A Brief Overview of DBT – Dialectical Behavioral Therapy

In this brief overview of Dialectical Behavioral Therapy (DBT), we are illustrating the efficacyopenfence-mulholland©saritzrogers of  DBT for the treatment of patients with suicidal behavior, bipolar disorder, and borderline personality disorder. DBT has been shown to reduce severe dysfunctional behaviors in clients. DBT uses validation has a tool to the client accept unpleasant thoughts and feelings rather than react to them in a dysfunctional way.  Simply put, dialectical means that two ideas can be true at the same time. Validation is the action of telling someone that what they see, feel, think or experience is real, logical and understandable. It’s important to remember that validation is non-judgmental and doesn’t mean you agree or even approve of the behavior you are validating.

 

Over the last year, Visions has effectively trained the staff to be DBT informed. We hold regular DBT skills groups at our residential and outpatient facilities. We have adopted and incorporated DBT skills into our day-to-day interactions with clients and are finding it to be incredibly beneficial.

 

I took some time to speak to Jesse Engdahl, MA, RRW, about his observations and experience with running the DBT skills group. He said, “We are happily surprised that it’s (DBT) become a community within a community. It’s set itself apart through the kids’ commitment to not only use the skills but in their support of each other. There is a high level of trust. We have kids coming into IOP who’ve felt marginalized and who hadn’t felt a broader amount of support, but find their place in DBT.”

 

The emphasis on validation in DBT is profound. Someone suffering from borderline personality disorder often has a movie playing in their heads and when the validity of that “movie” is denied, it can create a waterfall of dysregulation which can include anxiety, depression, anger, and fear. Taking a counter-intuitive stance and validating one’s reality is has been shown to be particularly efficacious. It deescalates the anxiety, and it teaches the client to self-regulate.

 

Joseph Rogers, MDiv-Candidate and DBT skills group facilitator and mindfulness teacher succinctly illustrates the value of our DBT groups, “Our DBT skills group gives our clients the confidence that they have the ability to meet their difficulties with skills that can be found within themselves and their capabilities.  By utilizing daily skills diary cards and reporting on their results, clients are able to see where they are being effective and can acknowledge the positive outcomes they are responsible for through their actions.  DBT has the ability to move clients out of their diagnosis toward a confidence in their personhood.”

 

Wise Words on Self-Care: A Guest Post from Alumni

Self-care is one of the most important things we learn to do in recovery. When we drink and malibu-elmatador--©saritphotographyuse, or when we suffer from mental illness, we look for outside sources to self-soothe. Our internal resources are often verboten to us; they are either non-existent or significantly unsafe. The recovery process helps us cultivate that inner resource, where we become able to self-soothe, and take care of our own needs without sacrificing our well-being.

 

Occasionally, one of our alumni writes guest posts for us, sharing what it’s like to be a young adult in recovery from mental illness and addiction, and how she is learning to live fully. To every woman I work with, I encourage self-care. To every newcomer I meet and extend my hand, I encourage self-care. This young lady really breaks down some of the necessary components of finding and cultivating self-care. I’m honored to share her voice:

Personal or self-awareness is essential when acknowledging and learning about yourself. Recognition of your needs is the first step. Second would be to put those things into action. In dealing with physical needs you must first distinguish the basics.

Sleep is essential for all humans; it plays a major role in ones emotional state. Exercise also has a sizeable portion in a healthy life. Staying active is vital in maintaining ones physical health. Whether it be a lot or a little, it is incredibly important. Keep in mind that exercise of any kind releases endorphins in the brain, and this is equally significant in supporting and preserving a healthy emotional state of mind.

When it comes to both of these forms of self-care, moderation is imperative. Where sleep and exercise are helpful and quite necessary, too much or too little of each of these things are not. Too much sleep may indicate a person who is suffering from depression. Sleeping the day away could be a direct result of trying to hide or suppress feelings. Sleeping too little could also suggest that a person is overworked or even depressed.

On the other hand, exercise, while very important, should not become your main focus. If exercise becomes an obsession, this could be viewed as a type of disorder (specifically having to do with your health concerning your weight and appetite). And exercising too little may force you to become sluggish and will not help your healthfulness.

