Choosing Recovery

Right now, I am fighting within myself. I’m battling the symptoms of my mental health diagnosis. I’m arguing with myself and the voices I hear that nobody else hears. See, one of the diagnosis I have is Major Depressive Disorder (MDD) with psychotic features. That means when my depression act up I hallucinate. Actually, I have what they call auditory hallucinations which means I hear things that nobody else hear and aren’t real.

I’m telling you this as I don’t choose to have a mental health condition/challenge but I do choose to be in recovery. I may not being doing well at the moment however, I am choosing to fight against the urges to self harm and what the voices are telling me to do.

My voices are encouraging me to act on the urges to self harm. I of course am NOT going to act on the urges or what the voices are encouraging me to do. I am choosing to NOT act them because I have the tools (or skills) to help myself. To help myself to NOT self harm by using Dialectical Behavior Therapy (DBT) skills.

Using the DBT skill I’ve learned over the last fourteen years is what has saved my life. It’s what has helped me start my recovery and remain in recovery despite set backs or “relapses.” I choose get back up and wipe the dust off when I do relapse in self harm behavior.

In fact when I realized that my self harm urges were high and that the voices were encouraging me to act on them, I contacted my treatment team to help me through. The person who helped gave me some encouragement as well as some suggestions they know that helps me. One of those suggestions was (and is) blogging. However, before I chose to take the persons suggestion to blog, I did a couple of other suggestions first so I could blog in a better head space. I first ate something and then I went for a three mile walk. After eating and going for a walk, it put me in a better head space to be able to write this blog post.

In fact blogging is helping me at the moment however, I am going to go do other DBT skills now. So, yes that means I will be ending this blog post. FYI: I AM CURRENTLY NOT DANGER TO MYSELF OR ANYONE ELSE. (In fact I’ve NEVER been a danger to anyone else.) I hope everyone has a good rest of their day. Peace Out, World!!!

A Major F*ck Up (Contains Graphic Images)

GRAPHIC IMAGES

(IN THIS POST)

It’s two o’clock in the morning on Monday, October 16th of 2017. This particular blog post is not going to be a pretty one. It’s not going to be a pretty one because, I’m not only going to be discussing what happened on Saturday night but showing you images. IMAGES THAT ARE QUITE GRAPHIC!!!

(SIDE NOTE: Before I continue on with this post I want to reassure you that I am NOT suicidal and I DON’T feel like harming myself at the moment. If I were to become suicidal and/or feel like self harming, I will take myself to the hospital like I did Saturday.)

Saturday night was not the most pleasant of days for me. Both my PTSD and Depression symptoms got the better of me. So much so that I ended up cutting myself. I scared myself so much by cutting myself that I called two close friends who took me to the hospital to get evaluated. I would have called Junior however he was working at the moment and didn’t need him to worry as he is a firefighter.

As I was stating my friends took me to the Emergency Room where my wounds got treated and I got evaluated for my state of mind. Everyone was in agreement that I could (and still can) remain safe and was able to return home.

I stayed with my friends till Junior got off work. He picked me up from my friends house. He looked at my wounds and redressed them. We discussed on what I could do the next time things go this bad. Next time I won’t be so hesitant to reach out for support of friends are so fearful of calling 911.

Part of the reason why I ended up cutting on Saturday night was because I was fearful of my symptoms and angry that I was having them. I did end up getting some stitches. You may or may not be able to see the stitches but wanted to fore warn you.

(FYI: I AM NOT CURRENTLY SUICIDAL!!! I CURRENTLY DO NOT FEEL LIKE HARMING MYSELF.)

THE BELOW IMAGES ARE GRAPHIC:

 

I just want to show you the realities of what happens when I am in an extremely bad head space. This is why I am grateful that I have a great support system. I am beyond grateful that I have a loving partner and awesome friends who are in my corner.

Thank you for reading my blog. I truly apologize if I triggered anyone with this particular blog post. Again, I want to reiterate: I AM NOT CURRENTLY SUICIDAL AND I DON’T WANT TO HARM MYSELF IN ANY WAY. I’M NOT A RISK OF HARMING MYSELF OR ANYONE ELSE. Again, I want to thank for reading my blog. I hope I didn’t trigger anyone. If I did, I truly do apologize. I hope everyone has a good Monday. Have a good work week everyone and Peace Out, World!!!

 

 

Tattoo of Hope

IMG_0001.JPG

Good Morning!! I hope everyone is having a good weekend. If you regularly read my blog you know that I got a new tattoo yesterday. In fact the tattoo I got yesterday evening is pictured above.

