Anyway, I was reviewing a document about the general principles of CBT (called SelfHelpCourse.pdf), and it outlines an important point about events, thoughts and emotions. I have pointed out in several articles and in my book about the behavioral chain:

Event -> Thought -> Emotion -> Action Impulse -> Behavior

The document says this about the different reactions a person may have to an event:

For instance, if someone you know passes you in the street without acknowledging you, you can interpret it several ways. You might think they don’t want to know you because no-one likes you (which may lead you to feel depressed), your thought may be that you hope they don’t stop to talk to you, because you won’t know what to say and they’ll think you’re boring and stupid (anxiety), you may think they’re being deliberately snotty (leading to anger). A healthier response might be that they just didn’t see you.

No related posts.

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DBT iPhone App

Are you in DBT? Do you want to know more about it? The creator of the new DBT iPhone application has graciously provided me with a coupon code for a free version of the app. If you’d like to receive this coupon code and want to download the app to your iPhone for free, please send me a direct message on twitter @bondobbs. I only have one, so I expect it to go fast.

UPDATE: You can also claim this code by commenting on this post and providing your email address (which is not shared). I will email you the code and instructions if you have problems redeeming it.

UPDATE 2: Code is gone! Sorry. However, if you’re still interested in the app go to www.diarycard.net

UPDATE 3: I got another code. The last one went fast. If you want it comment on this post.

UPDATE 4: Sorry the second code is gone. Yet, if you want the app for free, comment here. I will not post the comment, I’ll just ask for more codes and email them if I can get them. The codes are limited. Act fast!

UPDATE 5: OK, I’ve given away several codes. I have one more… the final one for me. If you want the final code, please comment on this thread. I will not post the comment, but will send you the code.

FINAL UPDATE: All codes are now gone. Thanks to Sammy for providing them to my readers!

Related posts:

1. Read my free eBook
2. DBT Self-Help App for the iPhone under works
3. A new DBT Diary Card Application for the iPhone

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F60.3 Emotionally Unstable (Borderline) Personality Disorder

A personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability. The ability to plan ahead may be minimal, and outbursts of intense anger may often lead to violence or “behavioural explosions”; these are easily precipitated when impulsive acts are criticized or thwarted by others. Two variants of this personality disorder are specified, and both share this general theme of impulsiveness and lack of self-control.

Impulsive type:
The predominant characteristics are emotional instability and lack of impulse control. Outbursts of violence or threatening behaviour are common, particularly in response to criticism by others.

Includes:

• explosive and aggressive personality (disorder)

Excludes:

• dissocial personality disorder

Borderline type:
Several of the characteristics of emotional instability are present; in addition, the patient’s own self-image, aims, and internal preferences (including sexual) are often unclear or disturbed. There are usually chronic feelings of emptiness. A liability to become involved in intense and unstable relationships may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self-harm (although these may occur without obvious precipitants).

Includes:

• borderline personality (disorder)

Related posts:

1. DSM-IV Criteria
2. Proposed Changes in the DSM-V for Borderline Personality Disorder
3. A Must-Read Interview with a recovered Borderline

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• Sending someone to therapy is not like having your car repaired. It involves a lot of hard work on the part of the patient/client and on the part of their loved ones and supporters.
• Therapy as usual (referred to as TAU in the studies) can actually make BPD worse in some individuals. There are several BPD-specific therapies, such as DBT, Schema-focused therapy and Mentalization-based therapy.
• Therapy requires the buy-in of the patient/client. If he/she doesn’t want to admit he/she has a problem or doesn’t trust the therapist with his/her feelings, therapy will likely not have a lasting effect.

Unfortunately, you can’t force someone to go to therapy if she doesn’t want to go (except through a court order). What I suggest is that you use the tools I offer for a while. After you do that for some time, the borderline might begin to gather some self-awareness or to share her inner thoughts and feelings with you. It is likely that these thoughts and feelings will be filled with shame, self-hatred and worry. At that point, you can say something like, “Boy, it must feel awful to feel that way about yourself. What do you think you can do to feel better?” or “That’s so painful to feel that way. Maybe therapy can help?”

My wife has resisted going to DBT because it identifies her as a borderline and she “doesn’t want to be that person.” She also resists because DBT seems like a therapy of last resort to her and, if she fails at it, she feels that she will have to be committed to a mental institution. I occasionally do reinforce to her that there are people who are trained to help her feel better and encourage her to look into it. She is in therapy, but not in DBT. My daughter does see a DBT therapist. She decided to go because she was so angry all the time, and she felt terrible. She wanted to learn how to feel better. At some point, her emotional pain reached an intolerable level.

I have tried to model these skills in my life and, by doing so, shown my wife that I can more adequately cope with emotional situations, both personal and interpersonal. This modeling encourages my wife to consider DBT (or another emotional training program) to help her feel better. My suggestion is that you practice effective tools, master them and use your mastery over emotional situations as a beacon for your borderline’s healing.

Related posts:

1. Mentalization Based Therapy Shows Promise with BPD
2. Can therapy actually hurt borderlines?
3. Ask Bon: How do I get my borderline loved one in therapy? What’s the best kind of therapy? How long will it take to cure them?

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A: Unless your borderline loved one is a minor or you have a court order, you can’t force anyone into therapy. Therapy must be a choice of the person that needs it. It will probably be much more effective if the person with BPD chooses to go to therapy. Yet, therapy is not like sending your car in for repairs. It’s not as if you send the person in to therapy, he/she gets a new part and comes out fixed. That’s not the way therapy works.

For BPD, the “gold standard” of therapy is Dialectic Behavior Therapy (DBT). It is an “evidence-based” treatment – meaning the therapy has been researched against “therapy as usual” (TAU) and been shown to be more effective than TAU. However, DBT is generally measured on reducing suicidal impulses and self-harm. DBT has been criticized for being most effective with the “lowest functioning” people with BPD. I personally like DBT in that it provides the borderline with essential skills that can make their lives more effective. DBT usually takes at least a year. It took my daughter two years to complete. For more on DBT from this blog, click here. It is also important to note that, in many circumstances, the family members can be more effective if they participate in the DBT treatment by learning the necessary skills to support the treatment.

Recently, a new treatment called Mentalization-Based Treatment (MBT) has come on to the scene – particularly in the UK. I only know of two places in the US that MBT is available. Mentalization-based therapy focusing on the skill of “mentalizing” and is an interactive therapy in which the moment-to-moment relationship between the client and the therapist helps encourage critical, integrative thinking. Mentalizing is a process and it requires participation of each person in a particular conversation. One must try to see the world through the other’s eyes and clearly express one’s own mental aspects including intent, desire, motivation, feelings and aspirations. For more on MBT on this blog, click here.

There are other therapies that can be effective with BPD including schema-focused therapy, STEPPS and transference-focused therapy.

Both DBT and MBT are quite expensive at this time.

Related posts:

1. Mentalization Based Therapy Shows Promise with BPD
2. Dialectical Behavior Therapy: Radical Acceptance
3. Ask Bon: How do I get my loved one with BPD to go to therapy?

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Six patients committed suicide while in hospital. A near-miss occurred when a patient with borderline personality disorder was placed in seclusion and had to be revived after trying to strangle himself. A nurse was delayed in reaching the patient due to difficulty finding a key to the seclusion room.

I don’t know why they’d put a suicidal person with BPD in seclusion. Wow.

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The BRTC is primarily a research clinic, offering treatment to members of the community as part of our clinical trials.  We are not currently recruiting for any clinical trials, but we periodically have openings for new clients in our Treatment Development Clinic (TDC).  Through TDC, clients receive Dialectical Behavior Therapy from doctoral students under the supervision of licensed psychologists.

TDC is currently accepting new clients in our FRIENDS AND FAMILY DBT Skills group.  This group is designed for family members, friends, and caregivers of people with chronic mental and physical health problems like borderline personality disorder, bipolar disorder, and Alzheimer’s disease.  For more information on this group, please call 206-543-3765.

I would urge all family members to consider attending this class (or a similar class). These DBT-FST (Dialectical Behavior Therapy Family Skills Training) are invaluable in understanding your family member with borderline personality disorder and creating a healing environment in the home.

Related posts:

1. DBT for the Family?
2. Ask Bon: How do I get my loved one with BPD to go to therapy?
3. Understanding Borderline Personality Disorder from WHYY

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“…BPD is present in about 6% of primary care patients and persons in community-based samples and in 15 to 20% of patients in psychiatric hospitals and outpatient clinics,” writes John G. Gunderson, MD, from the Psychosocial and Personality Research Program, McLean Hospital in Belmont, Massachusetts. “Patients with BPD usually enter treatment facilities after suicide attempts or after episodes of deliberate self-injury. Such episodes result in an average hospital stay of 6.3 days per year and nearly 1 emergency room visit every 2 years, rates that are 6 to 12 times those among patients with a major depressive disorder.”

As you can see BPD has a major financial impact on the health care system, not to mention the distress for the patients and their families.

When reviewing the various treatment options, the author says this about mentalization therapy:

Mentalization-based therapy is a cognitive or psychodynamic therapy including individual as well as group therapy. While assuming a “not-knowing” stance, the therapist insists that the patient “mentalize,” or examine and label his or her own experiences and those of others. This emphasis on thinking before reacting may be a process central to all effective therapies.

That “not-knowing” stance is what I tell the nons that I know: Be a detective, not a judge.

Related posts:

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2. Mentalization Based Therapy Shows Promise with BPD
3. Heather Locklear checks into in-patient facility

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In my group recently, a non-BPD was questioning his own “sanity” (I put it in quotes because I don’t believe that people with BPD are insane) and speculating that he was the one with BPD. One of our longer-time posters replied:

If you’re not throwing full-blown temper tantrums, freaking out because EVERYONE is out to get you, threatening to hurt or kill yourself, running away from those who love you because you’re afraid they’re going to leave you first, complaining that NOBODY loves or respects you AND popping pills and guzzling alcohol all at the same time… then, I think, you can go ahead and disqualify yourself.

Based on the polls that I have conducted over the past few months, I believe that she is right on the money. Here are the poll results from the last few polls about borderline behavior:

Borderline Behavior Poll Results

As you can see by these polls results, more than 73% responded that their borderlines (or themselves if they have the disorder) indicated that they have engaged in self-injury, suicide attempts and/or substance abuse. While these polls are certainly not scientific and it’s pretty much impossible for me to understand the profile of a person that responded, they results are, for me, striking. If 7 out of 10 (or more) individuals engage in these “low functioning” or ineffective borderline behaviors at some point in their lives, what should that tell us?

I believe that it tells us that the “typical” profile of someone with BPD is the “low functioning” or “classic” borderline. While I am sure there are others out there that operate in pretend mode (and pretend everything is ok while they “white-knuckle” their way through life), the vast majority of people with BPD seem to be caught in a spiral of ineffective and often dangerous behavior. They seem to me to be sending the message that they are in a great deal of emotional pain and are suffering greatly – that they will do anything to stop the pain that they feel. It also indicates to me that it is vital for parents of child with borderline-like traits and feelings do their best to get the child into appropriate treatment before their teenage years.

Related posts:

1. The great tree of behavior modification
2. A Must-Read Interview with a recovered Borderline
3. Does the mode of “failure to mentalize” determine the ineffective behavior of the borderline?

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IATROGENESIS, PSYCHOTHERAPY AND BORDERLINE PERSONALITY DISORDER

Pharmacological studies routinely explore the potential harm that a well-intentioned treatment may cause. In the case of psychosocial treatments we all too readily assume that at worst such treatments are inert. However, there may be particular disorders where psychotherapy represents a significant risk to the patient. Whatever the mechanisms of therapeutic change might be, traditional psychotherapeutic approaches depend for their effectiveness on the capacity of the individual to consider their experience of their own mental state alongside its re-presentation by the psychotherapist. The appreciation of the difference between one’s own experience of one’s mind and that presented by another person is key. It is the integration of one’s current experience of mind with the alternative view presented by the psychotherapist that must be at the foundation of a change process. The capacity to understand behaviour in terms of the associated mental states in self and other (the capacity to mentalise) is essential for the achievement of this integration.

Most individuals with no major psychological problems are in a relatively strong position to make productive use of an alternative perspective presented by the psychotherapist. However, those who have a very poor appreciation of their own and others’ perception of mind are unlikely to be able to benefit from traditional (particularly insight-oriented) psychological therapies. We have argued that persons with borderline personality disorder have an impoverished model of their own and others’ mental function (Bateman & Fonagy, 2004). Their schematic, rigid, sometimes extreme ideas about their own and others’ states of mind make them vulnerable to powerful emotional storms and apparently impulsive actions, and create profound problems of behavioural and affect regulation. The weaker an individual’s sense of their own subjectivity, the harder it is for them to compare the validity of their own perceptions of the way their mind works with that which a ‘mind expert’ presents. When presented with a coherent view of mental function in the context of psychotherapy, they are not able to compare the picture offered to them with a self-generated model and may all too often accept alternative perspectives uncritically or reject them wholesale.

Any psychological therapy can generate these divergent responses. Both cognitively based and dynamically orientated therapies offer causal explanations for underlying mental states. These can give ready-made answers and provide illusory stability by inducing a process of pseudo-mentalisation in which the patient takes on the explanations without question and makes them his/her own. Conversely, both types of perspective can be summarily and angrily dismissed as overly simplistic and patronising, which in turn fuels a sense of abandonment, feelings of isolation and desperation. Even focusing on how the patient feels can have its dangers. A person who has little capacity to discern the subjective state associated with anger cannot benefit from being told both that they are feeling angry and the underlying cause of that anger. Such an assertion addresses nothing that is known or can be integrated. It can only be accepted as true or rejected outright, but in neither case is it helpful. The dissonance between the patient’s inner experience and the perspective given by the therapist, in the context of feelings of attachment to the therapist, leads to bewilderment which in turn leads to instability as the patient attempts to integrate the different views and experiences. Unsurprisingly, this results in more rather than less mental and behavioural disturbance.

