Consistency is a Necessity for Recovery

Over the years I have learned that consistency with who my treatment team is key to my recovery. Unfortunately, as of lately that hasn’t been happening for me.

I learned on St. Patrick’s Day that my new therapist, was leaving the agency I seek services at for my mental health treatment. This loss hits me hard as this therapist was the direct supervisor of Diana and was updating me on her health at Diana’s request. Not only that, I was just starting to feel comfortable with her style of therapy as it was slightly different from Diana’s therapy style.

As difficult as it is to loose another therapist so close to Diana’s sudden departure due to cancer, I appreciate her effort in making sure she found the right fit. A fit I am unsure of at the moment and realize the uncertainty of a new therapist is causing some anxiety.

To lessen my anxiety of having a new therapist, my therapist thought it would be a good idea for me to meet the new therapist during our last session together at the location I will be now going to. No, I’m not changing mental health agencies, its that my new therapist is at different location than the one leaving and Diana were at. I am really appreciative of my therapist doing this for me as I know she didn’t have to do so.

My last session with my therapist has come and gone and tears shed on both ends which was quite unexpected for the both of us since our therapeutic relationship had only been for four months. Of course having therapist who was the direct supervisor of your previous therapist (Diana) was helpful to building trust with her. Even though I only met with my new therapist of all of seven minutes for an introduction and to set up a first appointment, I found it quite helpful.

As helpful as I found meeting my new therapist, no matter how briefly, I still have anxiety regarding my first appointment with her. As with any first appointment, I have with anyone, my anxiety usually increases however this time the anxiety is higher than it usually is. Not sure why but it is and if I continue to ask why I notice my anxiety start to rise.  I’ve also realized as my first appointment with my new therapist quickly approaches, there is an increase in the anxiety.

The increase of anxiety is where the use of my Dialectical Behavior Therapy (DBT) skills come in handy to help even if I don’t want to use them. See, DBT skills have helped me through some tough moments as an adult. Even though seeing a new therapist isn’t the toughest thing I have experienced in my life, it’s anxiety provoking enough needing to use my skills.

As I use my skills, I realize that there is a number of reason why to my anxiety is so high regarding my first appointment with this new therapist. Actually, there a roughly a handful of reasons. All those reasons lead to both the grief I have for Diana’s sudden departure due to cancer and having a new therapist leave in less than five months which leads to the consistency I need for my own recovery. Consistency that I fear I won’t have with my new therapist as she appears to be close to retirement age but then again that might not be an issue either but its an issue I have to wait till deal with in my first session with her. For me consistency is key for me to start to trusting people and hope that my new therapist sticks around for a good eighteen months. I don’t that doesn’t sound long but I don’t want to ask for too much as I am seeing her at a community mental health agency and know realistically that people don’t stick around for as long as Diana did. I trusted Diana and still do and hope she is doing well. Most importantly, I hope I can trust my new therapist.

Before, I end this particular post I want share something positive. I am slowly starting to trust my case manager. I see she is trying really hard and to me that shows that she cares. She cares enough to try to build a good rapport and to me that is a sign I can trust her. When I first wrote about her I didn’t give her such a positive light and its not any of her fault. I was angry at needing a case manager and that anger showed through in that particular post. My care manager does care and does want to help me. For me trusting her is a big thing.

It looks like this post is coming to an end and before it ends, I want to tell you all thanks for reading. I am grateful for each one of you. Have a wonderful Sunday evening all and Peace Out!!!

Crisis & Not Being Able To Say Goodbye

I don’t know where to begin. Lets begin with how difficult things have been lately. In October I lost three clients and a colleague. This put me in an unexpected whirlwind of a crisis. Dealing with four deaths so close to the third anniversary of the first miscarriage put me into a major crisis. A crisis that got me the “extra support” I had been advocating for since I got promoted to a Peer Specialist. The “extra support” came too late as was I was already quickly approaching hospitalization.