I have wanted to get a butterfly tattoo for several years now for several reasons. The main reason is that a butterfly is a sign of hope. Hope that all the struggles one goes through that beauty is on the other side. Think of the caterpillar and the darkness it goes through when it is in a cocoon and out from the cocoon the beauty of the butterfly emerges.

This is how I view recovery. Not just my recovery but other’s recovery. Knowing that the beauty of recovery looks differently  to each person and each person is in recovery from different issues.

For me my recovery is from a mental illness and cutting as well as eating disorders. Granted I have been in recovery from the eating disorders longer than my mental health issues but it is still recovery. I also am in recovery from cutting.

As you can see in the picture, I have scars from the cutting and that the butterfly covers up some of those scars. Scars that may look fresh but are not.  I purposely had the butterfly placed where it is because I wanted to show the beauty of what recovery looks like despite the scars I have, both visible and invisible to the eye.

Thank you for reading. I appreciate each and everyone of you and hope that what I blog about has meaning to someone just like my both my tattoos have meaning to me. Have a great weekend and peace out.

Looking Forward To Tomorrow

It’s been a long day and continues get longer. I, of coursed worked today and now I am waiting to start a Warm Line shift. I decided that I would fill in for someone who needed to take the day off from their shift. Others have done it for me so I will do it for others. I know I’m going to be tired by the end of my volunteer shift since I worked today as well but I am looking forward to tomorrow.

I am looking forward to tomorrow because at this time tomorrow I will be getting my second tattoo. I am going to be getting a butterfly on my right shoulder. I emailed an idea of the butterfly tattoo I desire to my tattoo artist informing him that the image I sent him was an idea of how I want the butterfly and would like his artistic style to the butterfly as well. From my understanding he is grateful for the idea and is “thrilled” to be able add his own style to the butterfly tattoo I emailed him. It was and is just an idea of how I would like the idea.

The placement of my tattoo will be covering up some scars on my shoulder. Scars that people always assume that are “fresh” when they are not. They just happened to be keloid scars. If you regularly read my blog you know that I have had issues with cutting myself in the height of my mental illness.

It seems that all the tattoo’s I plan on getting including the one I have and the butterfly I am getting tomorrow all have some meaning to me in regards to my mental illness. Most if not all I am going to get will be recovery related. Two or three will help bring awareness to mental illness like the semi-colon tattoo I already have. The butterfly has meaning to me as well and yes it involves my recovery dealing with mental illness. I will share with you the meaning behind it, tomorrow evening or Saturday morning when I do my weekly check in. Hell, I might just do an entire post on just my new tattoo after I get it. Yes, I will put up a picture of it on my blog.

I need to get going. My Warm Line shift is about to start. Have a wonderful evening. I hope to do another post tomorrow evening, weather it’s my weekly check in or about my butterfly tattoo. Peace Out!!!

Daily Prompt: Tattoo….You?

1030151853In response to The Daily Post’s writing prompt: “Tattoo….You?.” Do you have a tattoo? If so, what’s the story behind your ink? If you don’t have a tattoo, what might you consider getting emblazoned on you skin?

I just wanted to share with you all my first tattoo. In fact I got it yesterday, Friday, October 30, 2015. I got the semi-colon for a multitude of reasons and all of them are in regards to mental health. As some of you may or may not know that there is a project out there call Project Semi-Colon. It was created, if I’m not mistaken, to bring awareness to the stigma of cutting even in the mental health world. It was also created to bring awareness to those who deal with depression, anxiety and other such mental health diagnoses as well as those who lost their life to suicide. Another thing is that life is similar to a semi-colon; A semi-colon is used when a sentence could have been ended but wasn’t.

I personally got the semi-colon to remind myself how far I have come in my recovery and how many times I could have ended my life. In fact I have tried to take my life on many different occasions yet those attempts weren’t successful. Thankfully those attempts were intercepted by a semi-colon because clearly my story isn’t over. It isn’t over because I can share my recovery story with others. My story isn’t over because I can discuss how my life has been affected by mental illness to not only help others but to help lessen the stigma of mental illness.

Now on to why I chose the color I did. As you can tell from the picture my semi-colon tattoo is outlined in black and in filled in with purple. The purple has special meaning to me. When I was struggling a few years back my therapist reminded me to not think in black or white but shades of gray. I informed her that shades of gray weren’t exactly easy to do because it was gray out and it was depressing. She then suggested white and red would come up with shades of pink and she quickly remembered I’m not exactly a pink kind of woman. I then came up with red and blue which make purple. Long story short the purple is to help me think in shades of gray but only in color. Purple also has other meanings to me.