Related posts:

1. Are Borderlines Evil?
2. Mentalization Based Therapy Shows Promise with BPD
3. Angelina Jolie Tops the List of Searched On Celeb Borderlines

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Professor Richard Morriss, a professor of psychiatry at the University of Nottingham, said: ‘In people with depression who score highly on hypomania questionnaires there is a high prevalence of people with impulse control problems such as borderline personality disorder and intermittent explosive disorder who may superficially look like people with bipolar disorder.’

… which in combination with this finding: People with Borderline Personality Disorder over diagnosed with Bipolar Disorder …could have some interesting ramifications for the medical community.

The text of the article:

Bipolar depression unrecognised in primary care
03 Mar 11

By Christian Duffin

Up to a fifth of primary care patients with depression may have an undiagnosed bipolar disorder, a UK study suggests.

The researchers argue that their findings have important implications for GP diagnosis and assessment, because prescribing antidepressants as monotherapy for patients with bipolar disorder may result in mania and frequent mood swings.

The researchers believe that their study is the first to investigate the extent to which bipolar disorder is misdiagnosed as major depressive disorder among UK primary care patients.

The study involved a two-phase sampling technique to produce three estimates of unrecognised bipolar disorder.

The researchers initially collected diagnostic, clinical, psychosocial functioning and quality of life data from 11 GP practices in south Wales for patients with a diagnosis of unipolar depression.

576 of the 3,117 patients contacted sent back completed Hypomania Checklist (HCL-32) and Bipolar Spectrum Diagnostic Scale (BSDS) screening tool questionnaires, both used to test for bipolar disorder.

Of these, 154 were then given a comprehensive diagnostic and clinical assessment. 29 met the diagnostic criteria for bipolar disorder.

The researchers calculated three estimates of the prevalence of previously undiagnosed bipolar disorder, ranging from 3.3% up to 21.6%.

The estimates were based on different assumptions. The most conservative estimate assumed that all individuals who dropped out of the study did not have bipolar disorder.

Assuming that all of those who were invited to interview but did not attend did not have bipolar disorder resulted in a prevalence of 9.6%, while assuming all who were invited and attended had bipolar disorder resulted in a prevalence of 21.6%.

Lead researcher Dr Daniel Smith, a clinical senior lecturer in psychiatry at Cardiff University, said: ‘Although challenging, these are findings with potentially considerable implications for they way in which GPs approach the diagnosis and treatment of their patients with depression, especially when we consider how commonly antidepressants are prescribed in primary care and the potential for harm when antidepressants are used as monotherapy for bipolar disorder.’

He added: ‘It will be important that GPs are supported in developing strategies to ensure that their patients with depression receive the correct diagnosis with regard to the possibility of a primary bipolar illness.’

Dr Thomas Shackleton, a GP from Bottisham, near Cambridge with an interest in depression, said the research should serve as a reminder to GPs that they should screen for manic symptoms when they make they make a diagnosis for depression and during the follow-up at 5-12 weeks.

Dr Shackleton, also an advisor to NICE for its guidelines on depression, added: ‘This is a big issue because the majority of first presentations are depressive, and if you prescribe antidepressants you can induce a manic episode in someone who has bipolar disorder.

‘It can be difficult for GPs because if patients have impulsive or risky behaviour, such as risky sex or gambling, they tend you hide it from GPs. But GPs can explore patients’ histories and ask them if their family have had any concerns about them.’

Professor Richard Morriss, a professor of psychiatry at the University of Nottingham, said: ‘In people with depression who score highly on hypomania questionnaires there is a high prevalence of people with impulse control problems such as borderline personality disorder and intermittent explosive disorder who may superficially look like people with bipolar disorder.’

NICE GUIDELINES ON BIPOLAR DISORDER
-
- GPs should fully involve patients in decisions about their treatment and care, and determine treatment plans in collaboration with the patient’s preference.
- GPs should discuss contraception and the risks of pregnancy with all women of child-bearing potential, regardless of whether they are planning a pregnancy.
- People experiencing a manic episode, or severe depressive symptoms, should normally be seen again within a week of their first assessment, and then regularly at appropriate intervals, for example, every 2–4 weeks in the first 3 months and less often after that, if response is good.
- The treatment of bipolar disorder is based primarily on psychotropic medication, but side effects and potential harms will determine the choice of drug. A range of psychological and psychosocial interventions can also have a significant impact.
CG38 Bipolar disorder: NICE guideline, October 2006

Related posts:

1. Four reasons bipolar disorder is accepted and borderline personality disorder is not
2. Must Read Article about BPD and “coming off the couch”
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Getting Someone to Psychiatric Treatment Can Be Difficult and Inconclusive
By A. G. SULZBERGER and BENEDICT CAREY

TUCSON —What are you supposed to do with someone like Jared L. Loughner?

That question is as difficult to answer today as it was in the years and months and days leading up to the shooting here that left 6 dead and 13 wounded.

Millions of Americans have wondered about a troubled loved one, friend or co-worker, fearing not so much an act of violence, but — far more likely — self-inflicted harm, landing in the streets, in jail or on suicide watch. But those in a position to help often struggle with how to distinguish ominous behavior from the merely odd, the red flags from the red herrings.

In Mr. Loughner’s case there is no evidence that he ever received a formal diagnosis of mental illness, let alone treatment. Yet many psychiatrists say that the warning sings of a descent into psychosis were there for months, and perhaps far longer.

Moving a person who is resistant into treatment is an emotional, sometimes exhausting process that in the end may not lead to real changes in behavior. Mental health resources are scarce in most states, laws make it difficult to commit an adult involuntarily, and even after receiving treatment, patients frequently stop taking their medication or seeing a therapist, believing that they are no longer ill.

The Virginia Tech gunman was committed involuntarily before killing 32 people in a 2007 rampage.

With Mr. Loughner, dozens of people apparently saw warning signs: the classmates who listened as his dogmatic language grew more detached from reality. The police officers who nervously advised that he could not return to college without a medical note stating that he was not dangerous. His father, who chased him into the desert hours before the attack as Mr. Loughner carried a black bag full of ammunition.

“This isn’t an isolated incident,” said Daniel J. Ranieri, president of La Frontera Center, a nonprofit group that provides mental health services. “There are lots of people who are operating on the fringes who I would describe as pretty combustible. And most of them aren’t known to the mental health system.”

Dr. Jack McClellan, an adult and child psychiatrist at the University of Washington, said he advises people who are worried that someone is struggling with a mental disorder to watch for three things — a sudden change in personality, in thought processes, or in daily living. “This is not about whether someone is acting bizarrely; many people, especially young people, experiment with all sorts of strange beliefs and counterculture ideas,” Dr. McLellan said. “We’re talking about a real change. Is this the same person you knew three months ago?”

Those who have watched the mental unraveling of a loved one say that recognizing the signs is only the first step in an emotional, often confusing, process. About half of people with mental illnesses do not receive treatment, experts estimate, in part because many of them do not recognize that they even have an illness.

Pushing such a person into treatment is legally difficult in most states, especially when he or she is an adult — and the attempt itself can shatter the trust between a troubled soul and the one who is most desperate to help. Others, though, later express gratitude.

“If the reason is love, don’t worry if they’ll be mad at you,” said Robbie Alvarez, 28, who received a diagnosis of schizophrenia after being involuntarily committed when his increasingly erratic behavior led to a suicide attempt. At the time, he said, he was living in Phoenix with his parents, who he was convinced were trying to kill him. In Arizona it is easier to obtain an involuntary commitment than in many states because anyone can request an evaluation if they observe behavior that suggests a person may present a danger or is severely disabled (often state laws require some evidence of imminent danger to self or others).

But there are also questions about whether the system can accommodate an influx of new patients. Arizona’s mental health system has been badly strained by recent budget cuts that left those without Medicaid stripped of most of their services, including counseling and residential treatment, though eligibility remains for emergency services like involuntary commitment. And the state is trying to change eligibility requirements for Medicaid, which would potentially reduce financing further and leave more with limited services.

Still, people who have been through the experience argue that it is better to act sooner rather than later. “It’s not easy to know when we could or should intervene but I would rather err on the side of safety than not,” said H. Clarke Romans, executive director of the local chapter of the National Alliance on Mental Illness, an advocacy group, who had a son with schizophrenia.

The collective failure to move Mr. Loughner into treatment, either voluntarily or not, will never be fully understood, because those who knew the young man presumably wrestled separately and privately about whether to take action. But the inaction has certainly provoked second-guessing. Sheriff Clarence Dupnik of Pima County told CNN last Wednesday that Mr. Loughner’s parents were as shocked as everyone else. “It’s been very, very devastating for them,” he said. “They had absolutely no way to predict this kind of behavior.”

Linda Rosenberg, president of the National Council for Community Behavioral Healthcare, said, “The failure here is that we ignored someone for a long time who was clearly in tremendous distress.” Ms. Rosenberg, whose group is a nonprofit agency leading a campaign to teach people how to recognize and respond to signs of mental illness, added, “He wasn’t someone who could ask for help because his thinking was affected, and as a community no one said, let’s stop and make sure he gets help.”

At the University of Arizona, where a nursing student killed three instructors on campus eight years ago before killing himself, feelings of sadness and anger initially mixed with some guilt as the university examined the missed warning signs.

The overhauled process for addressing concerns is now more responsive, even if there are sometimes false alarms, said Melissa M. Vito, vice president for student affairs. “I guess I’d rather explain why I called someone’s parents than why I didn’t do something,” she said.

Many others feel the same way.

Four years ago Susan Junck watched her 18-year-old son return from community college to their Phoenix home one afternoon and, after preparing a snack, repeatedly call the police to accuse his mother of poisoning him. She assumed it was an isolated outburst, maybe connected to his marijuana use. In the coming months, though, her son’s behavior grew more alarming, culminating in an arrest for assaulting his girlfriend, who was at the center of a number of his conspiracy theories.

“I knew something was wrong but I literally just did not understand what,” Ms. Junck, 49, said in a recent interview. “It probably took a year before I realized my son has a mental illness. This isn’t drug related, this isn’t bad behavior, this isn’t teenage stuff. This is a serious mental illness.”

Fearful and desperate, she brought her son to an urgent psychiatric center and — after a five-hour wait — agreed to sign paperwork to have him involuntarily committed as a danger to himself or others. Her son screamed for her help as he was carried off. He was diagnosed with paranoid schizophrenia and remains in a residential treatment facility.

This week Erin Adams Goldman, a suicide prevention specialist with a mental health nonprofit organization in Tucson, is teaching the first local installment of a course that is being promoted around the country called mental health first aid, which instructs participants how to recognize and respond to the signs of mental illness.

A central tenet is that if a person has suspicions about mental illness it is better to open the conversation, either by approaching the individual directly, someone else who knows the person well or by asking for a professional evaluation.

“There is so much fear and mystery around mental illness that people are not even aware of how to recognize it and what to do about it,” Ms. Goldman said. “But we get a feeling when something is not right. And what we teach is to follow your gut and take some action.”

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Moran: Inspiration through empathy: Living with mental illness

Published: July 22, 2010 6:00 PM
Updated: August 05, 2010 8:00 AM

For Lorelei Andrews (not her real name), volunteering to offer support to local individuals living with mental illness is cornerstone to her daily life.

I had a chance to talk with her about her story and the current state of services in Kelowna for individuals living with mental illness.

She has worked as a server, a wedding planner, a full-time student (earning two degrees), and a bridal consultant.

In fact, she started one bridal gallery in Vancouver that has now become the largest in Canada, which may even be the venue for an upcoming television reality show.

However, about five years into her whirlwind career, she began experiencing anxiety.

“I was used to delivering 100 per cent all the time, I required it of myself,” recalled Lorelei.

She came to the point that with so much pressure, she started to think of the sale instead of the client. As a very thoughtful and empathetic person, she felt her self-worth sliding.

What began as a dip in productivity ended up with her entering “self-preservation mode,” and being prescribed various medications to balance out—resulting in a near comatose state for several months.

Lorelei is living with a mental illness. As productive and successful as she was, it struck her where she least expected it. It can happen to anyone: the successful executive, the homeless man asking for change, the young woman serving your coffee.

In fact, one in three Canadians will experience some form of mental illness in their lifetime—one in five will experience it this year.

After several rounds with psychiatrists, hospitalization and group therapy sessions, Lorelei was diagnosed first with bipolar disorder, which involves extreme mood swings.

She has since been more correctly diagnosed with pervasive post-traumatic stress disorder with symptoms of borderline personality disorder.

Lorelei was lucky. She had the drive and motivation to pick herself up and learn about her illness.

After the incorrect diagnosis, she began to self-advocate and attend various meetings and courses regarding mental illness.

While in Vancouver, she was offered a position in providing wellness and recovery planning for individuals with mental illness. “I found I had a talent for translating the doctor talk to regular people” said Lorelei.

She is now living completely organic. With her newfound skill set, she came to Kelowna and started a peer support group session that occurs once a week at the Kelowna and District Branch of the Canadian Mental Health Association.

“Our group is passionate, loving and empathetic, and they are so good to each other. A lot of us are hypersensitive, and with that comes great responsibility to control and manage our emotions,” said Lorelei, who maintains a positive outlook.

“It keeps me well and grounded and balanced; if I’m not living what I’m teaching, things don’t go well.”

What makes this group unique is the focus on mental health, rather than mental illness, which is steeped in stigma. Peers learn how to self-soothe and tolerate stress, as well as about the impact of mental illness in living a happy, healthy life.

“I’m inspired by what I see when I help someone change their perspective about what’s been bothering them. It’s the same thing I used to see in a girl’s eyes when she realized she was wearing the dress she was getting married in.”

