a sense in which her understanding what BPD is, is not important... not as important as her having the tools and stability to work on behaviors that negatively effect her life and her family.

To me, that ties in to a book that I'd strongly recommend you check out (if you haven't already): "I am Not Sick I Don't Need Help! by Dr. Xavier Amador.

While he wrote it with schizophrenia in view (his late brother had it), the concepts apply to many mental health issues, and the one that really stuck out to me was:

people get help for things that they experience as problems, not things that we experience as problems.

This is a problem for you, not for her:

Over the course of 6 months, she independently worked through a DBT workbook and has used techniques with a little bit of success.  She has some degree of self-motivation to improve, but doesn't grasp how critically important full transformation is.

For her to be motivated, she needs to want to change things that she experiences as problems in her life. The things that you experience as problems (coming from her) aren't going to be what motivates her, so even though -- and I agree with you -- full commitment to DBT could be so helpful, trying to "get her to grasp" that is going to be a dead end right now, and just frustrate both of you. This dynamic often comes up with parents with BPD children -- the more the parent tries to get the child to see that "you should take a college class, you need to get a part time job, you have to enroll in therapy, you need to attend your therapy sessions", the more the child digs in and resists.

Again, these are good things! But you can't want it more than she does. There are still appropriate boundaries to have in life, but they are rules for your own life that you decide on for yourself. You are the only person who can decide if you can be married to a spouse who does 30 minutes of therapy every other week. It's not on her to do more to fix your problem... it's your choice to watch her trajectory and decide for yourself what you are and aren't able to live with, if that makes sense.

Anyway, I wonder if it might be helpful for you two, and take some pressure off the relationship, for there to be understanding that she is working on her problems, not your problems. (I'm not speaking to what she should be doing regarding how her choices impact you, only because she isn't here. There are plenty of things she should be doing, but it's not helpful to bring them up, because you're here, and she's not. I'm definitely not saying that there is nothing for her to work on, or that she shouldn't make changes in areas that you experience as problems). I'm guessing she can sense some "push" or "encouragement" from you, some sense that you want her to be doing more? What would happen if you dialed that back?

In the example below, I asked why studies say DBT is reputed for having such a high success rate, yet most anecdotal stories indicate it never really gets better.  The last line is key:

1. Long-Term Remission Is Statistically Likely — But Misleading 
Several long-term studies show high remission rates for BPD:

The McLean Study of Adult Development (MSAD) – the most cited longitudinal study:

88% of patients met criteria for remission at 10 years.

However, only 50% achieved sustained remission, and many still had significant symptoms (like emotional dysregulation, manipulation, and identity disturbance).

Relapse rates were around 30% after 2 years of remission.

Caveat: These statistics only apply to people who received intensive treatment (often inpatient and long-term DBT), which is rare outside of research settings.

Another interesting factoid to file away is that there is a lot of self-selection on these boards.

People generally don't join when they have a high functioning BPD spouse or family member where things are "mostly fine". And, people typically don't join when they have a low functioning pwBPD who is in long term treatment.

People frequently join when they have a "worst of both worlds" scenario -- a pwBPD in their life who isn't getting treatment at the moment and who isn't improving or a livable person to be around.

Theoretically, the "intractable" pwBPD in our lives could actually be the smaller % of all pwBPD... it's just that it's the majority of the pwBPD in the lives of members here, because the difficulty of the situation draws us to more support than we'd need with a much higher functioning pwBPD ("life is great most of the time") or a much lower functioning pwBPD ("it's difficult but I have a family support group and family therapy and individual therapy and skills group and... at the hospital my pwBPD is in").

It totally makes sense to me that 88% of patients in the study met remission criteria after 10 years, and at the same time, it's not like 88% of 10+ year members here are experiencing their pwBPD improve. We get the tough ones 

...

All that to say --

My H and I had a marriage counselor for a while, and he suspected that both my H's mom and my mom had BPD type traits. Both moms survived childhood abuse and my mom has been open about having cPTSD. Infidelity was never present in either of their relationships, so that is different, but both my H and I would agree that our moms have definitely calmed down a lot from our childhoods. Both of them had or have ongoing therapy and both have a significant spiritual support system. If they were assessed maybe 30-40 years ago they may have received a BPD diagnosis -- hard to say for sure -- but now they definitely would not, and things are not getting worse.