As you can tell, I basically got the semi-colon tattoo to help start a conversation about mental health issues. If just one conversation about my tattoo helps lessen the stigma with mental illness then it’s done its job.

Thank you for reading. Have a good day. Stay safe out there today and have fun. Happy Halloween.

Self-Injury, Self-harm, Cutting & Other Such Info

I realize it is Saturday and that I forgot to do my Friday Feature on educating you all. I apologize for it being late. I have decided to get the info from Mental Health America at: http://www.mentalhealthamerica.net/self-injury  I have decided to do cutting and other self harm.

Self-injury

What is it?

  • Self-injury, also known as cutting or self-mutilation, occurs when someone intentionally and repeatedly harms herself/himself. The method most often used is cutting but other common behaviors include burning, punching, and drinking something harmful, like bleach or detergent.

Who does it?

  • It’s estimated that about two million people in the U.S. injure themselves in some way.  The majority are teenagers or young adults with young women outnumbering young men. They are of all races and backgrounds.

Why?

  • Often, people say they hurt themselves to express emotional pain or feelings they can’t put into words.
  • It can be a way to have control over your body when you can’t control anything else in your life. A lot of people who cut themselves also have an eating disorder.
  • Although they usually aren’t trying to kill themselves, sometimes they’re unable to control the injury and die accidentally.

How can I help a friend with this?

  • Ask about it. If your friend is hurting herself, she may be glad to have you bring it up so she can talk about it.  If she’s not injuring herself, she’s not going to start just because you said something about it.
  • Offer options but don’t tell him what he has to do or should do.  If he is using self-injury as a way to have some control, it won’t help if you try to take control of the situation.  Helping your friend see ways to get help – like talking to a parent, teacher, school counselor or mental health professional- may be the best thing you can do for him.
  • Seek support.  Knowing a friend is hurting herself this way can be frightening and stressful. Consider telling a teacher or other trusted adult. This person could help your friend get the help she needs. You may feel that you don’t have the right to tell anyone else.  But remember, you can still talk to a mental health professional about how the situation is affecting you, or you can get more information and advice from any number of organizations.
  • Remember you’re not responsible for ending the self-abuse.  You can’t make your friend stop hurting himself or get help from a professional. The only sure thing you can do is keep being a good friend.

How can I help myself?

  • Know that help is available.  Treatment is available for people who injure themselves. To learn about it, try talking to a professional person around you, someone like your school counselor.  If you’re not comfortable with that, think about contacting your local mental health association or checking out the S.A.F.E Alternatives website.
  • Know you are not alone.  Because so many people are self-injurers, it’s likely that there are people around who can understand and can help.
  • Know you can get better.  This is a difficult time in your life.  However, with help, you can get to the point where you don’t hurt yourself anymore.
  • Get help. Now is the best time to get help with this problem. If you wait, the problem will only get bigger and soon everyone will know about it.  But if you find a way to meet it head on today, you’ll be free of it and free to get on with your life. Free! A good way to be.
  • Your school’s counseling center

Warning Signs

Self-Injury is also termed self-mutilation, self-harm or self-abuse. The behavior is defined as the deliberate, repetitive, impulsive, non-lethal harming of one’s self. Self-injury includes: 1) cutting, 2) scratching, 3) picking scabs or interfering with wound healing, 4) burning, 5) punching self or objects, 6) infecting oneself, 7) inserting objects in body openings, 8) bruising or breaking bones, 9) some forms of hair-pulling, as well as other various forms of bodily harm. These behaviors, which pose serious risks, may by symptoms of a mental health problem that can be treated.