I met with my “extra support” and she made an already volatile situation worse. This person informed me that she “would not be able to use humor in sessions as it is unprofessional and wont abide by not using the two terms” that trigger me. Needless to say two days later I ended up in the hospital for fifteen days.  While in the hospital I found out that Diana, my therapist, wont be back till December due to medical issues. Okay, everyone deals with health issues. I was in the middle of a health issue at the moment myself. Granted it was a mental health crisis but I understood.

Dealing with a personal health crisis is not an easy thing to go through which is why when I was discharged from the hospital, I would be a chemo-buddy to friend of mine who was on an oncology unit. An oncology unit that my therapist was on. I being the person I am quickly walked past her room to see my friend. A friend who knew something that was up. I informed my friend that I would let her know more when I was able to get more information.

I was able to get some information the next day at the mental health agency, I see Diana at. They were “surprised” that I found out and “find it odd” that I had a friend on the same unit as my therapist. I found the statement “find it odd” a little odd because why would I spend my time and energy to figure out if my therapist was in the hospital especially since I was and am in a crisis dealing with my mental health and grief of a butt load of recent and past loss. Long story short I was given an appointment with Diana’s supervisor who informed me that Diana does have cancer and it is unlikely that she will be returning. To make matters worse, I have been put on the waiting list for another therapist. This makes no sense to me as they had given me a person to be of “extra support” in addition of Diana and now I have to wait till at least February to get a therapist. To make matters worse my extra support is going to be out till mid-January.

It really bothers me that I not only don’t get to say goodbye to Diana but I am not going to get any support till mid-January. Seriously, someone who recently got out of a psych ward is going to have little to no support. I feel like I am not being heard. What part of I am not doing well don’t people understand and to make matters worse my therapist of eight years is not around to help due to cancer. If Diana knew what was going on I am sure she would advocate for me or at least have a “goodbye” session like she promised. I know realistically I won’t have that “goodbye” session and I feel like my treatment team is just putting me on the shelf in hopes everything will resolve itself because “she is strong, has skills and resiliency” but that’s who they should be most concerned about. Those of us who “appear to be doing well” despite some major struggles at the moment.

The only reason why I am not going to do anything is because I am going back to work on Monday after being on FMLA for a month. Yes, I am going to only be working a limited schedule due to partial FMLA but at least its something to look forward to. Another reason why I am not going to do anything is because my clients don’t need to lose another staff member and if I leave my current employer I would like to give my clients some closure with at least being able to say goodbye. Something I won’t be able to do with Diana. As far as I know she is still alive but not coming back.

I should get going before the tears on my face short out my laptop. Have a good weekend everyone.

Weekly Check-In

It is Saturday morning and that means its time for my weekly check-in. I enjoyed my three day weekend last week.

I unfortunately called in sick most of last week because I wasn’t feeling well. I was dealing with a migraine that just wouldn’t go a way. Missing work is not my favorite thing especially since I love my job. I did end up going to see my doctor yesterday. She agrees that it was a migraine. She suspects that my migraine was caused by a combination of weather change, allergies, the fluorescent lights in my work environment and my depression symptoms increasing.

My doctor prescribed  me some allergy and migraine meds as well as suggested ways to decrease my exposure florescent lights. For example go for two, ten minute walks to get some natural light which will also help with my depression symptoms. My doctor also informed me that she would be in communication with my therapist and psychiatric nurse practitioner.

Long story short, my doctor did get a hold of my therapist who in return called me. Diana and I discussed on ways I can decrease my depression symptoms. We of course discussed the skills that help the most. The plan we came up with was to hang out with people from my natural support systems or at least call and talk to some of them on the phone. Other things on the list are, to blog, go on a walk, color, journal, read, and of course lots of chocolate.

Its amazing that I have health care professionals that are willing to communicate with each other. You don’t find that much now a days or at least here in the United States. I am grateful that I have people who look out for me. My therapist emailed Junior and Mama Bear to let them know what was going on even though they both already knew. Junior is working an overtime shift so he’s been checking up on me via text. Mama Bear took me out to breakfast and did some walking.