To learn more about living with mental illness, and to hear stories such as Lorelei’s, visit the CMHA Kelowna website at www.kelowna.cmha.bc.ca.

***

CMHA Kelowna, in partnership with Interior Health, is also holding a community forum regarding the state of mental health and addictions services, which occurs July 28, 5:30 p.m., at 504 Sutherland Ave.

For more information or to register, contact Charly Sinclair at 250-861-3644 or email charly.sinclair@cmha.bc.ca.

Watch for another story of another member of our community who is living with mental illness in Sunday’s edition of the Capital News and online at www.kelownacapnews.com. The Canadian Mental Health Association is a charitable association, which promotes the mental health of all and supports the resilience and recovery of people experiencing mental illness.

Jamie Moran is the director of promotion and development for the Okanagan branch of the CMHA.

Related posts:

1. Impulsiveness Article
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3. Validation Article from DBT’s perspective

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Treatment Poll Results

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coming out of the psycho closet

When Merinda Epstein, a Policy and Law Reform Officer of the Mental Health Legal Centre in Melborne Australia, made the decision to “come out” with borderline personality disorder as a consumer advocate, her therapist was horrified. She asked Epstein, “why would you want to talk about that diagnosis in public for? You’ve got a perfectly good psychotic diagnosis to use in public!”

Such unfortunately is the reaction many of us who self-identify as “borderline” encounter. You can be a drug addict, have depression, OCD, schizophrenia, or any other number of diagnoses and people will shake your hand and congratulate you on your courage and honesty. But if you say you have BPD, everyone—from counselors to well meaning friends to even DBT therapists, will prophesize that you’ve just ruined your chances of ever getting a good job, relationship or credit rating. The last thing you ever want to be in the line-up of mental illnesses is borderline. Even if you have it. Perhaps, especially if you have it.I didn’t know this at first. I came to the diagnosis from the twelve step community, where they say “you can’t save your ass and your face at the same time.” I didn’t care what I had, so long as I knew there’d be a solution to it. And the doctor assured me there was, in the form of a new treatment called dialectical behavior therapy (DBT). I called one of my few remaining friends as soon as I got out of the doctor’s office. “Good news!” I gushed “I have borderline personality disorder! And it makes perfect sense!”

There was a pause on the other end of the phone and then Laura shrieked, “there is no f-ing way you are borderline!!” I pulled the phone away from my ear. “Why not?” “Think fatal attraction.. Knives and stalking. Psychobitch from hell. That’s not you!”

My drug and alcohol counselor had a strikingly similar reaction when I told her during my next session. “You are not one of those!” she exclaimed. Both she and Laura begged me not to accept the borderline diagnosis. It wasn’t yet even an issue of going public, as with Epstein. Just self-identifying, just hitching my little wagon of dysfunction to this wildebeest elicited overwhelming negative reactions from others. (Borderlines, I should say here, don’t do well with negative reactions. Which is probably one of the reasons why so few of us “come out.”)And yet, little by little, the trickle is becoming a stream: Borderlines are coming out, voices gathering: Amanda Wang, AJ Mahari, Tami Green, Amanda Smith, Lisa Johnson, Merinda Epstein, to name just some of the most prominent. Go to Facebook, to Myspace, and other social networking sites, and the focus is shifting from message boards with anonymous sufferers to people with real names who are dedicating themselves to advocacy, building community, educating others, and sharing their experience with recovery. In the last year alone, we’ve seen more videos, books, e-books, blogs and public appearances by self-identified borderlines than we have in the past decade combined. Tami Green calls it BPD 2.0. The Borderline Recovery Movement has truly begun.

The thrill is not just that it’s happening, but how invaluably therapeutic the “coming out” process can be when there is the right support. There is more to recovery than treatment. Life is exposure, and challenging the stigma of BPD by “outing” oneself and connecting to others is a powerful technique in transforming shame and building resilience. It is not easy. But we are learning that in standing up and being open about the illness, we are able to challenge and overcome the deep self-hatred and guilt that fuels so much of our BPD symptoms ; that in facing the stigma and surviving the exposure, we are able to deeply accept all aspects of ourselves and others, positive and negative; that through this, we don’t need saviors or caretakers to fix us, but communities and companions to journey with us; that in risking the rejection and braving the pain of having “outed” ourselves, we discover the deep freedom of no longer having to hide; that as we stop fearing the diagnosis, we are no longer controlled by it.

With BPD 2.0 now a reality, a central question becomes: how can treatments and supports help people with BPD navigate the process– should they want to “come out” and connect with others in the recovery process? The answer is actually quite simple. Help us. Stop telling people with this diagnosis that it’s bad or shameful to have BPD. Affirm that when it’s time, it can be a good thing to “come out.” Just look at all the wild and wonderful people who’ve done it so far! Begin to harbor a conviction that borderline personality is not a curse but an opportunity for growth—both for those who have it, and those near and dear. Catch yourself if you start to think of Borderlines as “them”—the incurable, the lepers of psychiatry, the untreatable. If we continue down that route of condemnation, the river will dry up. Those of us who are finally emerging will retreat back into shame and despair. We will cry, why can’t people recover? And then there will be no recovery. We will never hear the voices of those who’ve passed through the fire, or gained the wisdom of transforming these painful symptoms into strengths. We’ll be right back where we started. Without hope.

And yet, that is the furthest thing from the truth. There is actually much more than hope. There is our experience, a serum of courage and strength that we’ll spoon to each other so long as there are mouths willing to open and hands willing to reach out.guest blogger Kiera Van Gelder, MFA, is the author of The Buddha and the Borderline:My Recovery from Borderline Personality Disorder through Dialectical Behavior Therapy, Buddhism, and Online Dating. You can visit her at www.kieravangelder.com.

Related posts:

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2. Read my free eBook
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Anti-depressants and Depression

I believe that it has. Why? Well, there are a number of reasons that depression is a catch-all diagnosis. One certainly is the influence of the pharmaceutical industry given that billions of dollars are spent on anti-depressants each year. Also, doctors who are not mental health professionals (like GP’s) are prescribing anti-depressants if their patients are “depressed”.

Unfortunately, sometimes depression is not accurate. Many times when people say “I’m feeling depressed” they are really expressing that they are feeling emotional pain. Sometimes emotional pain is normal, sometimes a great deal of emotional pain is not normal and becomes problematic. When someone is feeling too much emotionally, it is not depression.

Depression is usually a problem when someone is feeling a strong lack of emotions – causing a lack of interest in the usual activities (including sex) that once gave us pleasure. Although many configurations of “depression” exist (because it is a non-specific term nowadays), the configuration in which one lacks emotions is alexythimia, although if one lives without pleasure it’s called anhedonia. I suspect that most people, when they describe being “depressed” are really describing a combination of anhedonia (where they can’t enjoy anything anymore) and social anxiety.

As I said above, another configuration that is referred to as “depression” is when the emotional pain becomes too overwhelming. In this case the person is feeling too much and would possibly beg for anhedonia because, while the pleasure would not be present, at least the pain would go away. I think that BPD probably involves more of this kind of “depression” than other disorders. The constant emotional pain leads people to doing anything to stop it (thus, this site’s name), including substance abuse, sexual promiscuity, risk-taking, self-injury and other seemingly self-defeating behaviors.

How can this be explained? How can someone be in such emotional pain all the time? One explanation comes from the study of u-opiods in the brain. A recent study by Stanley and Siever showed that people with BPD have too few u-opiods (the precursor for natural pain-killing neuro-chemicals) AND have over-active u-opiod receptors. This combination provides a baseline of pain and, when opiods are added, the brain feasts on these pain-killing substances with the over-active receptors. This is why some people with BPD can ingest large quantities of pain killers to seemingly little effect (or less effect than those without the disorder). I have heard people with BPD say they only feel “normal” while taking pain killers.

So, the question here is two-fold: First, are anti-depressants an appropriate treatment for emotional pain that is not really “depression”? And secondly, if not, what is? Low-dose pain-killers?

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Director’s Blog
April 19, 2010
What’s in a Name? — The Outlook for Borderline Personality Disorder

Thomas Insel

In Shakespeare’s “Romeo and Juliet,” the question is posed to illustrate that a name doesn’t define a person’s feelings or intent. In psychiatry, the same may be said of that which we call borderline personality disorder. Noted primarily for symptoms such as impaired mood regulation, unstable relationships with others, and self-harming behaviors, the name “borderline personality disorder,” fails to capture the essence of this serious mental illness.

As currently defined, borderline personality disorder is considered a reflection of an essential aspect of a person’s character that influences his or her way of seeing and being seen in the world. Recent research, however, has shown that symptoms of the disorder aren’t constant and may not always be as enduring as some researchers and clinicians may think. Yet fluctuating moods and behavior also happen to define another mental illness, bipolar disorder, with which borderline personality disorder may be confused….

He concludes with this:

…Whatever the outcome of reclassification efforts, however, we must keep in mind the essence of the question — that “borderline personality disorder” by any other name would still be as real, as disabling, and as necessary to treat, as other serious mental illnesses.

Read the whole post here.

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Remission Common in BPD, but Good Functioning Lags

A substantial majority of patients with borderline personality disorder (BPD) experience remission of symptoms, and their remission tends to be stable over time compared with other mental disorders—but only half of patients also achieve good social and vocational functioning.

Those were among the findings of a 10-year study of remission and recovery in BPD patients. The study was published online in AJP in Advance on April 15 and will appear in the June print edition of the American Journal of Psychiatry.

“Symptomatically, this is a good prognosis,” said Mary Zanarini, Ed.D., lead author of the study, in an interview with Psychiatric News. “The idea that people with BPD never get better isn’t true. But as much as they get better symptomatically, it’s clear that we need to pay attention to psychosocial and vocational functioning. Just to talk about symptoms isn’t enough.”

In the study, 290 inpatients at McLean Hospital in Belmont, Mass., who met both DSM-III-R and Revised Diagnostic Interview for Borderlines criteria for BPD were assessed at admission using a series of semi-structured interviews and self-report measures. The same instruments were readministered every two years for 10 years.

At the 10-year mark, 249 patients remained in the study. (Of the 41 patients who were no longer in the study, 12 had committed suicide, seven died of other causes, nine discontinued their participation, and 13 were lost to follow-up.)

Recovery was defined as not only remission of symptoms, but being able to function both socially and vocationally. Social functioning was defined as having at least one emotionally sustainable relationship with a friend, spouse, partner, or other non-blood-related individual. Vocational functioning was defined as the ability to perform full-time work competently and consistently.

Study results showed that 93 percent of the patients achieved remission of symptoms lasting at least two years, and 86 percent achieved remission lasting at least four years. However, only 50 percent achieved the full definition of recovery including social and vocational functioning (see chart).

Zanarini speculated that many patients may have temperamental problems—anger and/or extreme abandonment issues—that persist after the remission of symptoms and that hold them back socially and vocationally. “All of our manualized treatments for BPD are aimed at acute symptoms—self-mutiliation and suicidality—and those are the symptoms that remit the most quickly,” she told Psychiatric News.

She said that a rehabilitation model of treatment incorporating training in life skills—use of public transportion, budgeting, personal care, and vocational training—is key to fully addressing the recovery needs of patients who achieve remission of BPD symptoms.

The study’s other notable finding was that despite the difficulty many patients have in achieving full recovery, both remission of symptoms and full recovery, when they do occur, tend to be stable over time. Of those who achieved recovery, only 34 percent relapsed. Of those who achieved a two-year remission of symptoms, 30 percent had a symptomatic recurrence, and of those who achieved a sustained remission at four years, only 15 percent experienced a recurrence.

Zanarini and colleagues noted in their report that those rates compare favorably with remission and recurrence rates for common Axis I disorders studied longitudinally, such as major depression and dysthymic disorder. “[T]he high rate of sustained symptomatic remission and the low rate of symptomatic recurrence after sustained remission are among the most optimistic findings about borderline personality disorder reported to date,” they said.

In an interview with Psychiatric News, Zanarini said, “Depression and bipolar disorder tend to remit quickly but recur much more often. Recovery from BPD is more akin to the process of maturation. It occurs slowly, but once you achieve a certain level, you stay there, and it takes some enormous stressor to push you back.”

Joel Paris, M.D., an expert in BPD, reviewed the study for Psychiatric News. He said that it confirms and extends findings from the Collaborative Longitudinal Personality Disorders Study and the McLean Study of Adult Development. This study found that while symptomatic improvement is sufficient for many patients to stop meeting criteria for the disorder—such as no longer cutting themselves or overdosing—functional improvement is much slower.

“The study suggests that while BPD is by no means incurable, many patients continue to function at a low level for years,” Paris said. “So what are the clinical implications? On the one hand, when we thought that BPD was a life sentence, we avoided treating patients who can in fact be helped. And some people do make a full recovery, going on to live normal lives. On the other hand, other cases are more chronic. If we become too optimistic, we may mislead our patients into expecting the impossible and not provide the supportive and rehabilitative services they need.”

“Time to Attainment of Recovery From Borderline Personality Disorder and Stability of Recovery: A 10-Year Prospective Follow-Up Study” is posted at <http://ajp.psychiatryonline.org/pap.dtl>.

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Study shows long-term success in recovery from borderline personality disorder
April 15, 2010 |  6:00 am

Borderline Borderline personality disorder has long been considered one of the toughest psychiatric disorders to resolve. There have been many questions about how to best treat the condition, which is marked by unstable relationships, unhappiness, mood changes, impulsive behavior and poor decision-making.

Advances in understanding and treating the condition have been made in recent years, however. And a new study offers hope that recovery, although challenging, can be long-lasting.