  • Warning Signs. Warning signs that someone is injuring themselves include: unexplained frequent injury including cuts and burns, wearing long pants and sleeves in warm weather, low self-esteem, difficulty handling feelings, relationship problems, and poor functioning at work, school or home.
  • Incidence & onset. Experts estimate the incidence of habitual self-injurers is nearly 1% of the population, with a higher proportion of females than males. The typical onset of self-harming acts is at puberty. The behaviors often last 5-10 years but can persist much longer without appropriate treatment.
  • Background of self-injurers. Though not exclusively, the person seeking treatment is usually from a middle to upper class background, of average to high intelligence, and has low self-esteem. Nearly 50% report physical and/or sexual abuse during his or her childhood. Many report (as high as 90%), that they were discouraged from expressing emotions, particularly anger and sadness.
  • Behavior patterns. Many who self-harm use multiple methods. Cutting arms or legs is the most common practice. Self-injurers may attempt to conceal the resultant scarring with clothing, and if discovered, often make excuses as to how an injury happened.
  • Reasons for behaviors. Self-injurers commonly report they feel empty inside, over or under stimulated, unable to express their feelings, lonely, not understood by others and fearful of intimate relationships and adult responsibilities. Self-injury is their way to cope with or relieve painful or hard-to-express feelings, and is generally not a suicide attempt. But relief is temporary, and a self-destructive cycle often develops without proper treatment.
  • Dangers. Self-injurers often become desperate about their lack of self-control and the addictive-like nature of their acts, which may lead them to true suicide attempts. The self-injury behaviors may also cause more harm than intended, which could result in medical complications or death. Eating disorders and alcohol or substance abuse intensify the threats to the individual’s overall health and quality of life.
  • Diagnoses. The diagnosis for someone who self-injures can only be determined by a licensed psychiatric professional. Self-harm behavior can be a symptom of several psychiatric illnesses: personality disorders (esp. borderline personality disorder); bipolar disorder (manic depression); major depression; anxiety disorders (esp. obsessive-compulsive disorder); as well as psychoses such as schizophrenia.
  • Evaluation. If someone displays the signs and symptoms of self-injury, a mental health professional with self-injury expertise should be consulted. An evaluation or assessment is the first step, followed by a recommended course of treatment to prevent the self-destructive cycle from continuing.
  • Treatment. Self-injury treatment options include outpatient therapy, partial (6-12 hours a day) and inpatient hospitalization. When the behaviors interfere with daily living, such as employment and relationships, and are health or life-threatening, a specialized self-injury hospital program with an experienced staff is recommended.

The effective treatment of self-injury is most often a combination of medication, cognitive/behavioral therapy, and interpersonal therapy, supplemented by other treatment services as needed. Medication is often useful in the management of depression, anxiety, obsessive-compulsive behaviors, and the racing thoughts that may accompany self-injury. Cognitive/behavioral therapy helps individuals understand and manage their destructive thoughts and behaviors. Contracts, journals, and behavior logs are useful tools for regaining self-control. Interpersonal therapy assists individuals in gaining insight and skills for the development and maintenance of relationships. Services for eating disorders, alcohol/substance abuse, trauma abuse, and family therapy should be readily available and integrated into treatment, depending on individual needs.

In addition to the above, successful courses of treatment are marked by 1) patients who are actively involved in and committed to their treatment, 2) aftercare plans with support for the patient’s new self-management skills and behaviors, and 3) collaboration with referring and other involved professionals.

I’m sorry for it being so long. Thank you for reading. Have a wonderful weekend and Peace Out!!!

Giving Haiku Another Try

Apparently when I first tried a Haiku style poem the first time, I didn’t do correctly so here I am giving it another try because I really want to learn this style of poetry and do it correctly. I hope you all enjoy the following poem:

Untitled Haiku

(for now)

by Gertie

Gloomy days are sad

Sad enough to cut myself

Refusing to cut

As you can tell many of my poems come real life. My life. My life of living with a mental illness and how poetry plays a major part of my recovery process. Poetry comes naturally to me and find it frustrating when I have to spend  thirty minutes on one. No the above poem didn’t take me thirty minutes do but yesterdays took me that long. It usually takes me about five to fifteen minutes to create a poem. I love writing poem because it therapeutic for me. Thank you for reading. Have an awesome weekend.

Writing 201: Poetry; Day Five: Map, Ode, Metaphor

Railroad

by Gertie

The scars on her arms are like a railroad,

A railroad map to where her life was;

And where it is she is going. Now she has a cause.

A cause that no longer makes her an ugly toad.

A toad that now helps others to recover.

As this toad has turned human she now has a lover.

A lover that is her by her side,

And who is full of pride

To be apart of a strong woman’s life.

A life that no longer is full of internal strife.

Dialectical Behavior Therapy (DBT)

Happy Friday!!! It being Friday, that means it is time for me to do my educational feature. I have decided to do the topic of Dialectical Behavior Therapy (DBT). The reason being is because I did the topic of Borderline Personality Disorder (BPD). I got the following information off of the  Linehan Institute; Behavior Tech at:   http://behavioraltech.org/resources/whatisdbt.cfm

What is DBT?