Yes, I still have my migraine but at least the pain is subsiding with meds and skills. I am grateful that I have health care professionals in my life that care. I am just as grateful that I have natural support system the love and care about me. Have a wonderful weekend everyone and peace out all.

Hello, 2016

Happy New Years!! As I sit here typing, twenty hours into 2016 I cant help but think of my hopes and dreams for the coming year. I also cant help but think on how much differently my hopes and dreams for the coming year are different from last year.

They are different because last year at this time I thought I was going to be a mama however I am not because of a miscarriage. The miscarriage did a major toll on me emotionally last year and hope that the grief work that my therapist and I recently started helps.

The reason why I hope the grief work helps is because I felt like I went backwards with my mental health recovery in 2015. Yes, I realize that the miscarriage was what ultimately caused my depression relapse. In fact I was diagnosed with postpartum depression which I didn’t really realize could happen with women who miscarry. It doesn’t surprise me that women who miscarry can be diagnosed with it but I just didn’t connect the dots.

As many of you know my recovery means the world to me. As I look at what I want my life to look like at the end of 2016, I have to look at my recovery and what it means to me and how it will look to me. Of course, this is something I will be discussing with my therapist, psychiatric nurse practitioner, and natural supports to see what they have to say about what I want my recovery to look like. They are apart of my recovery and without them and their help, I wouldn’t be in recovery.

I am realizing as I continue to write this blog post, it is going in a different direction than I had originally planned and I am okay with it. I am okay with it because I will be able to devote what I was planning on blogging about today and blog about on that topic tomorrow.

I know that discussing how my miscarriage affected my depression and recovery will not only open doors to help others discuss their struggles but help me as well. The miscarriage affected me a great deal including my blog. I wish it didn’t effect my blog but it did.

As I end this post I want to thank you for reading and/or reading my blog. I am grateful for each one of you. Have a very Happy New Years. Hello, 2016, I am looking forward to what you have to bring even the bad and the ugly.

Weekly Goals

Happy Monday!!! Its a start of another work week and we all know what that means; time for me to do another set of weekly goals. So I will say how I did with last weeks goals.

1)  Read Speaker of the Dead by Orson Scott Card. I was able to spend about an hour in one sitting this week to read which is a rare occurrence. I was able to read twice for an hour so I am a happy camper.

2)  Work on jigsaw puzzle. Spent about fifteen minutes a day doing the puzzle. It is taking some time to do.

3)  Color. Did some coloring but not much.

4)  Finish Writing 201: Poetry. I finished the course and hope that you all enjoyed my poems.

5)  Work on a self-help workbook; The Dialectical Behavior Therapy Skills Workbook by Matthew McKay, PhD., Jeffery C. Wood, PSY.D., and Jeffrey Brantley, MD. Yup I worked on an entire chapter.

Now on to this weeks goals.

1)  Read Speaker of the Dead by Orson Scott Card. I will finish this book eventually.

2)  Work on jigsaw puzzle. The jigsaw puzzle is getting done slowly but surely.

3)  Color. Looks like I could be finishing up one coloring page here in the next week or two.

4)  Work on a self-help workbook; The Dialectical Behavior Therapy Skills Workbook by Matthew McKay, PhD., Jeffery C. Wood, PSY.D., and Jeffrey Brantley, MD. I’m hoping to get another chapter done this week.

5) See my therapist. I see my therapist on Wednesday. We will most likely be discussing ways to cope with getting my yearly done.

6)  Go to my doctor’s appointment. I have my annual female exam on Thursday. I have a difficult time with these particular appointments because of all the trauma I have been through.

Well, those are my weekly goals for this week. Please don’t hesitate to take a look at the blogging event over at: http://greenembe.rs/2015/10/19/building-rome-week-42-for-2015/ Have a wonderful week. Peace Out!!!

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!!

Borderline Personality Disorder (BPD)

Happy Friday everyone. It is another Friday and that means it is time for my educational blogging feature. Today’s topic is Borderline Personality Disorder (BPD). I got the following information from: https://www.nimh.nih.gov/index.shtml

What is Borderline Personality Disorder?