Hygiene and nutrition are two more exceedingly important factors to be aware of when handling self-care. Hygiene goes without saying, but nutrition is something that many either do not take into consideration at all, or become preoccupied with. Overall, physical needs transfer to emotional wellness when you begin to take your health and wellbeing into your own hands.

For emotional security, taking pride in yourself is crucial when working on self-care. Doing things for you should be your main priority. As my mom often says, “You cannot help someone else without first taking care of yourself.” Happiness comes from doing what you love, so pursue hobbies that you find joy in and take pleasure in. For me, that means going on a bike ride, playing the drums, taking photos, and writing. It took me a long time to find things I genuinely liked. For some people, they have known their whole life and even turn it into a profession. Others may pursue their passion as a hobby and many people have yet to find out what they love to do. Even if you don’t really pursue something, there are plenty of things that you can do to have fun and enjoy yourself.

Some other activities one can partake in are singing, dancing, taking a drive, or riding a train, taking a bath, going to the beach or for a swim, getting a massage, or even being of service to someone else in some way.

Doing kind things for other people is probably one of the most helpful things you can do for you. Helping others encourages you to get out of yourself.

Acknowledging my own specific difficulties and balancing love and patience for myself with gratitude and recognition for what I already have is a critical balance. For example, I personally struggle with manic-depression, or Bi-Polar disorder. This means that taking my medication for the mental illness that I face is a fundamental and key part of upholding and literally balancing my life.

Reaching out to others whether it is a friend, relative, or a therapist, is a productive way to take care of your mental state. Checking in with someone to not only talk about your struggles and/or triumphs, but also about theirs, is a great method when encouraging self-care for you and others. For those of us in 12-step programs, calling a sponsor and going to meetings is a positive way to turn your frown upside down. Relating to another person is almost always helpful when you are struggling with something. Going to a meeting can get you out of your head and into the open arms of a fellow 12-stepper.

Many people believe that spirituality plays a large role in turning one’s attitude around. I believe that no matter what religion you practice, faith you believe in, or Higher Power you trust and respect, you can find self-care in spirituality. My teacher, and someone that I look up to and greatly respect likes to approach every situation with a level of compassion that is almost unheard of. However you practice self-care, do it kindly, but whatever you do, get into action.

Alumni Voices: “I’m 17, Bipolar and In Recovery”

I’m pleased to share a guest post from one of our Alumni, bravely sharing about her experience as a bipolar teen in recovery. She is not only inspiring and courageous, her post is a testament to the clarity and hope willingness and recovery brings.

 

"Morning Dew" Day38 / #365Project  D...

“I’m 17, Bipolar and in Recovery”

How old are you when you are in the 5th grade? Ten, maybe 11 years old? I was probably closer to 11 given that I was held back in preschool. Now, who exactly gets held back in preschool? I didn’t really pay it any mind when I was in preschool, yet I still struggle with the shame of having repeated a grade so early on in my education. I remember feeling extremely uncomfortable in the 3rd grade for having to be pulled out of class to learn to read in a private room with Mrs. A, the learning specialist teacher. Learning to read had come so easily to my older sister, C; it was not the same case for me.

So back to my original question: I was 11, and I had already been diagnosed with ADHD. By the time I was in the 8th grade, I was prescribed 100 mg of Adderall per day. Well, it turns out that I did have a mild case of ADHD, yet it also turns out that ADHD is commonly misdiagnosed and mistaken for bipolar Disorder. No one found out that I had a mood disorder until I came to Visions.

 

It is not uncommon for a person who is bipolar to not want to take their medication. The first time I went through Visions treatment I was diagnosed as having mood instability and not full-blown bipolar Disorder. This mood disorder accounts for a lot of the feelings I was having before and even after I came through Visions. Before I reached the point of needing inpatient care for the first time, which far preceded the time in which it took for me to ask for it, I had experienced quite a bit of depression. I have also dealt with my fair share of manic episodes.