Many Zanarini of McLean Hospital in Massachusetts studied 290 hospitalized patients with BPD over 10 years. Half of the patients recovered from the disorder after 10 years of follow-up. Recovery was defined as at least two years without symptoms and both social and vocational functioning. Overall, 93% of patients achieved a remission of symptoms lasting at least two years and 86% for at least four years.

The research suggests that while it may be difficult to achieve recovery, once recovery has been attained it appears to last. While many treatments focus on symptoms, therapy should include work on improving relationships and functioning in the workplace, areas that vastly boost the odds of long-term recovery, the authors said.

The study is published online Thursday in The American Journal of Psychiatry.

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Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder
Anthony Bateman, M.A., F.R.C.Psych., and Peter Fonagy, Ph.D., F.B.A.

Objective: This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder.

Method: Patients (N=134) consecutively referred to a specialist personality disorder treatment center and meeting selection criteria were randomly allocated to MBT or SCM. Eleven mental health professionals equal in years of experience and training served as therapists. Independent evaluators blind to treatment allocation conducted assessments every 6 months. The primary outcome was the occurrence of crisis events, a composite of suicidal and severe self-injurious behaviors and hospitalization. Secondary outcomes included social and interpersonal functioning and self-reported symptoms. Outcome measures, assessed at 6-month intervals, were analyzed using mixed effects logistic regressions for binary data, Poisson regression models for count data, and mixed effects linear growth curve models for self-report variables.

Results: Substantial improvements were observed in both conditions across all outcome variables. Patients randomly assigned to MBT showed a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalization.

Conclusions: Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required.

http://focus.psychiatryonline.org/cgi/content/abstract/8/1/55

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Mentalizing conference call with Drs. Peter Fonagy & Efrain Bleiberg
At the request of participants and the positive response to this November 2009 presentation on the interactive conference call, we are making this tape availalble.

Download conference call

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If Bipolar Disorder Is Over-diagnosed, What Are The Actual Diagnoses?

ScienceDaily (July 29, 2009) — A year ago, a study by Rhode Island Hospital and Brown University researchers reported that fewer than half the patients previously diagnosed with bipolar disorder received an actual diagnosis of bipolar disorder after using a comprehensive, psychiatric diagnostic interview tool –the Structured Clinical Interview for DSM-IV (SCID). In this follow-up study, the researchers have determined the actual diagnoses of those patients.

Their study is published in the July 28 ahead of print online edition of The Journal of Clinical Psychiatry.

Under the direction of lead author Mark Zimmerman, MD, director of outpatient psychiatry at Rhode Island Hospital, the researchers’ findings indicate that patients who received a previous diagnosis of bipolar disorder that was not confirmed by a SCID, they were significantly more likely to be diagnosed with borderline personality disorder as well as impulse control disorders.

Their research involved the study of 82 psychiatric outpatients who reported that they received a previous diagnosis of bipolar disorder that was not later confirmed through the use of the SCID. The diagnoses in these patients were compared to 528 patients who were not previously diagnosed with bipolar disorder. The study was conducted between May 2001 and March 2005.

Zimmerman, who is also an associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, says, “In our study, one quarter of the patients over-diagnosed with bipolar disorder met DSM-IV criteria for borderline personality disorder. Looking at these results another way, nearly 40 percent (20 of 52) of patients diagnosed with DSM-IV borderline personality disorder had been over-diagnosed with bipolar disorder.”

The results of the study also indicate that patients who had been over-diagnosed with bipolar disorder were more frequently diagnosed with major depressive disorder, antisocial personality disorder, posttraumatic stress disorder and eating and impulse disorders.

Zimmerman and colleagues note that “we hypothesize that in patients with mood instability, physicians are inclined to diagnose a potentially medication-responsive disorder such as bipolar disorder rather than a disorder such as borderline personality disorder that is less medication-responsive.”

In their previously published study that concluded bipolar disorder was over-diagnosed, they studied 700 patients. Of the 700 patients, 145 reported they had been previously diagnosed as having bipolar disorder; however, fewer than half of the 145 patients (43.4 percent) were diagnosed with bipolar disorder based on the SCID. The authors state that the over-diagnosis of bipolar disorder can have serious consequences, because while bipolar disorder is treated with mood stabilizers, no medications have been approved for the treatment of borderline personality disorder. As a result, over-diagnosing bipolar disorder can unnecessarily expose patients to serious medication side effects, including possible impact to renal, endocrine, hepatic, immunologic and metabolic functions.

Zimmerman concludes, “Because evidence continues to emerge establishing the efficacy of certain forms of psychotherapy for borderline personality disorder, over-diagnosing bipolar disorder in patients with borderline personality disorder can result in the failure to recommend the most appropriate forms of treatment.”

Along with Zimmerman, other researchers involved in the study include Camile Ruggero, PhD; Iwona Chelminski, PhD and Diane Young, PhD, all of Rhode Island Hospital and Brown University.

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Emotional validation strategies contrast with approaches that focus on the overreactivity of emotions or the distorted basis of their generation. Thus, they are more like the approach of Greenberg and Safran (1987), who make a distinction between primary or “authentic” emotions and secondary of “learned” emotions. The latter are reactions to primary cognitive appraisals and emotional responses; they are the end products of chains of feelings and thoughts. Dysfunctional and maladaptive emotions, according to Greenberg and Safran, are usually secondary emotions that block the experience and expression of primary emotions. These authors go on to suggest that “all primary affective emotions provides adaptive motivational information to the organism” (1987, p. 176). The important point here is the suggestion that dysfunctional and maladaptive responses to events are often connected or interwoven with “authentic” or valid responses to these events. Finding and amplifying these primary responses constitute the essence of emotional validation. The honesty of the therapist in applying these strategies cannot be overstressed. If emotional validation strategies are used as change strategies – that is, if lip service is given to validation in order to simply to calm the patient down for the “real work” – the therapist can expect the therapy to backfire. Such honesty, in turn, depends on the therapist’s belief that there is a substantial validity to be found, and that searching for it is therapeutically useful.

Cognitive-Behavioral Treatment of Borderline Personality Disorder

This idea is an important one for loved ones of those with BPD because it touches on several points:

• It acknowledges that emotional validation focuses on “normal” emotional reactions, not “the overreactivity of emotions or the distorted basis of their generation.” That is the way of emotional invalidation, i.e. “You’re overreacting to something trivial. Look at what really happened.” I see that expression from Non-BPs all the time.
• It points out the differences between primary and secondary emotions. This distinction is extreme useful for Non-BPs. Why? Because most often the anger and rage are secondary emotions (not always) and that is typically what Nons focus on. If the emotional validation is used for secondary emotions, then I interpret this as not therapeutic, because you are “validating the invalid.”
• Probing (gently and compassionately) for the primary emotions seems to be a more effective strategy and those are the emotions that can be validated effectively.
• One has to approach emotional validation as a tool unto itself – without using it as a “change strategy.” That is, “it is ok to feel that, but you have to change the way you feel to be ‘normal’.” That is, bound to backfire.
• If this distinction of primary and secondary emotions – the first being true and “authentic”, the second being dysfunctional and maladaptive – is applied to the concept of mentalization, then the idea within mentalization to use emotional validation to probe for further feelings begins to make more sense. One has to help the BP locate the primary emotion.

When Hope is Not Enough
Get the Non-BPD book that is designed for
staying and working on the relationship

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Event -> Interpretation -> Emotional/Physical Feelings -> Action Impulses -> Expression and Behavior

DBT-FST seems to me to operate at the Action Impulses to Expression and Behavior link, while validating the Emotional/Physical Feelings link. Don’t get me wrong, the DBT-FST skills are extremely powerful in communicating with someone with BPD. Yet, the change that is requested is at the end of the chain. I have heard that Marsha Linehan is quoted as saying something like, “Just because you feel like a crazy person, doesn’t mean you have to behave like one.” The point here is that DBT is a behavioral therapy and by modifying behavior, that works backwards toward regulating emotion and tolerating distress. In other words, DBT trains you to behave differently based on your feelings. When you gradually learn that your new behavior is more effective than the previous behavior, you break the conditioned chain between Action Impulses and Expression and Behavior. That is the essence of the DBT skill “Opposite Action.” An interesting side note is that by practicing Opposite Action (that is, doing the exact opposite of what your feelings implore you to do – such as engaging when you feel sad, rather than hiding under the covers all day), you actually feel better, because the action does work backward. Dr. Paul Ekman found that configuring one’s face to mimic a certain feeling actually causes that feeling to be experienced. That is the theory behind DBT’s “Half Smile” skill. Ultimately though, by working at that link in the chain, the person still feels the emotion, yet he or she just behaves differently than the emotion originally informed him/her to behave.

MBT on the other hand takes on the on the problem at the Interpretation link. By asking questions and being open to alternative interpretations, the person with BPD is more likely to have a broader view of other people’s behavior and the events in life. DBT never asks about the intent or motivation of the other person and just takes the interpretation as a given in a person with BPD. If a person with BPD says something happens and that something means X, then in DBT it means X. There is very little questioning of the validity of the interpretation X. In MBT, however, the interpretation X can be questioned and alternative interpretations (such as Y or Z) can be examined. The nice thing about this is that when the person with BPD is faced with a similar situation, he/she is less likely to jump to conclusion X and might consider Y or Z.

An example of the differences in the two approaches is as follows:

My daughter comes home from school after being teased by a boy on the playground. My daughter ends up throwing a thermos at the boy’s head.

With DBT, I would validate her anger and ask her how she could behave more effectively the next time this teasing occurs. So next time she will behave more effectively and not throw the thermos.

With MBT, I would validate her feelings and begin to probe with curious and straight-forward questions as to the intent of the boy. Perhaps he actually likes my daughter and that is why he is teasing. Perhaps he is showing off to his friends. If this approach is taken, my daughter is more likely to consider the boy’s motivation for the teasing. If she understands the motivation, she can actually never get angry and risk throwing the thermos.

All of that being said, I believe these skills have to be learned as a “ladder” to effectiveness. You can’t start at point E without going through points A-D. DBT-FST provide the foundation for more advanced skills, like those in MBT.

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“Sam and Lindsay are speaking,” the source tells PEOPLE. “But Sam has begged Lindsay to get help.”

“Lindsay, despite appearances, is insecure and has relied on Samantha and their relationship to build her up,” explains the pal. “Lindsay barely sleeps, which explains a lot of her behavior. She’s exhausted. She can’t even sit down for a minute without pacing around the room. It’s really sad.”

Sam is begging Lindsay to get help? For what? Well, perhaps we know.  Looking at Lindsay’s case, I can’t help but see Borderline Personality Disorder (BPD). She is erractic, emotional and sexually confused. She has all the classic signs of an untreated person with BPD. I hope she gets help – and I hope that, if she is diagnosed with BPD, she would come out publically and say so – to reduce the stigma of the disorder.

Lindsay Lohan and BPD?

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Thursday, Jan. 08, 2009

Minds on The Edge

By John Cloud/Seattle

Doctors used to have poetic names for diseases. A physician would speak of consumption because the illness seemed to eat you from within. Now we just use the name of the bacterium that causes the illness: tuberculosis. Psychology, though, remains a profession practiced partly as science and partly as linguistic art.

Because our knowledge of the mind’s afflictions remains so limited, psychologists–even when writing in academic publications–still deploy metaphors to understand difficult disorders. And possibly the most difficult of all to fathom–and thus one of the most creatively named–is the mysterious-sounding borderline personality disorder (BPD). University of Washington psychologist Marsha Linehan, one of the world’s leading experts on BPD, describes it this way: “Borderline individuals are the psychological equivalent of third-degree-burn patients. They simply have, so to speak, no emotional skin. Even the slightest touch or movement can create immense suffering.”

Borderlines are the patients psychologists fear most. As many as 75% hurt themselves, and approximately 10% commit suicide–an extraordinarily high suicide rate (by comparison, the suicide rate for mood disorders is about 6%). Borderline patients seem to have no internal governor; they are capable of deep love and profound rage almost simultaneously. They are powerfully connected to the people close to them and terrified by the possibility of losing them–yet attack those people so unexpectedly that they often ensure the very abandonment they fear. When they want to hold, they claw instead. Many therapists have no clue how to treat borderlines. And yet diagnosis of the condition appears to be on the rise.

A 2008 study of nearly 35,000 adults in the Journal of Clinical Psychiatry found that 5.9%–which would translate into 18 million Americans–had been given a BPD diagnosis. As recently as 2000, the American Psychiatric Association believed that only 2% had BPD. (In contrast, clinicians diagnose bipolar disorder and schizophrenia in about 1% of the population.) BPD has long been regarded as an illness disproportionately affecting women, but the latest research shows no difference in prevalence rates for men and women. Regardless of gender, people in their 20s are at higher risk for BPD than those older or younger.

What defines borderline personality disorder–and makes it so explosive–is the sufferers’ inability to calibrate their feelings and behavior. When faced with an event that makes them depressed or angry, they often become inconsolable or enraged. Such problems may be exacerbated by impulsive behaviors: overeating or substance abuse; suicide attempts; intentional self-injury. (The methods of self-harm that borderlines choose can be gruesomely creative. One psychologist told me of a woman who used fingernail clippers to pull off slivers of her skin.”

No one knows exactly what causes BPD, but the familiar nature-nurture combination of genetic and environmental misfortune is the likely culprit. Linehan has found that some borderline individuals come from homes where they were abused, some from stifling families in which children were told to go to their room if they had to cry, and some from normal families that buckled under the stress of an economic or health-care crisis and failed to provide kids with adequate validation and emotional coaching. “The child does not learn how to understand, label, regulate or tolerate emotional responses, and instead learns to oscillate between emotional inhibition and extreme emotional lability,” Linehan and her colleagues write in a paper to be published in a leading journal, Psychological Bulletin.

Those with borderline disorder usually appear as criminals in the media. In the past decade, hundreds of stories in major newspapers have recounted violent crimes committed by those said to have the disorder. A typical example from last year was the lurid tale of an Ontario man labeled borderline who used a screwdriver to gouge out his wife’s right eye. (She lived; he got 14 years.”