Borderline personality disorder (BPD) is a serious mental illness marked by unstable moods, behavior, and relationships. In 1980, the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) listed BPD as a diagnosable illness for the first time. Most psychiatrists and other mental health professionals use the DSM to diagnose mental illnesses.

Because some people with severe BPD have brief psychotic episodes, experts originally thought of this illness as atypical, or borderline, versions of other mental disorders. While mental health experts now generally agree that the name “borderline personality disorder” is misleading, a more accurate term does not exist yet.

Most people who have BPD suffer from:

  • Problems with regulating emotions and thoughts
  • Impulsive and reckless behavior
  • Unstable relationships with other people.

People with this disorder also have high rates of co-occurring disorders, such as depression, anxiety disorders, substance abuse, and eating disorders, along with self-harm, suicidal behaviors, and completed suicides.

Causes

Research on the possible causes and risk factors for BPD is still at a very early stage. However, scientists generally agree that genetic and environmental factors are likely to be involved.

Studies on twins with BPD suggest that the illness is strongly inherited. Another study shows that a person can inherit his or her temperament and specific personality traits, particularly impulsiveness and aggression. Scientists are studying genes that help regulate emotions and impulse control for possible links to the disorder.

Social or cultural factors may increase the risk for BPD. For example, being part of a community or culture in which unstable family relationships are common may increase a person’s risk for the disorder. Impulsiveness, poor judgment in lifestyle choices, and other consequences of BPD may lead individuals to risky situations. Adults with borderline personality disorder are considerably more likely to be the victim of violence, including rape and other crimes.

Signs & Symptoms

According to the DSM, Fourth Edition, Text Revision (DSM-IV-TR), to be diagnosed with borderline personality disorder, a person must show an enduring pattern of behavior that includes at least five of the following symptoms:

  • Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment, whether real or perceived
  • A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)
  • Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)
  • Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating
  • Recurring suicidal behaviors or threats or self-harming behavior, such as cutting
  • Intense and highly changeable moods, with each episode lasting from a few hours to a few days
  • Chronic feelings of emptiness and/or boredom
  • Inappropriate, intense anger or problems controlling anger
  • Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.

Seemingly mundane events may trigger symptoms. For example, people with BPD may feel angry and distressed over minor separations—such as vacations, business trips, or sudden changes of plans—from people to whom they feel close. Studies show that people with this disorder may see anger in an emotionally neutral face and have a stronger reaction to words with negative meanings than people who do not have the disorder.

Suicide and Self-harm

Self-injurious behavior includes suicide and suicide attempts, as well as self-harming behaviors, described below. As many as 80 percent of people with BPD have suicidal behaviors, and about 4 to 9 percent commit suicide.

Suicide is one of the most tragic outcomes of any mental illness. Some treatments can help reduce suicidal behaviors in people with BPD. For example, one study showed that dialectical behavior therapy (DBT) reduced suicide attempts in women by half compared with other types of psychotherapy, or talk therapy. DBT also reduced use of emergency room and inpatient services and retained more participants in therapy, compared to other approaches to treatment.

Unlike suicide attempts, self-harming behaviors do not stem from a desire to die. However, some self-harming behaviors may be life threatening. Self-harming behaviors linked with BPD include cutting, burning, hitting, head banging, hair pulling, and other harmful acts. People with BPD may self-harm to help regulate their emotions, to punish themselves, or to express their pain. They do not always see these behaviors as harmful.

Who Is At Risk?

According to data from a subsample of participants in a national survey on mental disorders, about 1.6 percent of adults in the United States have BPD in a given year.  BPD usually begins during adolescence or early adulthood. Some studies suggest that early symptoms of the illness may occur during childhood.

Diagnosis

Unfortunately, BPD is often underdiagnosed or misdiagnosed.

A mental health professional experienced in diagnosing and treating mental disorders—such as a psychiatrist, psychologist, clinical social worker, or psychiatric nurse—can detect BPD based on a thorough interview and a discussion about symptoms. A careful and thorough medical exam can help rule out other possible causes of symptoms.