 

For someone with a mood instability disorder, drugs of any kind will make for a much more painful and deep depression, a much more insane manic high, and will far from help the situation. This is not to say that abusing any kind of drugs or medication, illicit or otherwise, will help anyone. Yet, when your brain chemistry is already messed up and you continue to pile any kind of chemically enhanced drugs on top of that, it makes for a manic-depressive individual.

 

It is not uncommon for a person who is bipolar to not want to take their medication. The first time I left treatment, I wasn’t taking my medication as prescribed. I missed many days in a row, I took it at different times throughout the day, and I even flushed a whole handful of my pills down the toilet. This definitely didn’t help my condition. The combination of illicit drug use, consistently missing my meds, and a variety of other unpleasant behaviors can only lead to a few options. Those of us in recovery know what those options are.

 

Given that I had already been locked up in a psych ward at the age of 14, had not yet been to Juvi, and was still breathing, the last option would be recovery.

 

I haven’t discussed my recovery much because it is not only something I deal with on a daily basis, but it is also something that I am quite insecure about. As I have already shared, I have been through Visions Adolescent Treatment twice. I once had almost a year and a half of sobriety. I had gotten sober at 15, yet I prided myself on the time I had sober, and not the work I was doing. How could I? I wasn’t actually working a program.

 

I had struggled with the idea of sobriety the moment I found out what the other residents were using in my inpatient program. I had only been smoking weed, while the other residents were in treatment for much harder drugs. I knew that I deserved to be there; my story was pretty intense, yet I still felt insecure about my drug use.

 

That statement alone is what reminds me on a daily basis that I need to be sober. Only an addict-alcoholic would feel the need to go further and to use harder. I guess that wasn’t enough for me, because after about a year and four months of sobriety, I relapsed. This time, it did not take long for me to realize how utterly unmanageable my life was.

 

I did not need to prove to anyone else that it was a good idea for me to be sober, especially not my mother. That’s another good point: Only someone who is extremely sick and in their illness would put someone they love in that much pain. I guess I still had to prove it to myself.

 

Today, when I have a moment where I think of using, I think of my family. I say to myself, “Even if I’m not an addict, I couldn’t put them through what I used to.” I believe that the “issues” I deal with are not only related to one another, but they are also a gift: Not only is my recovery a gift, but I see my bipolar disorder as a gift as well. I feel lucky to have the ability to feel things as intensely as I do. I hope that this will be that last time I am getting sober. I will take one day at a time in keeping it that way.

 

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Behavioral Health Educational Seminar: Complex Approaches for Complex Disorders

Christina Howard introducing David Miklowitz, PhD.

On Friday, September 28, we had the honor of co-hosting a Behavioral Health Educational Seminar, addressing Treatment Resistant Mood Disorders, and BiPolar Disorders. We co-hosted the seminar with Austen Riggs and PCH Treatment at the beautiful Victorian in Santa Monica, California.

Eric Plakun, MD, DFAPA, FACPsych and Director of Admissions and Public Relations at Austen Riggs Center spoke about A Psychodynamic Approach to Treatment Resistant Mood Disorders.

David J. Miklowitz, PhD, Professor of Psychiatry in the Divisions of Child and Adolescent Psychiatry at the UCLA Semel Institute and the Bipolar Treatment Consultant at PCH Treatment Center spoke about Bipolar Disorder: Current Thinking About Diagnosis and Treatment. Dr. Miklowitz is also a Senior Clinical Research Fellow in the Department of Psychiatry at Oxford University.

These informational seminars are a wonderful way to build upon one’s education, building upon the ever-changing information surrounding mental health care. Things will change with the new DSM-V slated to come out in the next year. We are incredibly fortunate to have so many knowledgable professionals in our midst.

Check out a few photos from the event. I must say, aside from incredible information from the speakers, the food was out of this world.

 

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DBT, Mental Health & Addiction

Mindfulness

Image by kenleyneufeld via Flickr

Sometimes someone comes into contact with treatment because their drug use got out of control only to discover their problem isn’t actually addiction, but rather, an untreated mental health issue. Often times the misuse of drugs and alcohol is an ardent attempt to quell the feelings of anxiety or lift the fog of depression. Sometimes it’s a way to disengage from the flashbacks of trauma. Sometimes it’s a way to close the door on a panic attack. However, many times, these modes of self-treatment go too far, and the claws of addiction sink in, creating another layer to uncover and treat. Still, once the addiction piece of the puzzle is treated, therein lies the deeper, more complicated issue of mental illness. What then?