There are several theories about why the number of borderline diagnoses may be rising. A parsimonious explanation is that because of advances in treating common mood problems like short-term depression, more health-care resources are available to identify difficult disorders like BPD. Another explanation is hopeful: BPD treatment has improved dramatically in the past few years. Until recently, a diagnosis of borderline personality disorder was seen as a “death sentence,” as Dr. Kenneth Silk of the University of Michigan wrote in the April 2008 issue of the American Journal of Psychiatry. Clinicians often avoided naming the illness and instead told patients they had a less stigmatizing disorder.

Therapeutic advances have changed the landscape. Since 1991, as Dr. Joel Paris points out in his 2008 book, Treatment of Borderline Personality Disorder, researchers have conducted at least 17 randomized trials of various psychotherapies for borderline illness, and most have shown encouraging results. According to a big Harvard project called the McLean Study of Adult Development, 88% of those who received a diagnosis of BPD no longer meet the criteria for the disorder a decade after starting treatment. Most show some improvement within a year.

Still, the rise in borderline diagnoses may illustrate something about our particular historical moment. Culturally speaking, every age has its signature crack-up illness. In the 1950s, an era of postwar trauma, nuclear fear and the self-medicating three-martini lunch, it was anxiety. (In 1956, 1 in 50 Americans was regularly taking mood-numbing tranquilizers like Miltown–a chemical blunderbuss compared with today’s sleep aids and antianxiety meds.) During the ’60s and ’70s, an age of suspicion and Watergate, schizophrenics of the One Flew Over the Cuckoo’s Nest sort captured the imagination–mental patients as paranoid heroes. Many mental institutions were emptied at the end of this period. In the ’90s, after serotonin-manipulating drugs were released and so many patients were listening to Prozac, thousands of news stories suggested, incorrectly, that the problem of chronic depression had been finally solved. Whether driven by scary headlines, popular movies or just pharmacological faddishness, the decade and the disorder do tend to find each other.

So, is borderline the illness of our age? When so many of us are clawing to keep homes and paychecks, might we have become more sensitized to other kinds of desperation? In a world so uncertain, maybe it’s natural to lose one’s emotional skin. It’s too soon to tell if that’s the case, but BPD does have at least one thing in common with the recession. As Dr. Allen Frances, a former chair of the Duke psychiatry department, has written, “Everyone talks about [BPD], but it usually seems that no one knows quite what to do about it.”

Inside the Mind

To have coffee with Lily (a pseudonym), you wouldn’t get much sense of how she has suffered. She is 40 but could pass for 30. She has blue eyes and long blond hair that falls across her shoulders in slightly curly tendrils. On the December day we met at a diner outside Seattle, she wore a pink wool cap pulled down tight and an Adidas jumper zipped all the way. She was friendly but not terribly expressive, and she carried an aura of self-protection.

At one point in the late ’90s, Lily was taking five drugs that doctors had prescribed: three antidepressants, an antianxiety medication and a sleeping pill. Borderline patients are often overmedicated–partly because therapists see them as difficult–but for Lily, as for most borderlines, the meds did little. “Drug treatment for BPD is much less impressive than most people think,” Paris writes in Treatment of Borderline Personality Disorder.

As a teenager, Lily felt little self-confidence. “Junior high and high school just sucks, right?” she said, laughing. “But I had a propensity to take it a little more seriously.” With the help of therapy, she made it through high school and college, but in her late 20s, she became dissatisfied with her job selling specialty equipment. One October day, as she headed out for a mountain-biking trip, she looked at the dun sky and had the feeling that something was wrong. Bleakness massed around her quickly, much faster than it had when she was younger. Soon, nothing gave Lily much joy.

She recalled a talk show in which girls had discussed cutting themselves as a release, a way to relieve depression. “I was so numb,” she said. “I just wanted to feel something–anything.” So she took a knife from the kitchen and cut deeply into her left arm.

If Lily had a hard time figuring out what was behind such dark emotions, she was in good company. When a psychoanalyst named Adolph Stern coined the term borderline in the 1930s, borderline patients were said to be those between Freud’s two big clusters: psychosis and neurosis. Borderlines, Stern wrote rather poetically, exhibit “psychic bleeding–paralysis in the face of crises.” Later, in the 1940s, Dr. Helene Deutsch said borderlines experience “inner emptiness, which the patient seeks to remedy by attaching himself or herself to one after another social or religious group.” By 1968, when Basic Books published the groundbreaking monograph The Borderline Syndrome, the No. 1 characteristic of borderline patients was said to be, simply, anger.

Eventually, borderlines became pretty much anything a therapist said they were. Says Dr. Kenneth Duckworth, medical director of the National Alliance on Mental Illness: “If you hated the patient–if the patient was pissing you off–you would bandy this term about: ‘Oh, you’re just a borderline.’ It was a diagnosis that was a wastebasket of hostility.”

It was Linehan who changed all that. In the early 1990s, she became the first researcher to conduct a randomized study on the treatment of borderline personality disorder. The trial–which showed that a treatment she created called “dialectical behavior therapy” significantly reduced borderlines’ tendency to hurt themselves as well as the number of days they spent as inpatients–astonished a field that had come to see borderlines as hopeless.

Dialectical behavior therapy is so named because at its heart lies the requirement that both patients and therapists find synthesis in various contradictions, or dialectics. For instance, therapists must accept patients just as they are (angry, confrontational, hurting) within the context of trying to teach them how to change. Patients must end the borderline propensity for black-and-white thinking, while realizing that some behaviors are right and some are simply wrong. “The patient’s first dilemma,” Linehan wrote in her 558-page masterwork, 1993′s Cognitive-Behavioral Treatment of Borderline Personality Disorder, “has to do with whom to blame for her predicament. Is she evil, the cause of her own troubles? Or, are other people in the environment or fate to blame? … Is the patient really vulnerable and unable to control her own behavior …? Or is she bad, able to control her reactions but unwilling to do so …? What the borderline individual seems unable to do is to hold both of these contradictory positions in mind.”

Linehan’s achievement was to realize that borderlines are, in fact, on the border between various dualities–dualities that they have to learn to accept and reconcile in order to change their lives. That’s easy to say but seems impossible to do–until you see it work.

A Life Redeemed

After she cut herself, Lily was horrified. In a panic, she called her father, who took her to the hospital. When she was released, she and her parents redoubled their efforts to find her good psychiatric treatment. Through a friend at the University of Washington, they heard about Linehan and contacted her Behavioral Research & Therapy Clinics, which are housed in a homey little annex on the UW campus, where you might find little foil-wrapped chocolates next to the coffee and tea.

Linehan, who grew up in Tulsa, Okla., and spent several years as a nun before becoming a psychologist, embodies several dialectical contradictions: a nun who has never lived in a convent; a careful scientist whose most engaging feature is her wry irreverence; a 65-year-old who has a maternal steeliness but was never a mother. It doesn’t pay to underestimate Marsha Linehan. In Cognitive-Behavioral Therapy for Borderline Personality Disorder, she writes, “If the patient says, ‘I am going to kill myself,’ the therapist might reply, ‘I thought you agreed not to drop out of therapy.’”

In one intense session a few years ago, a patient told Linehan that her work stress was going to lead her to suicide. The patient said Linehan could never understand this stress because she was a successful psychologist. Suicidal borderline patients often confront and alienate therapists in this fashion; for many years, this kind of confrontation was seen as a defining characteristic of the disorder. Linehan believes that borderlines are hurting, not manipulating, but that doesn’t mean she indulges them. In this particular confrontation, Linehan responded, “I do understand. I live with a similar amount of stress … You can just imagine how stressful it is for me to have a patient constantly threatening to kill herself. Both of us have to worry about being fired!”

Such in-your-face tactics were highly controversial when Linehan started out. Other mental-health professionals accused her in public meetings of being heartless, even unethical. But her therapy has saved so many lives and worked so well in randomized trials that few criticize her today. For Lily, who calls Linehan’s therapy “Zen philosophy meets tough love,” Linehan was the first therapist to understand that managing Lily’s illness would require Lily to take a new kind of responsibility–a willingness to grow the emotional skin she never had.

In the beginning, Lily resisted Linehan’s assistance. She felt no one could truly understand the depths of her pain. But Linehan was the first therapist who responded to Lily with more than just endless psychoanalysis and pills. Instead, Linehan taught her practical methods of getting by day-to-day. Once, just after she started with Linehan, Lily locked herself in her parents’ bathroom and swallowed six or seven antidepressants in a half-hearted suicide attempt. Her father broke the door down; her mother called the police. Lily never lost consciousness, but the cops said she had to go to the hospital anyway. Linehan advised Lily’s parents not to accompany her. She also told them they needed to get Lily to work the next day. Lily learned that she wouldn’t be cosseted.

Linehan also taught Lily various skills to regulate her emotions. Among the most important is one Linehan calls the “wise mind”–a kind of calm, Zen state that Linehan insists even the most debilitated patients can achieve. “Generally,” she writes, “I have patients follow their breath … and try to let their focus settle into their physical center, at the bottom of their inhalation. That very centered point is wise mind.” Lily remembers this sensation clearly; she came to feel that her dark moods had a physical location in her body–her solar plexus–and when she focused on it, she could deactivate a destructive emotion.

Another skill Linehan taught Lily (and many others, via a popular DVD called Opposite Action) was an anti-anger technique for social situations: “Don’t make the situation worse,” Linehan counsels on the DVD. “And if possible, be a little tiny bit on the kind side. O.K.?”

If some of this sounds like advice you heard in kindergarten, it should. Remember that borderlines have never learned to regulate their emotions. It’s important to note that Linehan doesn’t just practice tough love with her patients; she also tells them she knows they are hurting and doing the best they can. She emphasizes that she believes in them even though many therapists have tossed them aside. “Clients cannot fail,” she says. “But both treatment and a therapist can fail.” Both compassion and irreverence, both validation and tough love–these are the dialectics at the heart of Linehan’s approach.

One criticism of Linehan’s Zen-derived method is that for some patients, it seems too foreign, too removed from Western experience. Linehan knows her therapy works for most people, but that doesn’t mean she’s unwilling to list its faults. “It takes too long. There are too many components. It takes too much training for therapists,” she says.

Such shortcomings have not dissuaded other therapists from learning Linehan’s techniques. Some 10,000 of them have been trained in dialectical behavior therapy, and Linehan, to her dismay, has become something of a cult figure. “Cults in psychology hurt patients,” she says. “People should try whatever works, not my therapy because it has my name on it.”

Lily, for one, is glad that it’s the therapy she did try. One of her favorite films used to be James Mangold’s 1999 adaptation of Girl, Interrupted, in which Winona Ryder plays a real-life borderline author. When Ryder’s character learns she has received a diagnosis of borderline personality disorder, she indignantly asks, “Borderline between what and what?” It’s a question that weighed on Lily for years and one that many of us may start asking if borderline diagnoses continue to increase. But today Lily is able to laugh about the film because she knows, finally, that the answer doesn’t really matter. The key is not defining that uncertain borderline but learning to be happy there.

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Article published Dec 5, 2008
Innocent plea entered by caregiver in case where woman died
By Thatcher Moats Times Argus Staff
BARRE – Julie Davis is accused of doing too little too late to help a vulnerable adult who died while in her care last summer.

Davis, 47, of Calais pleaded innocent in Vermont District Court in Barre Thursday to neglect of a vulnerable adult by a caregiver, which carries a potential penalty of 15 years in prison and a $10,000 fine.

Davis was the caregiver responsible for Jean Lemire when Lemire, 45, died last August of hypothermia after being removed from Davis’ Calais home.

Lemire’s core body temperature was 82 degrees when she arrived at Central Vermont Medical Center, and she had multiple bruises, lacerations and a broken rib, court records state. When rescue workers found Lemire, she was soaking wet and had significant bruising on her face and chest, according to Jay Copping of the East Calais rescue squad. Lemire had been eating mud and grass, and Copping told police that he extracted muddy water and grass from Lemire as he attempted to force a tube down her throat.

The court records paint a picture of Lemire as a difficult person to handle, who become more so in the days leading up to her death. Her worsened condition may have been triggered by news of the death of her nephew, who family members said she was close to. Lemire was also scheduled to be moved from Davis’ residence, according to the affidavit, which also may have caused anxiety.

Davis told investigators that Lemire was a self-mutilator who would punch herself in the face and slam her face into the walls. Davis said that in the five days before she died, Lemire refused to sleep and often ran into the woods naked. She also ran over to a neighbors’ house without her clothes on a few days before her death.

On the day of Lemire’s death, Davis said Lemire had been given her morning dose of medication and then spent the majority of the day outside.

However, Davis didn’t call 911 until Lemire collapsed and stopped breathing. Davis had been trying to get Lemire to eat and drink Gatorade, she told investigators, and she performed CPR on Lemire until rescue workers arrived.

Shirley Cichonowicz, a sister and guardian of Lemire, told police that at the hospital the family decided to take Lemire off life support. Lemire died that Aug. 9 at about 10 p.m., according to court records.

Thursday’s proceeding in Vermont District Court in Barre was brief, and Davis was released on conditions. About 15 of Lemire’s family members were in the courthouse, and they filed out of the courtroom after the arraignment but declined to comment.

In an interview with police, Davis’ supervisor and Lemire’s case manager, Karen Daley-Regan, said that Lemire should have been placed in a crisis home based on her behavior in the days before her death.

Daley-Regan said that Lemire’s behavior before her death was uncharacteristic. But she also said that Lemire was known to take her clothes off and had an eating disorder, two of the things that lead to the woman’s death.

On Aug. 5, Daley-Regan prepared a monthly log that indicated no irregular issues with Lemire or Davis, court records state.