The mental health professional may ask about symptoms and personal and family medical histories, including any history of mental illnesses. This information can help the mental health professional decide on the best treatment. In some cases, co-occurring mental illnesses may have symptoms that overlap with BPD, making it difficult to distinguish borderline personality disorder from other mental illnesses. For example, a person may describe feelings of depression but may not bring other symptoms to the mental health professional’s attention.

Women with BPD are more likely to have co-occurring disorders such as major depression, anxiety disorders, or eating disorders. In men, BPD is more likely to co-occur with disorders such as substance abuse or antisocial personality disorder. According to the NIMH-funded National Comorbidity Survey Replication—the largest national study to date of mental disorders in U.S. adults—about 85 percent of people with BPD also meet the diagnostic criteria for another mental illness. Other illnesses that often occur with BPD include diabetes, high blood pressure, chronic back pain, arthritis, and fibromyalgia. These conditions are associated with obesity, which is a common side effect of the medications prescribed to treat BPD and other mental disorders.

No single test can diagnose BPD. Scientists funded by NIMH are looking for ways to improve diagnosis of this disorder. One study found that adults with BPD showed excessive emotional reactions when looking at words with unpleasant meanings, compared with healthy people. People with more severe BPD showed a more intense emotional response than people who had less severe BPD.

Treatments

BPD is often viewed as difficult to treat. However, recent research shows that BPD can be treated effectively, and that many people with this illness improve over time.

BPD can be treated with psychotherapy, or “talk” therapy. In some cases, a mental health professional may also recommend medications to treat specific symptoms. When a person is under more than one professional’s care, it is essential for the professionals to coordinate with one another on the treatment plan.

The treatments described below are just some of the options that may be available to a person with BPD. However, the research on treatments is still in very early stages. More studies are needed to determine the effectiveness of these treatments, who may benefit the most, and how best to deliver treatments.

Psychotherapy

Psychotherapy is usually the first treatment for people with BPD. Current research suggests psychotherapy can relieve some symptoms, but further studies are needed to better understand how well psychotherapy works.

It is important that people in therapy get along with and trust their therapist. The very nature of BPD can make it difficult for people with this disorder to maintain this type of bond with their therapist.

Types of psychotherapy used to treat BPD include the following: Cognitive behavioral therapy (CBT). CBT can help people with BPD identify and change core beliefs and/or behaviors that underlie inaccurate perceptions of themselves and others and problems interacting with others. CBT may help reduce a range of mood and anxiety symptoms and reduce the number of suicidal or self-harming behaviors.

  1. Dialectical behavior therapy (DBT). This type of therapy focuses on the concept of mindfulness, or being aware of and attentive to the current situation. DBT teaches skills to control intense emotions, reduces self-destructive behaviors, and improves relationships. This therapy differs from CBT in that it seeks a balance between changing and accepting beliefs and behaviors.
  2. Schema-focused therapy. This type of therapy combines elements of CBT with other forms of psychotherapy that focus on reframing schemas, or the ways people view themselves. This approach is based on the idea that BPD stems from a dysfunctional self-image—possibly brought on by negative childhood experiences—that affects how people react to their environment, interact with others, and cope with problems or stress.

Therapy can be provided one-on-one between the therapist and the patient or in a group setting. Therapist-led group sessions may help teach people with BPD how to interact with others and how to express themselves effectively.

One type of group therapy, Systems Training for Emotional Predictability and Problem Solving (STEPPS), is designed as a relatively brief treatment consisting of 20 two-hour sessions led by an experienced social worker. Scientists funded by NIMH reported that STEPPS, when used with other types of treatment (medications or individual psychotherapy), can help reduce symptoms and problem behaviors of BPD, relieve symptoms of depression, and improve quality of life. The effectiveness of this type of therapy has not been extensively studied.

Families of people with BPD may also benefit from therapy. The challenges of dealing with an ill relative on a daily basis can be very stressful, and family members may unknowingly act in ways that worsen their relative’s symptoms.

