Yesterday Was Not a Good Day

Good Morning, World or at least it is three twenty one in the morning in Seattle. Yesterday (Tuesday) was not a good day for me. I ended up in the hospital twice in the Emergency Room due to being suicidal. First time I went in it was four something in morning and was discharged. Thankfully I got home just in time for my psychiatric nurse practitioner called me for our phone appointment, She put me on Ativan which was a good thing.

Being home was not a good thing so I called my therapist who is fairly new to me and appears to be a great therapist. I also called one of the supervisors who happens to be my therapist supervisor. I called the both and left them both an email. The supervisor suggested to go back to the hospital so I did. But the first thing I did was have my grandpa and uncle pick up Billie with his supplies to take to grandpa. My uncle and grandpa dropped me back at the same hospital I was earlier.

On that note they had already did shift change and the social worker on duty was surprised to see me as I’m not going to the Emergency Room for mental health in over four years. Partly glad it was her and partly wish she wasn’t her. She pointed out some stuff I needed to hear which let me come back home. I’m glad she helped me make that decision as I fear if I ended back in a psych ward I most likely would have retreated to old behavior.

As of right now I can’t sleep for unknown reasons so I took an Ativan to help with my anxiety since Billie my cat is with my grandpa and uncle. I know Billie is in good hands but I sure do miss the little dude. Well not so little as he is fifteen and a half pounds. He could loos a few pounds just like I do.

I do not have much to say in this particular blog post. I do want to thank you for reading my blog. It is greatly appreciated that you the reader, read my blog. If it was not for you the reader, reading my blog, I would not be writing my blog. Thank you again, from the bottom of my heart for reading my blog. Peace Out, World!!!

Late Lunch With Friends

Good Afternoon, World!!! I spent time with friends. We met at Red Robin and ate there. I had my usual, The Whiskey Bar-be-Que Burger. I love Red Robin and spending time with my friends.

We discussed what we were doing with our lives like we always do. We mainly discussed are careers and education. I discussed my job interview yesterday and how I feel that I nailed it. I hope I really get the job. One of my friends discussed her getting into the University of Washington (UW) school of Social Work to get her masters degree. She says I was her “inspiration” to get into social work.

We also discussed the baseball game we are going to this Friday. They are rooting for the Seattle Mariners while I will be rooting for the Los Angeles Angels of Anaheim. I being from Anaheim will root for the Angels no matter what.

Thank you for reading!!! Peace Out, World!!!!

Home From the Emergency Room (E.R)

Good Evening, World!!! I am home from the Emergency Room (E.R). I went to the E.R because I self harmed again. I ended up getting stitches. While in the E.R I used my coping skills. I ended up doing some are work. Specifically, I colored mandala’s. The nurses and social work were impressed with my color scheme of the mandala’s.

The social worker on duty asked what let me to self harm this time and I explained that I dissociated and that is when I self harmed. Dissociation is a problem for me and when I self harm while dissociated it makes it that much worse for me.

Now that I am home, I will be working on one of my workbooks. Not sure which one yet but I will do one. I have found that workbooks help me with my recovery. My therapist likes the fact that I do self help workbooks to help myself and my recovery.

Thank you for reading. Peace out, World!!!

More Ramblings From Me, Gertie

Hello, World!!! The workshop I was suppose to attend got cancelled. I am okay with that as I was able to do something else. I was still able to have lunch with my friend and hang out with her for an hour. It was good company to be with a fellow peer who has a Masters in Social Work. (MSW). My friend thinks I would make a great social worker and would love me to get my education. Hell, I would love me to get my education. My friend and I discussed a great deal on on how Peer Support and Social Work have a lot in common.

Speaking of social work, my therapist is a social worker. We did our fifteen minute check in over the phone today. We discussed the disappointment I had with the workshop being cancelled. We also talked about the joy I had spending time with my friend. Before we ended our conversation we talked about what I was going to do for the weekend. I informed my therapist that I would most likely be working on one of my workbooks. He asked which one and I said probably the three that I am currently working on. I informed him I’ll try to do a chapter in all of them and that one of them is almost done and if I finish before my session with him on Tuesday that I would like to discuss it with him. He likes the idea of discussing the workbooks I do.