But the next day Davis reported that Lemire had gone to a neighbor’s home naked.

Daley-Regan then told Davis that she needed to have her eyes on Lemire at all times, but Daley-Regan did not do a home visit.

Daley-Regan told police that on Aug. 7 she checked in with Davis, who did not say there was an emergency.

Daley-Regan told police that had she known what was going on at the Davis residence, she would have intervened.

Davis told investigators that she tried to communicate what was going on when she talked to Daley-Regan, but also admitted she did not try hard enough. Davis also told police that she knows she should have done more to help Lemire, according to court records.

Communication was not Davis’ strength, according to a former colleague who was the case manager for one of Davis’ previous clients.

Troy Busconi, of the Vermont Crisis Intervention Network at Upper Valley Services, was the case manager for Shawn Leary, whom Davis cared for at one time.

Busconi told police that Davis lacked communication skills, and said he heard about a seizure that Leary had had only long after the incident. And when Davis asked for help, she would “not communicate it directly,” Busconi told investigators.

Davis had a limited skill set, but did the best she could, Busconi told police.

Last May, Adult Protective Services received a complaint that a caregiver was being abusive to her client in a local drugstore. The complainant, Lisa Sargent, took down the license plate number on the vehicle, which was registered to Doug Ballou, who lived with Davis in Calais.

Sargent also told police that the caregiver was referring to the client as “Jean.”

Another caregiver told police that he witnessed Davis scream at Lemire to get her to do things.

It also appears that Lemire was not the first client to die while in the care of Davis. The affidavit is not entirely clear on how much responsibility Davis may have had for the death of a man named Doug Lafrance, who, according to court records, died of pneumonia. But he was in her care when he died, according to the affidavit.

Police pointed out that in the two deaths, Davis did not call 911 until it was too late.

Lemire had been a client of Lincoln Street Inc., a non-profit agency based in Springfield, dedicated to caring for people with developmental disabilities, for 24 years. She was diagnosed with borderline personality disorder, according to the affidavit, and also suffered from anorexia, bulimia, seizure disorder and other conditions.

Lemire required daily doses of a handful of mood stabilizing and anti-depressant drugs.

Davis, who has been a homecare provider for 11 years, began caring for Lemire late last March.

Joan Senecal, the commissioner of the state Department of Aging and Disability, could not be reached for comment yesterday. Cheryl Thrall, the executive director at Lincoln Street declined to comment.

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May 30, 2006

Behavior

A Case in Point for the Maxim ‘Do No Harm’

By RICHARD A. FRIEDMAN, M.D.

Everyone knows that talking about your feelings is supposed to be good for you. In part, that’s probably why psychotherapy is widely viewed as a healthy pursuit. Conventional wisdom has it that self-knowledge is always a boon, and, like wealth, you can never have too much of it.

That’s what I thought until I met Helen.

Helen was a successful 52-year-old professional who had been married for 30 years. After watching “The Celebration,” a movie in which the family patriarch is publicly unmasked as a sexual predator by his children, Helen recovered what she believed were memories of sexual abuse by her father.

Over the course of several months, she felt depressed and angry and decided to start psychotherapy for the first time. Her therapist recommended twice-weekly sessions and encouraged her to discuss her childhood and memories of sexual abuse.

She became more depressed and anxious during the initial treatment, hardly unexpected given the traumatic material she had to deal with. But then something alarming began to happen.

Helen began to abuse alcohol, something she had never done before, and to cut her wrists superficially, an old behavior that she had stopped in her 20′s.

Helen was confused. If therapy was supposed to help her, why did she feel so much worse? What could explain the fact that this previously high-performing professional woman had become a serious alcohol abuser who was cutting her wrists several times a week with a razor?

The problem was that Helen had what psychiatrists call borderline personality disorder, and therapy had encouraged a process of self-exploration that proved toxic to her.

She did not have the psychological resources to deal with the intense emotions that this kind of therapy unleashed.

Borderline patients frequently use alcohol or drugs to try to stabilize their overly reactive moods, and they often injure themselves to relieve unbearable psychic pain.

In hindsight, it’s easy to see that this was just the wrong treatment for this particular patient. Yet even when she was given a more supportive treatment, aimed at helping her cope rather than delve into her feelings, she still floundered and didn’t function nearly as well as she did before having any therapy.

It will sound heretical coming from a psychiatrist, but there are some patients who feel worse and get worse when they are in psychotherapy. For some, the problem is getting the wrong type of treatment; for others, it may be the relationship with the therapist that is problematic, regardless of the specific treatment.

In an analysis of psychotherapy studies, Dr. Michael Lambert, a professor of psychology at Brigham Young University and a well-known expert in psychotherapy research, found that about 5 percent to 10 percent of patients deteriorated with psychotherapy.

This is not a trivial problem considering that 3.5 percent of all Americans were in psychotherapy each year from 1987 to 1997, according to a 2002 study published in The American Journal of Psychiatry by Dr. Mark Olfson of the College of Physicians and Surgeons of Columbia.

Although we are not very good at predicting which patients are likely to get worse with treatment, it’s not that hard to spot them once they are in therapy and things aren’t going well.

A few years back, one of my residents was treating a young man in psychotherapy who had great difficulty deciding what he wanted to do with his life.

He wasn’t depressed, but he was a very passive person.

It became clear that the patient was using the treatment not to understand his passivity, but to indulge it; he enjoyed talking about what he should do, but made no steps outside of therapy despite many attempts to address his behavior. We stopped his psychotherapy and referred him for vocational counseling.

The possible benefits of no treatment go beyond just patients who get worse in therapy. Some patients have been in psychotherapy for so long that it isn’t clear what the advantage of treatment is; in some of these cases, stopping therapy gives patients a chance to discover that they might do fine without it.

Others might seek treatment during a crisis or when they are grief-stricken. As painful as these situations can be, if people are generally healthy and have good social supports, they are likely just to feel better with time and probably don’t need any treatment at all.

At first blush, it might sound paradoxical — even uncaring — but sometimes the best treatment is no treatment at all.

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October 21, 2008

Mind

When All Else Fails, Blaming the Patient Often Comes Next

By RICHARD A. FRIEDMAN, M.D

Doctors and psychotherapists generally don’t like it when their patients don’t get better. But the fact is that lots of patients elude our clinical skill and therapeutic cleverness. That’s often when the trouble starts.

I met one such patient not long ago, a man in his early 30s, who had suffered from depression since his teenage years. In six years of psychotherapy, he had been given nearly every antidepressant under the sun, but his mood hadn’t budged.

Weeping in my office one day, he explained that he was depressed because he was a failure and a whiner. “Even my therapist agreed with me,” he said. “She said that maybe I don’t want to get better.”

I could well imagine his therapist’s frustration. She had been working with him for nearly three years without significant progress, and she was now doing what many clinicians do when the chips are down: blame the patient for failing to improve.

“I think he has an unconscious desire to remain sick,” she told me.

About a month later, I saw this patient respond remarkably well to a novel treatment. Free of depression at last, he was joyful and relieved — an odd reaction, you must admit, from someone who secretly wished to be ill.

Not just that, but he no longer felt like a failure and was much more upbeat about his future prospects.

I decided to challenge him. “How come you’re feeling so much better despite the fact that nothing in your life has really changed in the past few weeks?”

“Well, I guess I just think like that when I’m down.”

Exactly. His sense of worthlessness was a result of his depression, not a cause of it. It’s easy to understand why the patient couldn’t see this: depression itself distorts thinking and lowers self-esteem. But why did his therapist collude with the patient’s depressive symptoms and tell him, in effect, that he didn’t want to get better?

For an all too human reason, I think. Chronically ill, treatment-resistant patients can challenge the confidence of therapists themselves, who may be reluctant to question their treatment; it’s easier — and less painful — to view the patient as intentionally or unconsciously resistant.

I recall an elderly woman who was referred by a colleague for intractable depression, in which I have a special interest. I was eager to help her.several months and many treatments later, I began to get frustrated that she was no better and noticed that my thinking about her shifted. I wondered whether there was something about the sick role that she found rewarding.

After all, she had constant visits from friends and family members, not to mention an army of medical experts who were all trying, in vain, to cure her. If she got better, she might lose all that care and attention.

Then one morning, shortly after starting a new combination of antidepressants, she called. I did not recognize the cheerful voice. “I’m feeling really good,” she told me. “Not depressed at all.”

My delight aside, I felt chagrined that I had begun to write her off as a help-rejecting crank.

Of course, it makes good medical sense for therapists to rethink the diagnosis and treatment of any patient who fails to improve. But this is a double-edged sword.

Another patient, a young woman with unstable moods, was recently hospitalized with a diagnosis of bipolar disorder. When she failed to respond to two mood stabilizers, the staff began to entertain a diagnosis of borderline personality disorder, which involves emotionally chaotic relationships and impaired ability to function in the world.

“She’s pretty aggressive and demeaning, and we think she has some serious character pathology,” one of the residents told me.

But partly treated bipolar disorder can mimic borderline personality disorder, and after she received a third mood stabilizer, her “personality disorder” melted away, along with her provocative behavior.

This patient had frustrated her clinicians with her lack of response to treatment. In turn, her doctors reacted by changing her diagnosis to a personality disorder. The change in thinking shifted the blame from the clinicians to the patient herself, who was now viewed more as bad than sick.

To be sure, some patients really do want to be sick. People with Munchausen syndrome, for example, deliberately produce physical or psychological symptoms for the express purpose of assuming the sick role. And they will go to extraordinary means to defeat doctors who try to “treat” them.

But a vast majority of patients want to feel better, and for them the burden of illness is painful enough. Let’s keep the blame on the disease, not the patient.

Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College.

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Experts Argue That Borderline Personality Disorder Should Be Shifted to Axis I

Thursday October 16, 2008

In a recent paper published in Biological Psychiatry, Dr. Antonia New and her colleagues at the Mount Sinai School of Medicine and Bronx VA Medical Center argue the case for shifting borderline personality disorder (BPD) from Axis I to Axis II of the Diagnostic and Statistical Manual of Mental Disorders (DSM).In the most current, fourth edition of the DSM, BPD is diagnosed on Axis II, which is reserved for “longstanding disorders,” such as personality disorders. In their paper, Dr. New and her colleagues argue that research has not supported the distinction between BPD and Axis I disorders, and that moving BPD to Axis I will spur new research on this serious condition.

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Mental Health Coverage Expanded by Rescue Package (Update2)
By Aliza Marcus

Oct. 3 (Bloomberg) — Health insurers that provide mental- health benefits will be barred from providing less coverage than they do for other medical services under the $700 billion financial-markets rescue package approved by Congress.

The plan was backed by a 263-171 vote in the House of Representatives today and signed by President George W. Bush. The package incorporates a measure requiring so-called mental health parity for health plans enrolling more than 50 employees.

“Aren’t we all pleased across America that this legislation includes the mental health parity act?” House Speaker Nancy Pelosi, a California Democrat, said in a speech before the vote.

The mental-health measure was among provisions added to the financial rescue package to win support after the House initially rejected the bailout legislation. The Senate, which supported the expansion of mental health coverage benefits in tax legislation passed last month, approved the revised financial rescue plan on Oct. 1.

“It seemed like it was getting lost after the bailout issue arose, but now with this bill it’s just happened,” said Steve Vetzner, spokesman for the Mental Health America advocacy group in Alexandria, Virginia. “This has been a long struggle and long fight.”

The act is intended to eliminate what supporters call unequal access to care from insurers that set higher co-payments and other limitations on services such as mental health counseling compared with physical ailments.

$3.4 Billion

The House and Senate previously disagreed about how to cover the cost to the federal government of the expanded benefit, estimated at $3.4 billion over five years by the Congressional Budget Office in 2007.

The estimate is related to tax revenue that would be lost because employers would pay more for health insurance premiums, to cover the expanded benefits, instead of turning over some of this money as taxable wages to employees.

Health insurers and businesses worked with Congress on the measure, which built up wide support from stakeholders in the health-care field, said Aetna Inc. Chief Executive Officer Ronald Williams in a statement on Business Wire.

“They had a deal for a long time,” said Kim Monk, an analyst at Capital Alpha Partners, in Washington, in a telephone interview. “The challenge was how to off-set the cost,”

Employers will now be looking for well-managed mental health networks to help them reduce costs associated with implementing the legislation, Monk said. “Not all insurers have this, so they may have to beef it up.”

To contact the reporter on this story: Aliza Marcus in Washington at amarcus8@bloomberg.net

Last Updated: October 3, 2008 15:26 EDT

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October 1, 2008

Editorial

Oh So Close to Mental Health Parity

Congress is within a whisker of passing a sound and fair-minded bill to require that group health insurance coverage for mental illness and substance abuse be provided on the same terms as coverage for physical illnesses. It would be a shame if the legislation, which caps more than a decade of struggle to achieve mental health parity in insurance coverage, were allowed to die while Congressional energies are focused on the all-consuming economic crisis.

The bill would not require employers or health plans to cover mental illness or drug or alcohol abuse. But if they do, the treatment limits and financial requirements could be no more restrictive than those that apply to medical or surgical benefits. A 1996 law had required parity in setting annual and lifetime spending limits, but insurers found ways to circumvent it. The new bill closes loopholes by requiring parity in deductibles, co-payments and out-of-pocket expenses — and in setting treatment limitations, such as the maximum number of doctor visits and days of coverage allowed.

The bill is endorsed by President Bush, business groups, insurance companies, the medical community and mental health advocates. Both the House, in a stand-alone bill, and the Senate, as part of a broader tax relief bill, have approved it by large margins. But it requires a final shove because the measure is snarled in a broader legislative struggle over how to pay for tax revenues that would be reduced by this measure and others. Is there a statesman who can push this worthy parity legislation through to final passage before adjournment?