Overview

Dialectical Behavior Therapy (DBT) is a cognitive behavioral treatment that was originally developed to treat chronically suicidal individuals diagnosed with borderline personality disorder (BPD) and it is now recognized as the gold standard psychological treatment for this population. In addition, research has shown that it is effective in treating a wide range of other disorders such as substance dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders.

What are the components of DBT?

In its standard form, there are four components of DBT: skills training group, individual treatment, DBT phone coaching, and consultation team.

  1. DBT skills training group is focused on enhancing clients’ capabilities by teaching them behavioral skills. The group is run like a class where the group leader teaches the skills and assigns homework for clients to practice using the skills in their everyday lives. Groups meet on a weekly basis for approximately 2.5 hours and it takes 24 weeks to get through the full skills curriculum, which is often repeated to create a 1-year program. Briefer schedules that teach only a subset of the skills have also been developed for particular populations and settings.
  2. DBT individual therapy is focused on enhancing client motivation and helping clients to apply the skills to specific challenges and events in their lives. In the standard DBT model, individual therapy takes place once a week for as long as the client is in therapy and runs concurrently with skills groups.
  3. DBT phone coaching is focused on providing clients with in-the-moment coaching on how to use skills to effectively cope with difficult situations that arise in their everyday lives. Clients can call their individual therapist between sessions to receive coaching at the times when they need help the most.
  4. DBT therapist consultation team is intended to be therapy for the therapists and to support DBT providers in their work with people who often have severe, complex, difficult-to-treat disorders. The consultation team is designed to help therapists stay motivated and competent so they can provide the best treatment possible. Teams typically meet weekly and are composed of individual therapists and group leaders who share responsibility for each client’s care.

What skills are taught in DBT?

DBT includes four sets of behavioral skills.

  • Mindfulness: the practice of being fully aware and present in this one moment
  • Distress Tolerance: how to tolerate pain in difficult situations, not change it
  • Interpersonal Effectiveness: how to ask for what you want and say no while maintaining self-respect and relationships with others
  • Emotion Regulation: how to change emotions that you want to change

There is increasing evidence that DBT skills training alone is a promising intervention for a wide variety of both clinical and nonclinical populations and across settings.

What does “dialectical” mean?

The term “dialectical” means a synthesis or integration of opposites. The primary dialectic within DBT is between the seemingly opposite strategies of acceptance and change. For example, DBT therapists accept clients as they are while also acknowledging that they need to change in order to reach their goals. In addition, all of the skills and strategies taught in DBT are balanced in terms of acceptance and change. For example, the four skills modules include two sets of acceptance-oriented skills (mindfulness and distress tolerance) and two sets of change-oriented skills (emotion regulation and interpersonal effectiveness).

How does DBT prioritize treatment targets?

Clients who receive DBT typically have multiple problems that require treatment. DBT uses a hierarchy of treatment targets to help the therapist determine the order in which problems should be addressed. The treatment targets in order of priority are:

  1. Life-threatening behaviors: First and foremost, behaviors that could lead to the client’s death are targeted, including all forms of suicidal and non-suicidal self-injury, suicidal ideation, suicide communications, and other behaviors engaged in for the purpose of causing bodily harm.
  2. Therapy-interfering behaviors: This includes any behavior that interferes with the client receiving effective treatment. These behaviors can be on the part of the client and/or the therapist, such as coming late to sessions, cancelling appointments, and being non-collaborative in working towards treatment goals.
  3. Quality of life behaviors: This category includes any other type of behavior that interferes with clients having a reasonable quality of life, such as mental disorders, relationship problems, and financial or housing crises.
  4. Skills acquisition: This refers to the need for clients to learn new skillful behaviors to replace ineffective behaviors and help them achieve their goals.

Within a session, presenting problems are addressed in the above order. For example, if the client is expressing a wish to commit suicide and reports recurrent binge eating, the therapist will target the suicidal behaviors first. The underlying assumption is that DBT will be ineffective if the client is dead or refuses to attend treatment sessions.

What are the stages of treatment in DBT?

DBT is divided into four stages of treatment. Stages are defined by the severity of the client’s behaviors, and therapists work with their clients to reach the goals of each stage in their progress toward having a life that they experience as worth living.