So anecdotally, yes, it is possible for persons with "BPD traits" to recover and go into remission. But neither of them would've been captured in the McLean study because neither needed or went to inpatient or long term DBT. And that doesn't mean that our childhoods were great or that our dads/stepdads had an easy time.

...

One more thought to toss back and forth: have you checked out the National Education Alliance for Borderline Personality Disorder's Family Connections program? It could be a good supplementary support for you, and they have a lot of very good, clinical, up-to-date research and training material. It's focused on making family life more livable when there's a pwBPD in the family structure (whether spouse, child, parent, ex, etc). When I took it last winter, it was clear they were looping in the most recent research they could, to their teaching and toolset.

I also appreciated their Family Guidelines for how to structure and navigate family life with a pwBPD, in a way that doesn't build frustration and resentment in you and me. It strikes a nice balance between: "OK, you're the non, so yes, there will be changes you make in how you interact" with "don't protect the pwBPD from the natural consequences of their choices". It's not all your fault... and, it's not all their fault. It's not all on them to make the changes... and, it's not all on you to make the changes. But everyone wants a more peaceful family life, so here are some guidelines to try.

I'd be really interested to hear your thoughts if you check out the NEABPD links and material, given that you're navigating this gray area of -- do I stay, is it good enough, do I go, the kids are older but not that old, she might be doing better but she might not. Having some guidelines to orient you could help provide you with structure as you're in a decision-making chapter in life.

None of this is easy... I get it.

[GaGrl]

Our family experience with my husband's ex, who is uNPD/BPD is with absolute intractability. We are older, so this is close to a lifetime of DH experiencing and observing her disordered behaviors. She has never had therapy, although she has promised to do so several times with her current partner, once going far enough to make an appointment, which she subsequently cancelled.

I would look at bi-weekly therapy and the DBT workbook as progress, albeit slow.

In some ways, Ex is better, in other ways, worse. She no longer has constant and blatant affairs -- this ended about 6-7 years ago. She still is terrified of abandonment but doesn't modify her behavior that pushes people away. She still charms people into friendship then takes advantage of their generosity. What"s new is an element of paranoia that didn't manifest earlier -- her house has cameras everywhere. She believes her partner sneaks out of the house at 3 AM to see women, so there are dead bolts on exterior doors and on TBE inside of their bedroom door -- she locks them in every night, then wears the key around her neck. Windows are nailed shut. It's so dangerous.

My stepdaughter and granddaughter have reached an ability to distance themselves and maintain contact. DH still gets an occasional panicked call.

[kells76]

Couple more thoughts to clear things up.

I think sometimes it can feel like there's an implied way you have to feel, if A is true or if A is not true:

"30 minutes EOW plus a DBT workbook is enough therapy" (then I guess I should feel happy?)
"30 minutes EOW plus a DBT workbook is enough therapy" (then I guess I should stay with her?)
"30 minutes EOW plus a DBT workbook is enough therapy" (so now I don't get to complain?)
"30 minutes EOW plus a DBT workbook is enough therapy" (so I'm the problem if I don't feel like it is?)

This sounds like a situation where many things can be true at the same time:

Like Gagrl mentioned,

I would look at bi-weekly therapy and the DBT workbook as progress, albeit slow.

Yes, EOW therapy and a DBT workbook is progress

and

that can still not be livable for you.

What she's doing for treatment is certainly one variable going into assessing your relationship. But it's not like "OK, well, now she's at weekly therapy plus two DBT workbooks, so I guess I have to stay and be happy?"

She can be doing a lot in therapy, and making progress... and, the relationship can be damaged enough that the two of you cannot resuscitate it.

Or:

she might only ever do this much in therapy, and never do more or really "improve"... and you could decide that you can live with that, and make a life worth living together.

Just feels like less of an either-or situation ("if she's improving, I stay; if she's not, I go"), and more of a both-and situation.

She's got her thing going on, with her own timeline... you can take that into account, and ultimately, you make your own choices about what you can live with.

She might make a "full recovery", but be a different enough person after recovery that the two of you cannot have a life together any more. She might not achieve full recovery, but you choose to be OK with that and make it work.

Hope that adds a little clarity to the discussion -- you're in the driver's seat for a lot of decisions, independent of whether she ever does enough therapy or not. That's something only you can decide for yourself.