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Well, my experience has been that marital counseling doesn’t really help
much when a BP is involved, because counselors really don’t understand the
dynamics of BPD.  While their goal is to promote better communication
between partners, they tend to focus on resolving the complaints.
Of course, BPs have LOTS of complaints (which
really are not the problem), so nons just end up feeling attacked… even by
the counselor at times.  When counselors do this, it tends to validate the
BPs feeling that their nons really are the problem.  It sometimes even
leaves the non feeling like he/she really is the problem.

I suspect you may want to continue this “counseling” approach, since it is
SOMETHING your BP has agreed to.  If so, my suggestion would be for you to
be as honest as possible with the counselor about YOUR FEELINGS.  Don’t
waste your time (and money) defending against your BPs accusations and don’t
point fingers back.  (This only makes you look bad to the counselor… like
you never let your BP talk or express himself… ha!, I know!)  Simply ASK
for advice on how to communicate better (since that is the goal of the
counselor to get you communicating with one another.)  Try the suggestion a
few times, and if it doesn’t work, then you can come back the following
session and express your disappointment and confusion about why it isn’t
working.  Eventually, after enough times of doing this, your counselor will
(hopefully) recognize that he/she cannot help you and will refer you to
someone more qualified (like a DBT specialist, if your lucky enough to have
one of those in your area.)

My only comment on this statement – which is wonderful IMO – is the idea that the complaints are “not really the problem.” If those complaints are not really the problem, what is? Well, I believe it is that the BP FEELS bad (negative emotions) and judged (so they judge back). I think if someone who DOES understand the dynamics of BPD works with a couple, the therapist can hopefully deal with the real issue: the painful emotions.

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Ignored Psych Patient Dies on Hospital Floor

Video Shows Death in NYC Hospital Already Faces a Lawsuit for ‘Squalid’ Psych Care

By DAVID SCHOETZ

July 1, 2008—

Even pared down to a few minutes, the hour-long surveillance video is disturbing.

At 5:32 a.m. June 19, a woman in a hospital gown in the waiting area of the psychiatric emergency room of a New York City hospital topples first to her knees before collapsing on her face.

A full hour passes. Other people stream in and out of the waiting room, including hospital security guards. The woman writes something on the ground before going completely still. Finally, someone takes notice and alerts the staff. But by then, at 6:36 a.m., the woman is already dead.

The woman, 49-year-old Esmin Green, died on the floor of the waiting room at the Kings County Hospital Center Psychiatric Emergency Department. Her exact cause of death has not been released.

The native of Jamaica, who had been waiting for a bed when she collapsed, had been involuntarily admitted the previous day for “agitation and psychosis,” according to the City Health and Hospital Corp., which acknowledged June 20 that Green had been left unattended on the ground for an hour.

Alan Aviles, the president of the Health and Hospital Corp., had already announced that six hospital employees, including staff members who oversee patient care and security, face disciplinary action for their lack of response. Two of the employees were fired, while four unionized staff members must go through termination proceedings.

The hospital, in the Brooklyn borough of New York City, may have a much bigger problem on its hands. In May, Kings County Hospital was targeted in a federal lawsuit by three organizations that described hospital conditions as “inhumane.” Attorneys for the plaintiff released the footage of Green’s death Monday night to illustrate in brutal detail some of the allegations made in the suit.

The Mental Hygiene Legal Service, New York Civil Liberties Union and Kirland & Ellis LLP filed the lawsuit after an investigation at the hospital “showed that Kings County psychiatric facilities are overcrowded and often dangerously unsanitary and that patients — including children and the physically disabled — are routinely ignored and abused,” according to the groups’ May 3 release announcing the suit.

The groups claim that alleged mistreatment of patients at the hospital is a violation of the federal Americans With Disabilities Act as well as several New York State provisions that guarantee the delivery of mental health services in a safe and sanitary manner.

Aviles is named as one of the lead defendants in the 36-page suit, which specifically cites five patients, all with some type of disability, who allege “abusive and neglectful” treatment at Kings County.

One patient, L.D., claimed that she was laughed at when she asked to call her family and was placed in a bed with soiled sheets. Another patient, identified as J.P., said that she had to sleep sitting up in a wheelchair after she got up in the night to use the bathroom and returned to find another patient in her bed.

The New York Daily News reported that in addition to the neglect in Green’s case, staff members entered false information into her medical chart during the hour in which she lay on the ground to cover up the lack of treatment.

At 6 a.m. on the morning of her death, according to the Daily News, Green’s medical chart reportedly listed the patient as “awake, up and about, went to the bathroom.” Green had been in the same spot on the ground for more than a half-hour. At 6:08 a.m., she stopped moving, according to the footage. But her chart described her at 6:20 a.m. as “sitting quietly in the waiting room.” In reality, she may have already been dead.

Ana Marengo, a spokeswoman for the Health and Hospital Corp., would not address the exact entries in Green’s medical chart, but did say, “There appears to be some discrepancies” that have been forwarded, along with the entire case, to various New York City investigative departments.

“It is clear that some of our employees failed to act based on our compassionate standards of care,” administrators wrote in a statement last night that followed the video’s release.

Hospital administrators outlined a series of improvements already made to the Kings County psychiatric program, including the addition of staff and expanding space to cope with overcrowding. They pledged a series of improvements, including the appointment of an “interim administrator” who will report directly to Aviles, and a guarantee that patients in the psychiatric emergency unit will be checked on every 15 minutes.

In June, USA Today reported that nearly 80 percent of hospitals said that mentally ill patients sometimes wait up to four hours or more for emergency care, citing a study by the American College of Emergency Physicians that surveyed 328 emergency medical directors.

Physicians blamed the delayed care on shrinking budgets that have prompted many hospitals to either consolidate mental health services or shut them down completely. Since 2000, the number of psychiatric beds has dropped 12 percent, according to the medical organization’s statistics.

Copyright © 2008 ABC News Internet Ventures

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Mentally ill face extra-long ER waits

By Julie Appleby, USA TODAY

Psychiatric patients who need hospitalization wait for hours in emergency departments for admission because hospitals are dropping mental health units and beds are scarce, a new survey says.

Nearly 80% of hospitals said mentally ill patients sometimes wait four hours or more to be admitted, says the American College of Emergency Physicians, which surveyed 328 emergency medical directors. About 10% said patients wait more than a day on average.

Average admission times for non-psychiatric patients were shorter: Only 30% of directors said those patients waited four hours or more. Yet 84% of the medical directors said ER wait times for all patients would drop if their hospitals had better psychiatric services.

Only half of the hospitals surveyed had psychiatric units. The rest transferred patients, sometimes far from homes and families. Hospitals are closing their units because of inadequate payments from government and insurers, unpaid costs for the uninsured and too few psychiatrists willing to work in hospitals, says James Bentley of the American Hospital Association.

Patients with mental illness “are the ones we hold the longest because there are so few psychiatric services available, and the ones that are available are overwhelmed,” says David Mendelson, of the physicians group.

The long waits can be troublesome for mentally ill patients, says Bruce Schwartz, director of psychiatry at Montefiore Medical Center in the Bronx, N.Y. “For individuals in need of admission because they’re psychotic or severely depressed, it can be a very uncomfortable, scary, disorienting time.”

The survey found 61% of hospitals do not have psychiatry staff caring for ER patients while they wait, although they receive treatment for other medical problems.

The poll comes amid growing concern about wait times and overcrowding in the nation’s ERs, which experienced a 14% jump in visits for all illnesses and injuries from 2001 to 2005.

Since 2000, the number of psychiatric beds in U.S. community hospitals dropped 12%, the association’s statistics show. The number of hospital beds overall fell 4%.

In March, the closure of Santa Rosa Memorial Hospital’s psychiatric unit left California’s Sonoma County without hospital-based care for mentally ill patients. Now patients must be taken 40 miles or more away to other hospitals.

“It’s not unheard of for people to spend a night or even a couple of nights (in the ER),” says Sonoma County Mental Health Services Director Art Ewart.

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1. ABC News Reports: Ignored Psych Patient Dies on Hospital Floor
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3. Mistakes Costing Lives

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Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up.

Blum N, St John D, Pfohl B, Stuart S, McCormick B, Allen J, Arndt S, Black DW.

Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.

OBJECTIVE: Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a 20-week manual-based group treatment program for outpatients with borderline personality disorder that combines cognitive behavioral elements and skills training with a systems component. The authors compared STEPPS plus treatment as usual with treatment as usual alone in a randomized controlled trial. METHOD: Subjects with borderline personality disorder were randomly assigned to STEPPS plus treatment as usual or treatment as usual alone. Total score on the Zanarini Rating Scale for Borderline Personality Disorder was the primary outcome measure. Secondary outcomes included measures of global functioning, depression, impulsivity, and social functioning; suicide attempts and self-harm acts; and crisis utilization. Subjects were followed 1 year posttreatment. A linear mixed-effects model was used in the analysis. RESULTS: Data pertaining to 124 subjects (STEPPS plus treatment as usual [N=65]; treatment as usual alone [N=59]) were analyzed. Subjects assigned to STEPPS plus treatment as usual experienced greater improvement in the Zanarini Rating Scale for Borderline Personality Disorder total score and subscales assessing affective, cognitive, interpersonal, and impulsive domains. STEPPS plus treatment as usual also led to greater improvements in impulsivity, negative affectivity, mood, and global functioning. These differences yielded moderate to large effect sizes. There were no differences between groups for suicide attempts, self-harm acts, or hospitalizations. Most gains attributed to STEPPS were maintained during follow-up. Fewer STEPPS plus treatment as usual subjects had emergency department visits during treatment and follow-up. The discontinuation rate was high in both groups. CONCLUSIONS: STEPPS, an adjunctive group treatment, can deliver clinically meaningful improvements in borderline personality disorder-related symptoms and behaviors, enhance global functioning, and relieve depression.

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The study, “8-Year Follow-Up of Patients Treated for Borderline Personality Disorder: Mentalization-Based Treatment Versus Treatment as Usual,” is the latest analysis of a randomized trial first reported in AJP in October 1999 and titled “Effectiveness of Partial Hospitalization in the Treatment of Borderline Personality Disorder: A Randomized Controlled Trial.”

Joel Paris, M.D., an expert on BPD, explained that mentalization therapy, developed by Bateman and Fonagy in the 1990s, is based on attachment theory and on observations that BPD patients have a failure of “mentalization”—the ability to observe their own emotions and those of other people and to appreciate how their behavior may affect others.

“Mentalization-based therapy can be considered as an amalgam of psychodynamic and cognitive methods,” he told Psychiatric News.

For instance, a case report included in the study describes a 24-year-old woman who was referred from forensic services after her arrest for setting fire to her university dormitory.

She had a history of recent suicide attempts and regularly burned herself with cigarettes and a hot iron. In individual sessions, treatment initially focused on clarifying her own feelings and others’ experience of her; later it progressed to helping her appreciate how her experiences of self-doubt and emotional turbulence led to a sense of fragmentation that was controlled only by experiences of intense physical pain, according to Bateman and Fonagy.

“The individual therapist identified these processes while focusing on the way she represented her own mental states and those of others with whom she interacted,” they wrote. “Gradually this was explored within the relationship with the therapist.”

They report the patient as stating, “It never occurred to me that what I did had an effect on anyone else.”

I have to say the suicide figures are astounding, especially when it comes to attempts. I mean, over 80% in two of the categories!

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2. A failure to mentalize – Mentalization Information Part 2
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Xanax has to be the absolute worst drug to treat BPD. Why?See the results of these (rather old) studies:

Alprazolam (benzodiazepine)

Gardner, D.L. & Cowdry, R.W.
Am. J. Psychiatry. 1985 – Alprazolam-induced dyscontrol in borderline personality disorder.
The short-acting benzodiazepine alprazolam has been associated with precipitating serious dyscontrol in one placebo-controlled crossover study of patients with BPD
The authors suggest that caution be used in prescribing alprazolam to patients with similar histories.

Alprazolam (benzodiazepine) / carbamazepine and trifluoperazine and tranylcypromine.

Cowdry RW, Gardner DL. – Intramural Research Program, National Institute of Mental Health, Bethesda
Arch Gen Psychiatry. 1988 – Pharmacotherapy of borderline personality disorder. Alprazolam, carbamazepine, trifluoperazine, and tranylcypromine.
Physicians rated patients as significantly improved relative to placebo while receiving tranylcypromine and carbamazepine. Patients rated themselves as significantly improved relative to placebo only while receiving tranylcypromine. Patients who tolerated a full trial of trifluoperazine showed improvement, those receiving carbamazepine demonstrated a marked decrease in the severity of behavioral dyscontrol, and those receiving alprazolam had an increase in the severity of the episodes of serious dyscontrol

My wife has gotten much better since I started on this quest of learning about BPD and what, as a loved one, I can do about it (and what I can’t). Yet, she still over-medicates on benzos. So, my list member basically issued me a challenge to see if there is anything I can figure out to do to reduce the pill taking. One member of the list locks up his wife’s pills and doles them out when she needs them. I hesitate to follow his example because I don’t want to be in the position of being my wife’s keeper. Plus, in the past when I have held her pills for her (usually at her request), I have been raged at for “hiding” or “stealing” them (neither of which I do).

Here is my question/challenge: Have any of you been able to come up with an effective way to reduce over-medicating on benzos? That question goes out to the people with BPD (if you have found a way yourself) and to the family members (if you have found a workable solution). This area is one where I have made little head-way and would like some help.

Thanks.

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DBT is a behavioral therapy.

The idea is to learn a new behavior by repeated conditioning.

“Fake it until you make it”

It can be effective…Pavlov showed that a lower species can
learn through behavior therapy.

The question is then…is there a better way?

My thought…learn what you need before seeking a product….then buyer beware.