  1. In Stage 1, the client is miserable and their behavior is out of control: they may be trying to kill themselves, self-harming, using drugs and alcohol, and/or engaging in other types of self-destructive behaviors. When clients first start DBT treatment, they often describe their experience of their mental illness as “being in hell.” The goal of Stage 1 is for the client to move from being out of control to achieving behavioral control.
  2. In Stage 2, they’re living a life of quiet desperation: their behavior is under control but they continue to suffer, often due to past trauma and invalidation. Their emotional experience is inhibited. The goal of Stage 2 is to help the client move from a state of quiet desperation to one of full emotional experiencing. This is the stage in which post-traumatic stress disorder (PTSD) would be treated.
  3. In Stage 3, the challenge is to learn to live: to define life goals, build self-respect, and find peace and happiness. The goal is that the client leads a life of ordinary happiness and unhappiness.
  4. For some people, a fourth stage is needed: finding a deeper meaning through a spiritual existence. Linehan has posited a Stage 4 specifically for those clients for whom a life of ordinary happiness and unhappiness fails to meet a further goal of spiritual fulfillment or a sense of connectedness of a greater whole. In this stage, the goal of treatment is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom.

How effective is DBT?

Research has shown DBT to be effective in reducing suicidal behavior, non-suicidal self-injury, psychiatric hospitalization, treatment dropout, substance use, anger, and depression and improving social and global functioning. For a review of the research on DBT, click here. In this video, DBT Developer and Behavioral Tech founder Dr. Marsha Linehan describes the amazing changes she’s seen in people who have received DBT and gotten out of hell.

Dive Deeper

Philosophy and Principles of DBT

DBT is based on three philosophical positions. Behavioral science underpins the DBT bio-social model of the development of BPD, as well as the DBT behavioral change strategies and protocols. Zen and contemplative practices underpin DBT mindfulness skills and acceptance practices for both therapists and clients. DBT was the first psychotherapy to incorporate mindfulness as a core component, and the Mindfulness skills in DBT are a behavioral translation of Zen practice. The dialectical synthesis of a “technology” of acceptance with a “technology” of change was what distinguished DBT from the behavioral interventions of the 1970s and 1980s. Dialectics furthermore keeps the entire treatment focused on a synthesis of opposites, primarily on acceptance and change, but also on the whole as well as the parts, and maintains an emphasis on flexibility, movement, speed, and flow in the treatment.

True to dialectics, DBT strategies are designed in pairs representing acceptance (validation, reciprocal communication, environmental intervention on behalf of the client) and change (problem solving, irreverence, consultation-to-the-patients about how they can change their own environment). Strategies are further divided into procedures; a set of principles guides the selection of strategies and procedures depending on the needs of the individual client. Clients are also taught a series of behavioral skills designed to promote both acceptance and change. A focus on replacing dysfunctional behaviors with skillful behaviors is woven throughout DBT.

DBT is a principle-based treatment that includes protocols. As a principle-based treatment, DBT is quite flexible due to its modular construction. Not only are strategies and procedures individualized, but various aspects of the treatment, such as disorder-specific protocols, can be included or withdrawn from the treatment as needed. To guide therapists in individualizing priorities for targeting disorders and behavioral problems, DBT incorporates a concept of levels of disorder (based on severity, risk, disability, pervasiveness, and complexity) that in turn guides stages of treatment and provides a hierarchy of what to treat when for a particular patient. In contrast, skills training is protocol based. Once a skills curriculum is determined, what is taught in a session is guided by the curriculum, not by the needs of a single client during that session.

The Development of DBT

In the late 1970s, Marsha M. Linehan attempted to apply standard Cognitive Behavior Therapy (CBT) to the problems of adult women with histories of chronic suicide attempts, suicidal ideation, and non-suicidal injury. Trained as a behaviorist, she was interested in treating these and other discrete behaviors. Through consultation with colleagues, however, she concluded that she was treating women who met criteria for Borderline Personality Disorder (BPD). In the late 1970s, CBT had gained prominence as an effective psychotherapy for a range of serious problems. Dr. Linehan was keenly interested in investigating whether or not it would prove helpful for individuals whose suicidality was in response to extremely painful problems. As she and her research team applied standard CBT, they encountered numerous problems with its use. Three were particularly troublesome:

  1. Clients receiving CBT found the unrelenting focus on change inherent to CBT to be invalidating. Clients responded by withdrawing from treatment, by becoming angry, or by vacillating between the two. This resulted in a high drop-out rate. If clients do not attend treatment, they cannot benefit from treatment.
  2. Clients unintentionally positively reinforced their therapists for ineffective treatment while punishing their therapists for effective therapy. For example, the research team noticed through its review of taped sessions that therapists would “back off” pushing for change of behavior when the client’s response was one of anger, emotional withdrawal, shame, or threats of self-harm. Similarly, clients would reward the therapist with interpersonal warmth or engagement if the therapist allowed them to change the topic of the session from one they did not want to discuss to one they did want to discuss.
  3. The sheer volume and severity of problems presented by clients made it impossible to use the standard CBT format. Individual therapists simply did not have time to both address the problems presented by clients (suicide attempts, self-harm, urges to quit treatment, noncompliance with homework assignments, untreated depression, anxiety disorders, and more) and have session time devoted to helping the client learn and apply more adaptive skills.