Again, this is not easy stuff, at all, and I'm glad you've found multiple resources to lean on right now.

[zachira]

My understanding of DBT is it is intended for the most impaired people with BPD, involves intense individual and group therapy. Study after study of what makes therapy successful show that the relationship between the therapist and client are what determines the best outcomes and the modality used is less important. Many people who become therapists do so because they have serious psychological problems themselves. The really effective therapists have had therapy themselves, know they can't treat everybody, get help either through supervision and/or personal therapy when needed, and do their best to be aware of when they are impaired in treating a client because of transference of their own problems onto the client.

[ForeverDad]

Hope that adds a little clarity to the discussion -- you're in the driver's seat for a lot of decisions, independent of whether she ever does enough therapy or not. That's something only you can decide for yourself.

I just read kells' reply and as a retired programmer (actually, they retired me) all her ands, ors, ifs and maybe a couple buts too reminded me of the many possible outcomes when using AND, OR and NOT operators.  Some of the combinations can bend the mind.

Since you are both adults, you can make your decisions, just like she can do for herself.

[Notwendy]

I am not familiar with DBT but I would think that since BPD is on a spectrum, I think how much DBT and for how long would be individualized to a person. Also, since the behaviors can vary according to times of stress, or less stress- progress may not be completely linear- probably two steps forward, one step backwards, or circular sometimes- but one would see a trend over time. I don't know how the researchers tracked this.

I also would look at the long term. A quick change in behavior isn't long term change. Reading about what DBT addresses, I would look for improvement (progress, not perfection) in the areas of focus. .How does the person manage distress? They may still get upset but be able to "come down" sooner. Emotion regulation- rages don't last as long or may not be as extreme. Mindfulness- are they able to do that better? and interpersonal skills- are these improving some?

I think the decision to stay or leave is a personal one, made on one's own boundaries, tolerance, emotional well being and other personal circumstances, not on the progress of the other person, because that isn't a constant linear process. Everyone can have their own good and bad days. It seems you are willing to give this some time to observe. During this time, also look at any behaviors on your part that may be perpetuating the BPD behaviors- are you doing things to enable them? Enabling behaviors can interfere with the partner's progress. Also check in with your own emotional well being.

[pantherpanther]

The responses on this thread have been about 1000x more helpful than I could've hoped.  I appreciate the truly deep insights.  For anyone else dealing with BPD AND infidelity, I'll share one from a friend that has been really helpful -- "You don't have to decide now."  The tough part is that every day feels like carrying an anchor while waiting, helping, analyzing, and hoping for improvement.

Within the span of a few days, I discovered the affair, the debt, and BPD was diagnosed.  Ya know, pretty standard Christmas break.  Like many here, I'm prioritizing the kids above self.

[ForeverDad]

Like many here, I'm prioritizing the kids above self.

The children growing up in dysfunctional family environment definitely are negatively impacted by their experience.  Even if they desire not to experience it in their own future marriages, they can so easily end up, by being so familiar and used to the chaos, choosing mates who are like one or the other of the parents, either the parent who misbehaves almost to the point of abuse or the parent who passively appeases the other.

So what you can do is set an example of what is healthy behavior and healthy boundaries.  The dysfunction does not have to be passed on to future generations.

[BlueNavigator]

A LOT of great thoughts here--I learned a lot just reading through.

A few thoughts I will throw in. Before my wife wBPD was diagnosed, she attended therapy regularly. She had a great relationship with her therapist, and her therapist enjoyed her. The therapist validated everything my wife said. Even though I was going to graduate school full-time, providing all the financial support, and doing 50% of the chores (dishes, laundry, etc) the therapist would tell her all the time about how she must be tired and overwhelmed because of how overworked she is and ask me to take over things so she can have a break. When my wife finally saw a psychiatrist who diagnosed BPD on the second visit, my wife told the therapist who said, "No way!" The therapist promised to learns "some DBT" and teach it to her but that never really happened either.

Therapy isn't like McDonald's--where if I order a Big Mac in Chicago or LA it's basically the same. It varies a lot.

My wife has done two DBT groups (and is signing up for a third), and they've been helpful, especially in the short term.

Your wife will have the relationships (including therapy relationships) of her choosing. And the same goes for you! Don't let therapy be weaponized against you--making it a condition of the relationship. Stay or leave based on what you want and how you are treated.