I think I am going to do a painting for my friend as she requested me to do one for her. She doesn’t care of what. She is going to be paying me for it which I told her she didn’t need to do so.

After painting, I think I am going to read. I love reading as it helps me a great deal.

Thanks for reading. Happy Friday. Peace Out, World!!!

Bruised Face & Stitches Where The Sun Don’t Shine

Hello, World!!! It is just barely two in the morning in my neck of the woods. I haven’t had the best of nights. I was sexually assaulted yesterday evening. Unfortunately, Junior is working his shift as a firefighter so I don’t have his support at the moment.

I will however have his support once he gets home later on in the morning. I didn’t call 911 but I did take myself to the emergency room (E.R) to get checked out. I have a bruised up face and stitches where the sun don’t shine. Yes, I did get a rape kit done but haven’t filed a police report yet. I plan making a police report later on in the morning when Junior gets home as having the support might be easier for me to report it.

Thank you for reading and sorry for the sad and awful news. I know I will get through this with the help of my friends and the professionals that help me. I hope to keep you all updated. I hope everyone has a great day. Peace Out!!!

Just Sitting Here Pondering

As I sit here pondering about life, I can’t help but hope that things will start improving. Improving in regards to my mental health conditions. I guess what I am saying is that even though I am still feeling shitty, I am making some progress but not enough to do the things I want to do.

One of the things I want to get back to more than anything is work. For me work gives me a purpose in life even if its not a job I like. An example of a job I didn’t like was when I worked as a Courtesy Clerk (bagger) at a major grocery store chain for nine and half years. Then again, I don’t know if I could ever go back to working a job I don’t think I could at least like after experiencing having two positions in the mental health field that I loved with a passion. I realize that no matter how much one loves their job that there will be bad days at work.

As I talk about my desire to get back to work, I realized that I found out that my career path is meant to be in the mental health field. This leads me to wanting to get an education. An education that is related to the mental health field. It is my hope to go back to school to get my Associates in Applied Science Degree in Social and Human Services at local community college and hope to transfer to their Bachelors of Applied Behavioral Science Degree program.  Although, I have no plans of becoming a Peer Supervisor or even a Mental Health Case Manager at this point in time, it will give me the opportunity to do so in the future as well as make me more employable as a Peer Specialist.  Ultimately, I want to get a Masters in Social Work (MSW) but right now I just need to focus on getting my Associates Degree. Yes, I realize if I get Bachelors of Social Work (BSW), I could get advanced standing a MSW program however I’ve done the a math and it will ultimately cheaper for me to get my both my Associates and Bachelors degree’s at a community college than to transfer to a four year college or university. Now, I’m getting ahead of myself. I just need to focus on getting into school to get my Associates Degree.

As I focus on getting into school, I also need to focus on my mental health and get back to being stable. I see my therapist on Tuesday after not seeing her for three weeks due to her being on vacation. The jury is still out on my new therapist but things are going good thus far. From the way I see things, she appears to care. It also appears that she wants me to succeed but I’ve only seen her a half dozen time since April. I’m going to ask her if she could give me therapy related homework as I think it might help me in the long run but I think it could help me trust her more. Its going to take some time trusting her for a multitude of reason. None of them are on her. I’ve got a lot of shit to work on and hope she is up to the challenge.

Speaking of a challenge, I need to go and eat. I haven’t eaten since yesterday morning. So, I need to end this post and go eat. Have a wonderful evening. Happy Friday and peace out to everyone.

I Just Want to Get Back to Doing Well

It’s the middle of the night where I am at and all I want to do is cry. If you have been reading my blog you know I have struggling a great deal with my depression as well as with grief and loss. Struggling enough to where I felt it was in the best interest of the clients I serve and my recovery to resign from a job I worked endlessly to get and loved with a passion.

Anyone who as ever dealt with a mental health condition knows that there will be times where a relapse in our symptoms occur. Unfortunately, this relapse in my symptoms is lasting a bit longer than expected.  More or less what I am saying is I am not bouncing back as quickly as I have in recent years.