In response to these key problems with standard CBT, Linehan and her research team made significant modifications to standard CBT.

They added acceptance-based or validation strategies to the change-based strategies of CBT. Adding these communicated to the clients that they were both acceptable as they were and that their behaviors, including those that were self-harming, made real sense in some way. Further, therapists learned to highlight for clients when their thoughts, feelings, and behaviors were “perfectly normal,” helping clients discover that they had sound judgment and that they were capable of learning how and when to trust themselves. The new emphasis on acceptance did not occur to the exclusion of the emphasis on change: clients must change if they want to build a life worth living.

In the course of weaving in acceptance with change, Linehan noticed that another set of strategies – dialectics – came into play. Dialectical strategies give the therapist a means to balance acceptance and change in each session. They also serve to prevent both therapist and client from becoming stuck in the rigid thoughts, feelings, and behaviors that can occur when emotions run high, as they often do in the treatment of clients diagnosed with BPD. Dialectical strategies and a dialectical world view, with its emphasis on holism and synthesis, enable the therapist to blend acceptance and change in a manner that results in movement, speed, and flow in individual sessions and across the entire treatment. This counters the tendency, found in treatment with clients diagnosed with BPD, to become entrenched in arguments and polarizing or extreme positions.

Significant changes were also made to the structure of treatment in order to solve the problems encountered in the application of standard CBT.

In her original treatment manual, Cognitive-Behavioral Treatment of Borderline Personality Disorder (1993), Linehan hypothesizes that any comprehensive psychotherapy must meet five critical functions. The therapy must:

  1. Enhance and maintain the client’s motivation to change
  2. Enhance the client’s capabilities
  3. Ensure that the client’s new capabilities are generalized to all relevant environments
  4. Enhance the therapist’s motivation to treat clients while also enhancing the therapist’s capabilities
  5. Structure the environment so that treatment can take place

As already described, the structure of DBT includes four components: skills group, individual treatment, DBT phone coaching, and consultation team. These components meet the five critical functions of a comprehensive psychotherapy in the following ways:

  1. It is typically the individual therapist who maintains the client’s motivation for treatment, since the individual therapist is the most prominent individual working with the client.
  2. Skills are acquired and strengthened, and generalized through the combination of skills groups and homework assignments.
  3. Clients capabilities are generalized through phone coaching (clients are instructed to call therapists for coaching prior to engaging in self harm), in vivo coaching, and homework assignments.
  4. Therapists’ capabilities are enhanced and burnout is prevented through weekly consultation team meetings. The consultation team helps the therapist stay balanced in his or her approach to the client, while supporting and cheerleading the therapist in applying effective interventions.
  5. The environment can be structured in a variety of ways. For example, the home environment could be structured by the client and therapist meeting with family members to ensure that the client is not being reinforced for maladaptive behaviors or punished for effective behaviors in the home

True to dialectics, DBT strategies are designed in pairs representing acceptance (validation, reciprocal communication, environmental intervention on behalf of the client) and change (problem solving, irreverence, consultation-to-the-patients about how they can change their own environment). Strategies are further divided into procedures; a set of principles guides the selection of strategies and procedures depending on the needs of the individual client. Clients are also taught a series of behavioral skills designed to promote both acceptance and change. A focus on replacing dysfunctional behaviors with skillful behaviors is woven throughout DBT.

DBT is a principle-based treatment that includes protocols. As a principle-based treatment, DBT is quite flexible due to its modular construction. Not only are strategies and procedures individualized, but various aspects of the treatment, such as disorder-specific protocols, can be included or withdrawn from the treatment as needed. To guide therapists in individualizing priorities for targeting disorders and behavioral problems, DBT incorporates a concept of levels of disorder (based on severity, risk, disability, pervasiveness, and complexity) that in turn guides stages of treatment and provides a hierarchy of what to treat when for a particular patient. In contrast, skills training is protocol based. Once a skills curriculum is determined, what is taught in a session is guided by the curriculum, not by the needs of a single client during that session.