Some therapies, such as DBT-family skills training (DBT-FST), include family members in treatment sessions. These types of programs help families develop skills to better understand and support a relative with BPD. Other therapies, such as Family Connections, focus on the needs of family members. More research is needed to determine the effectiveness of family therapy in BPD. Studies with other mental disorders suggest that including family members can help in a person’s treatment.

Other types of therapy not listed in this booklet may be helpful for some people with BPD. Therapists often adapt psychotherapy to better meet a person’s needs. Therapists may switch from one type of therapy to another, mix techniques from different therapies, or use a combination therapy. For more information see the NIMH website section on psychotherapy.

Some symptoms of BPD may come and go, but the core symptoms of highly changeable moods, intense anger, and impulsiveness tend to be more persistent. People whose symptoms improve may continue to face issues related to co-occurring disorders, such as depression or post-traumatic stress disorder. However, encouraging research suggests that relapse, or the recurrence of full-blown symptoms after remission, is rare. In one study, 6 percent of people with BPD had a relapse after remission.

Medications

No medications have been approved by the U.S. Food and Drug Administration to treat BPD. Only a few studies show that medications are necessary or effective for people with this illness. However, many people with BPD are treated with medications in addition to psychotherapy. While medications do not cure BPD, some medications may be helpful in managing specific symptoms. For some people, medications can help reduce symptoms such as anxiety, depression, or aggression. Often, people are treated with several medications at the same time, but there is little evidence that this practice is necessary or effective.

Medications can cause different side effects in different people. People who have BPD should talk with their prescribing doctor about what to expect from a particular medication.

Other Treatments

Omega-3 fatty acids. One study done on 30 women with BPD showed that omega-3 fatty acids may help reduce symptoms of aggression and depression. The treatment seemed to be as well tolerated as commonly prescribed mood stabilizers and had few side effects. Fewer women who took omega-3 fatty acids dropped out of the study, compared to women who took a placebo (sugar pill).

With proper treatment, many people experience fewer or less severe symptoms. However, many factors affect the amount of time it takes for symptoms to improve, so it is important for people with BPD to be patient and to receive appropriate support during treatment.

Living With

Some people with BPD experience severe symptoms and require intensive, often inpatient, care. Others may use some outpatient treatments but never need hospitalization or emergency care. Some people who develop this disorder may improve without any treatment.
How can I help a friend or relative who has BPD?
If you know someone who has BPD, it affects you too. The first and most important thing you can do is help your friend or relative get the right diagnosis and treatment. You may need to make an appointment and go with your friend or relative to see the doctor. Encourage him or her to stay in treatment or to seek different treatment if symptoms do not appear to improve with the current treatment.
To help a friend or relative you can:
Offer emotional support, understanding, patience, and encouragement—change can be difficult and frightening to people with BPD, but it is possible for them to get better over time
  • Learn about mental disorders, including BPD, so you can understand what your friend or relative is experiencing
  • With permission from your friend or relative, talk with his or her therapist to learn about therapies that may involve family members, such as DBT-FST.

Never ignore comments about someone’s intent or plan to harm himself or herself or someone else. Report such comments to the person’s therapist or doctor. In urgent or potentially life-threatening situations, you may need to call the police.

How can I help myself if I have BPD?

Taking that first step to help yourself may be hard. It is important to realize that, although it may take some time, you can get better with treatment.

To help yourself:

  • Talk to your doctor about treatment options and stick with treatment
  • Try to maintain a stable schedule of meals and sleep times
  • Engage in mild activity or exercise to help reduce stress
  • Set realistic goals for yourself
  • Break up large tasks into small ones, set some priorities, and do what you can, as you can
  • Try to spend time with other people and confide in a trusted friend or family member
  • Tell others about events or situations that may trigger symptoms
  • Expect your symptoms to improve gradually, not immediately
  • Identify and seek out comforting situations, places, and people
  • Continue to educate yourself about this disorder.

Thank you for reading this long post. Again the above information is from: https://www.nimh.nih.gov/index.shtml Have an awesome weekend. Happy Friday. Peace out!!