The thing that hasn’t helped matters much is that things haven’t been all that consistent with my therapy. No fault to anyone.  As many of you know Diana suddenly left the agency where I seek mental health services at due to cancer which is still hard on me. So, I was assigned a new therapist who happened to be the direct supervisor of Diana which was quite helpful for me. Then she left to go on to bigger and better things which got me a new therapist.

A therapist that appears to care. She seems like an older, shorter version of Diana with straighter and grayer hair. As far as the sense of humor part of things, I’m not really sure as I’ve only had three sessions with her but she appears to have a caring heart like Diana. Granted my new therapist is not a Social Worker but that is okay because she use to be a nurse which means she has the heart of Social Worker. I realize I shouldn’t be picky on the degree of the therapist just as long as they have a degree in a field to where the person can practice therapy with the right licensure but in my  experience those who have a degree in Social Work seem to work best for me.  So for me my new therapist having a degree in nursing helps a great deal as nurses have some pretty big and caring hearts.

As far as me being up in the middling of the night wanting to cry is that I woke up with a nightmare. A nightmare due to childhood trauma. Any type of trauma sucks shit especially trauma you are still working on in therapy 30 years after it started. I hope that one day I can handle the after affects of the trauma without needing therapy but one can only hope.

For me hope is the only thing I have right now. Hope that I can get back to doing well enough to go back to work. I miss work but then again my recovery is extremely important. It is hope that I must hold on to as I know how doing well feels. It is my hope that I can be back to doing well.

Being well is something I want to get back to and I think attempting get back to sleep is part of getting well. Have a great night all and peace out.

Weekly Check-In

Good Morning, World!!! It’s hard to put a word or an emotion on how this week has been. I just know that this week has made me realize that I am where I am suppose to be in my life in regards to my career and place of employment.

This past week at work has been a week of accomplishments for me. On Tuesday, September 20th, myself and the two other members of my team at work found out that we are receiving the team of the year award. Apparently, we had more than one colleague nominate us for the team of the year award according to our supervisor. We will be receiving the Team of the Year Award at a breakfast we have once a year for our donors in a couple of weeks. The funny things I found all this out the day before my six month anniversary in my current position as a Peer Specialist. That means my six month anniversary was on Wednesday, September 21st. Hitting the sixth month mark at my employer is a major deal because your first six months is the probationary period. I am not sure if I “passed” my probationary period but I’m sure if I didn’t I would have been informed by my supervisor by now.  I love my job.

The love of my job brings me to the next topic of conversation of education. I have been thinking a great deal about going back to school to get a degree even if it is only an Associates degree. I finally made the decision this past week that I will be going back to school in September 2017 and what educational route I would take.  I plan on getting both my Associates Degree and Bachelors Degree at a local community college. Granted the Bachelors Degree isn’t a Bachelors of Social Work/Welfare degree but I can always get a MSW later on. So the educational path I am taking is getting an Associates of Applied Science in Social and Human Services with a certificate in Child & Family Studies and then get my Bachelors of Applied Science in Applied Behavior Science. I am going this route because 1) its cheaper because both degrees are at a community college and 2) I don’t know how realistic it is for me be able to get  a MSW. Yes, a MSW is something to aim for and is the goal I am shooting for but at this point in time I need focus on the smaller goals first to get to the big goal.

At this point in time, I realize that will need to not only focus on the big goal of getting a MSW but really need to focus on the smaller goals to get me there. I realize that in the coming months I will need to have something to focus on for a multitude of reasons. The reasons why I need to focus on my goals are as follows: 1) My depression tends reappear later on in the Autumn, 2) November 18th marks the third anniversary of me miscarrying my first set of twins, 3) the holidays are coming and is time where my depression not only acts up but my PTSD as well and 4) January 12th (2017) will be the second anniversary of me miscarrying my second set of twins. As you can see, I will need to have something to focus on. If I can focus on my goals then maybe the coming moths will not be so difficult for me. I hope to share with you my goals that I need to focus on between now and September of 2017 in regards to getting ready to attending school once again in another post.

On that note, I will need to end this post for now. Have a great weekend and 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!!