  1. Clients receiving CBT found the unrelenting focus on change inherent to CBT to be invalidating. Clients responded by withdrawing from treatment, by becoming angry, or by vacillating between the two. This resulted in a high drop-out rate. If clients do not attend treatment, they cannot benefit from treatment.
  2. Clients unintentionally positively reinforced their therapists for ineffective treatment while punishing their therapists for effective therapy. For example, the research team noticed through its review of taped sessions that therapists would “back off” pushing for change of behavior when the client’s response was one of anger, emotional withdrawal, shame, or threats of self-harm. Similarly, clients would reward the therapist with interpersonal warmth or engagement if the therapist allowed them to change the topic of the session from one they did not want to discuss to one they did want to discuss.
  3. The sheer volume and severity of problems presented by clients made it impossible to use the standard CBT format. Individual therapists simply did not have time to both address the problems presented by clients (suicide attempts, self-harm, urges to quit treatment, noncompliance with homework assignments, untreated depression, anxiety disorders, and more) and have session time devoted to helping the client learn and apply more adaptive skills.
  4. In response to these key problems with standard CBT, Linehan and her research team made significant modifications to standard CBT.

They added acceptance-based or validation strategies to the change-based strategies of CBT. Adding these communicated to the clients that they were both acceptable as they were and that their behaviors, including those that were self-harming, made real sense in some way. Further, therapists learned to highlight for clients when their thoughts, feelings, and behaviors were “perfectly normal,” helping clients discover that they had sound judgment and that they were capable of learning how and when to trust themselves. The new emphasis on acceptance did not occur to the exclusion of the emphasis on change: clients must change if they want to build a life worth living.

In the course of weaving in acceptance with change, Linehan noticed that another set of strategies – dialectics – came into play. Dialectical strategies give the therapist a means to balance acceptance and change in each session. They also serve to prevent both therapist and client from becoming stuck in the rigid thoughts, feelings, and behaviors that can occur when emotions run high, as they often do in the treatment of clients diagnosed with BPD. Dialectical strategies and a dialectical world view, with its emphasis on holism and synthesis, enable the therapist to blend acceptance and change in a manner that results in movement, speed, and flow in individual sessions and across the entire treatment. This counters the tendency, found in treatment with clients diagnosed with BPD, to become entrenched in arguments and polarizing or extreme positions.

Significant changes were also made to the structure of treatment in order to solve the problems encountered in the application of standard CBT.

In her original treatment manual, Cognitive-Behavioral Treatment of Borderline Personality Disorder (1993), Linehan hypothesizes that any comprehensive psychotherapy must meet five critical functions. The therapy must:

  1. Enhance and maintain the client’s motivation to change
  2. Enhance the client’s capabilities
  3. Ensure that the client’s new capabilities are generalized to all relevant environments
  4. Enhance the therapist’s motivation to treat clients while also enhancing the therapist’s capabilities
  5. Structure the environment so that treatment can take place

As already described, the structure of DBT includes four components: skills group, individual treatment, DBT phone coaching, and consultation team. These components meet the five critical functions of a comprehensive psychotherapy in the following ways:

  1. It is typically the individual therapist who maintains the client’s motivation for treatment, since the individual therapist is the most prominent individual working with the client.
  2. Skills are acquired and strengthened, and generalized through the combination of skills groups and homework assignments.
  3. Clients capabilities are generalized through phone coaching (clients are instructed to call therapists for coaching prior to engaging in self harm), in vivo coaching, and homework assignments.
  4. Therapists’ capabilities are enhanced and burnout is prevented through weekly consultation team meetings. The consultation team helps the therapist stay balanced in his or her approach to the client, while supporting and cheerleading the therapist in applying effective interventions.
  5. The environment can be structured in a variety of ways. For example, the home environment could be structured by the client and therapist meeting with family members to ensure that the client is not being reinforced for maladaptive behaviors or punished for effective behaviors in the home.

DBT has personally saved my life and am grateful to have had the opportunity to take an intensive outpatient DBT program. DBT is awesome and it is one of the best decisions I have made in my life. Have an awesome Friday and Peace Out!!

Writting 201: Poetry; Day Four: Imperfect, Limerick, Enjambment

UNTITLED POEM

(For Now)

by Gertie

All you seem to care about are my scars,

You don’t care about me wanting to jump in front of the moving cars.

Suicide is on my mind,

Wish you could be kind.

Please tell me a corny joke about being in a bar.

(Side Note: I wrote this poem back in February when I was feeling extremely suicidal. I AM NOT FEELING SUIDAL NOW)