My reaction to this message was complete disbelief. I can only suppose that this guy (who is a Christian BTW) doesn’t believe that humans are in the category of “lower species” (probably because they have a soul and are made in the image of God, as opposed to animals). Of course, his alternative (or “better way”) was his personal belief in Transactional Analysis (popularized by “I’m OK, You’re OK” in the 70s) and the “inner child vs. inner adult” dynamic. That is garbage and hasn’t been shown to be effective with BPD at all.

So, how does DBT work?

DBT is a behavioral therapy. It teaches skills to modify a person’s behavior. Basically, the client begins to behave in a fashion that is different that the behavior that they previously exhibited. The purpose is behavioral modification. The new behavior becomes reconditioned over the old behavior. There person become “retrained.” One of the main problem with BPD is poor/ineffective behavior. If the behavior can be modified, the results of the behavior will not exist. In other words, if you choose NOT to cut yourself, you will not have to go to the hospital and get stitches. Interestingly, I find that this “theory” follows the Buddhist idea of “dependent arising” – which governs “conditioned existence.” That idea is formulated as follows:

When this is, that is.
From the arising of this comes the arising of that.
When this isn’t, that isn’t.
From the cessation of this comes the cessation of that.

See this Wikipedia entry for more information.

DBT functions in four general areas:

1. Core Mindfulness
2. Distress Tolerance
3. Emotional Regulation
4. Interpersonal Effectiveness

One of the differences between DBT and CBT is that DBT emphasizes acceptance of certain things versus complete change. Why? Here is one explanation from Marsha Linehan in the interview with David Van Nuys on “Wise Counsel”:

Dr. Marsha: All right. DBT or Dialectical Behavior Therapy is an integration of two major approaches. The first approach is the approach of cognitive-behavioral therapy.

Dr. David: OK.

Dr. Marsha: So, it contains within that sort of standard cognitive-behavioral therapy or behavior therapy. As behavior therapy changes and improves, DBT changes right along with behavior therapy, cognitive-behavioral therapy and improve.

Dr. David: OK.

Dr. Marsha: Then it balances a technology of change with the corresponding technology of acceptance. The acceptance is a derivative primarily from contemplative spiritual practices of Zen, primarily, but also other contemplative practices. Mindfulness, mindfulness-based practices and also validation of clients.

The acceptance end of the treatment is two-part. It’s a radical acceptance of a client as the client is at this moment by the therapist and teaching the client the same corresponding ability to radically accept. The reason it’s called “dialectical” is because it’s a synthesis of acceptance and change. Back and forth, a constant transaction interplay all the time.

Dr. David: Yes, when I first heard the term “dialectical, ” of course, I immediately thought of Hegel and Karl Marx and so I wasn’t quite sure of what the relationship was but they did talk about synthesis and antitheses and then the… Have I got that right?

Dr. Marsha: Yeah, it’s the theses…

Dr. David: Theses and antitheses.

Dr. Marsha: The antitheses and then the synthesis. The notion is, “everything contains within it its opposite, ” which really means that nothing exists really without an opposite of it. Even if you take something as mundane as a box, there couldn’t be a box if there wasn’t a non-box, a no-box, a not-box, because a box is very defined as it’s this so there’s obviously something that’s not a box.

Everything that exists has its opposite and Dialectics looks at the tension between; what exists and its opposite, or the theses and the antitheses or the opposite, and looks at the transaction between them, and that tension and that transaction which always brings about change.

Dr. David: In terms then of your therapeutic work and your therapy model, what are those two poles of tension?

Dr. Marsha: Oh, there are many. There are many, many, many poles. One of the most fundamental poles is that within every unwise act, there is some inherent wisdom. Taking heroin, which is long term, a dysfunctional, destructive behavior in our culture. Within there, is the wisdom of, “You feel better immediately.” So there is dysfunction and function always coexisting together.

The tension is finding the synthesis of; “Are there other ways for example?” or “How to radically accept that if one’s in great pain, getting out of pain is reasonable” while at the same time accepting that if one is in great pain, getting out of great pain by doing something that will continue to pain in the future is not reasonable. You’re always looking for a synthesis, where is a point that without rejecting the other side.

Here is another explanation of why acceptance was inserted into DBT by Marsha Linehan:

Dialectical Behavior Therapy represents an integration of two traditions: the behavior and cognitive-behavioral therapy tradition which is focused on developing technologies of change, and the mindfulness tradition that comes out of various spiritual practices including Zen Buddhism and contemplative Christian practices. At the start of her career, Dr. Linehan set out to develop a treatment for chronically suicidal patients and found that many of them were so overwhelmed by significant problems that it was not possible to address them all. Instead of focusing solely on how patients could change, what was required was also to help patients to better tolerate their circumstances. She was familiar with Christian contemplative spiritual practices that emphasized surrender to God, but sought out alternative teachers (e.g., a Zen Buddhist and a Benedictine Monk) who could teach her a “technology of acceptance” that would be more free of particular religious overtones. After taking several months to immerse herself in acceptance practices, she began the task of translating them into a language that behaviorists could accept and DBT was born. Though at first she thought the therapy was for suicidal people, in 1980 when the diagnosis of Borderline Personality Disorder was added to the DSM, she realized that it was really a therapy made for treating BPD and similar sorts of issues.

So, through applying behavioral change (from CBT) and acceptance (from Buddhist practice) DBT effectively treats BPD (and similar sorts of issues).

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You can read the transcript here.

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http://www.helium.com/tm/339437/individuals-suffering-borderline-personality

In which the author gives some insight and advice about “dealing with” someone with Borderline Personality Disorder. I’d like to look at her advice by excerpting some of her text and then offer a little commentary.

First of all, she says this:

Individuals suffering from borderline personality disorder are very self-destructive and they have great difficulty forming any good relationships. A deep-seeded fear of abandonment is behind every wayward action and prolonged mood swing. It’s [sic] victims are mainly women who show frequent displays of inappropriate anger and who exhibit forms of self-mutilation. They also act on impulse, without regards to consequences and than [sic] hold others responsible for their actions. They are sexually permissive and may indulge in binge eating and drug abuse. Victims of this disorder may shop lift. Hell bent on harming themselves, they live with no discipline or boundary.

While this characterization is generally true, it suffers from what wikipedia calls “weasel words”. Basically, the words that are used slant the information toward being extremely judgmental. What I mean is the use of the words “great difficulty forming any good relationships,” “every wayward action and prolonged mood swing,” “show frequent displays of inappropriate anger,” and “they live with no discipline or boundary” all show us that the author is judgmental toward the sufferer. The idea of “prolonged mood swing” is incorrect as well, since the “moods” of a person with BPD generally last only hours. Also, the idea that “they are sexually permissive” MAY be true for some of the sufferers, but not for all. The idea that a “fear of abandonment is behind EVERY wayward action” is also incorrect. Much of the “actions” are motivated by pain relief and/or shame. Use of the words “no discipline” betrays the authors true feelings about people with the disorder and tells me she doesn’t understand the disorder very well (see below on “Tough Love”).

When Hope is Not Enough
Get the Non-BPD book that is designed for
staying and working on the relationship

The author goes on to say:

Group therapy can resolve self-destructive behaviors. These individuals learn better from their peers because of their resistance to authority. Impulse behavior can be curtailed in this same setting.

Which is basically wrong. Group therapy does work (especially in the context of DBT), but not for the reasons that the author suggests. It is not a “resistance to authority” that drives the effectiveness of group therapy. Instead, seeing that one is not the only sufferer and having the ability to support one another normalizes the disorder. You are not just the broken, shameful person that you feel you are. Interestingly, many people with BPD will criticize others in the group and report that they are not as “crazy” as those people are.

The thing I have the most problem with is this:

Tough love may be needed from family members and loved ones before the person asks for assistance.

This statement is completely false and possibly harmful. Here is the text of a post of mine in the ATSTP group which addresses Tough Love:

Depending on the actual problem with your son(s) the idea of “tough love” might be the worst thing for him (them). While it seems to work for substance abuse, tough love can be an awful mixture for those with ERD-like issues. The problem comes down to the “invalidating environment” as Marsha Linehan puts it. Tough love will invalidate a person’s basic feelings and lead to shame and the feeling of “brokenness”. I have seen this first-hand with one of my daughter’s friends. This friend is 16 now and is a classic BPD/ERD case. She has been kicked out of several “lock down” facilities. Recently her mother sent her to a “tough love”/boot camp. It was a total disaster for the kid and for the family.

A better approach IMO, is emotional validation + a sense of personal responsibility. This combination is built through letting the person know that feelings are not wrong or right, they just ARE. The second half comes through building mastery over their behavior associated with feelings. Bad feelings just exist. This is important because often a person with such issues will use behaviors (like drug abuse or cutting or raging) to make the bad feelings go away as quickly as possible. They need to learn to tolerate the distress and behave in an effective manner. Once this new behavior/reaction to feelings is practiced, they can eventually build mastery over the behaviors. This works backward to help quell the feelings.

It seems that most parents believe that emotional validation = “giving in” (or agreeing with the child or “poor discipline” or whatever). This is NOT the case. It’s difficult for me to express this more firmly. Remember the word “emotional” is important. If you validate invalid behavior, you are enabling. It is important to separate in your mind the emotions (which are natural) from the behavior (which can be painful to all involved). If that separation can be communicated to the person with ERD, it can be worked with. It is difficult, but possible.

Unfortunately, tough love is not the answer.

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Recovery possible for Borderline Patients

Dutch investigators prove effectiveness of new treatment.

For the first time in history it has been proven that Borderline
Personality Disorder can be effectively treated in its full range.
Investigators of Maastricht University, Vrije Universiteit Amsterdam, and Leiden University published in the June 2006 issue of the JAMA journal the Archives of General Psychiatry a study into the effectiveness of two psychotherapies for borderline patients. The study demonstrates that Schema focused therapy leads to complete recovery in about 50% of the patients, and in two-thirds to a significant improvement. The success of the therapies is strongly related to their duration and intensity (two sessions a week for three years). The results clearly contradict common ideas that borderline personality disorder cannot be fully cured, and that prolonged psychotherapy is useless.

Borderline Personality Disorder is generally known as “untreatable” and is quite common in the general population: 1 to 2.5 % of the population suffers from it. Characteristics are chronic instability, emotional dysregulation, self-mutilation, suicidal behaviour, impulsivity, abandonment fears, anger attacks, identity problems, and low stress tolerance. The medical and societal costs are high, and many of these people cannot participate in the labour process, or don’t function at levels that could be expected given their intellectual capacities. Usual care is limited in effectiveness, and even the best treatments so far can only successfully address a minority of the borderline problems.

Dr. Josephine Giesen-Bloo, Dr. Arnoud Arntz (projectleader), Dr. Philip Spinhoven, Dr. Richard van Dyck and other investigators of the universities mentioned above compared in the study two treatments for borderline personality disorder: Schema focused therapy (SFT) and
Transference focused psychotherapy (TFP). 86 patients recruited in 4 mental health institutes in the Netherlands (Maastricht, Amsterdam, The Hague, and Leiden) received two sessions SFT or TFP a week for 3 years. The effects of the treatments were assessed with 4 criteria:
borderline-symptoms (BPDSI-IV-score), general psychopathological symptoms, personality characteristics, and quality of life. During the 3 years assessments were conducted every 3 months. In 24% (TFP) and 46% (SFT) of the patients treatment led to full recovery. One year later the percentages even increased to 52% (SFT) and 29% (TFP). In the SFT condition two-thirds of the patients improved to a significant degree. On the other 3 criteria effects were also positive and in favour of SFT.

Positive effects became apparent after one year, with continuing
improvement in years 2-4. The investigators conclude that both
treatments have positive effects, with a clearly higher effectivity of SFT. Moreover, the lower dropout rate indicates that SFT induces a higher treatment allegiance in the patients than TFP.

SFT is a cognitive-behavioral therapy, in which patients acquire
insights in the patterns that underlie their problems. For borderline personality disorders these are classified into 4 standardized patterns, called schemas. By means of behavioural, cognitive and experiential techniques the disorder is treated. The treatment focuses on the relationship with the therapist, on daily life outside of therapy, and on traumatic childhood experiences (which are very common in this disorder).

TFP is a psychodynamic therapy. At start, a treatment contract is agreed upon, which remains at the centre during treatment. By continuous analysis and interpretation of the mutual relationship a structural change in personality of the patient is brought about.

Thus, both treatments address the problems at the level of the personality, whereas most common treatments are restricted to the reduction of specific symptoms of the disorder (i.e., self-destructive
behaviors).

The investigators plead for the recognition of SFT as an evidenced based treatment of borderline personality disorder. Despite the high number of sessions and the long duration, they observed that the treatment is cost-effective, as it leads to an immediate cost-reduction for society of 4500 Euros per patient per year, already during treatment. The common idea that prolonged psychotherapy is unjustified is, at least in the case of SFT for borderline personality disorder, incorrect.

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A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. 2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 3. identity disturbance: markedly and persistently unstable self-image or sense of self 4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. 5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) 7. chronic feelings of emptiness 8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 9. transient, stress-related paranoid ideation or severe dissociative symptoms

To me, this seems sort of weird, because there would be hundreds, if not thousands, of flavors of BPD.http://www.fortunecity.com/campus/psychology/781/bpd-dsm.htm

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2. The Myth of the High-Functioning Borderline
3. The DSM-IV and Bon’s view of BPD/ERD – What’s required?

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The most important thing is, Do not hospitalize a person with borderline personality disorder for any more than 48 hours. My self-destructive episodes – one leading right into another – came out only after my first and subsequent hospital admissions, after I learned the system was usually obligated to respond. Nothing that had happened to me before being admitted to a psychiatric unit for the first time could even approach the severity of the episodes that followed.

Should you hospitalize your BP? Maybe not.

http://ps.psychiatryonline.org/cgi/content/full/49/2/173

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