At Visions, we have embraced the mental health component of treatment and are adding a mental health track to our existing treatment plan. We are utilizing a wider range of treatment methodologies and branching into the area of Dialectical Behavioral Training (DBT). DBT is a “comprehensive cognitive behavioral treatment developed by Marsha M. Linehan over the last 25 years,”[i] and has primarily been used to treat patients struggling with suicidal ideation, suicide attempts, a desire to self-harm, and self-mutilation. After discovering numerous problems with the traditional use of cognitive behavioral therapy (CBT) in treating this particular clientele, Linehan began to integrate validation strategies (also known as acceptance-based interventions) into her treatment methodology.  By integrating these validation strategies, Linehan inevitably began empowering her clientele and creating an environment of acceptance, while also encouraging them to begin to recognize the need to consciously change negative behaviors. DBT has also become one of the more successful treatments for patients suffering from borderline personality disorder (BPD), a group typically resistant to the traditional use of CBT.

To illustrate some of the problems Marsha Linehan and her team encountered, here are the three issues they found to be the most troublesome with traditional CBT:

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

In addition to utilizing validation strategies, DBT also employs the use of mindfulness as one of the core concepts behind this therapy. Mindfulness is beneficial in the treatment of addiction and mental illness: it introduces the concept of non-judgmental observation, where we can observe our own actions and behaviors without criticism; Being mindful requires that we are engaged in present-time awareness: the here and now. This is where mindfulness is truly invaluable. If we are aware of our actions in the here and now, we are less likely to get caught in the destructive patterns of “what if? and “remember when?” In the practice of meditation, the act of “coming back to the breath” helps one stay in the present. Learning how to label emotions and feelings that may present themselves can help sufferers from getting lost in negative thought patterns. For example, if we are feeling scared or triggered, paranoid or angry, naming that emotion with non-judgmental observation will help us retain our present-time awareness.

In time, hopefully, the implementation of treatments such as DBT and mindfulness will help provide sufferers with some valuable tools for regulating emotion, distress tolerance and managing interpersonal relationships.

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Bipolar Children and Teens

The Starry Night

Image via Wikipedia

Bipolar disorder isn’t soley an issue for the adult population—it affects children and teens as well.
Bipolar disorder is a mental illness categorized by its behavioral and mental extremes. Often called “manic depression,” this illness is clearly defined by its moods. Typically recognized as the manic stage, the sufferer may be elated or intensely “up,” even hyper. The flip side of this is the depressive stage, identified by its extreme lows, deep sadness, physical ailments, and for some, suicidal ideation.
According to NIMH, several factors may contribute to this mental illness:
  • Genes, because the illness runs in families. Children with a parent or sibling with bipolar disorder are more likely to get the illness than other children.
  • Abnormal brain structure and brain function.
  • Anxiety disorders. Children with anxiety disorders are more likely to develop bipolar disorder.
Since the causes aren’t concretely defined, scientists continue to do research, seeking more definitive answers in hopes of finding viable solutions, including a possible means of prevention.

These mood episodes can last a week or even two and are heavy in their intensity.  NIMHhas provided a listof symptoms from the two phases of bipolar disorder. Keep in mind, these symptoms are determined by their intensity and are not to be confused with the natural ups and downs of childhood emotional development.

Children and teens having a manic episode may:
  • Feel very happy or act silly in a way that’s unusual
  • Have a very short temper
  • Talk really fast about a lot of different things
  • Have trouble sleeping but not feel tired
  • Have trouble staying focused
  • Talk and think about sex more often
  • Do risky things.
Children and teens having a depressive episode may:
  • Feel very sad
  • Complain about pain a lot, like stomachaches and headaches
  • Sleep too little or too much
  • Feel guilty and worthless
  • Eat too little or too much
  • Have little energy and no interest in fun activities
  • Think about death or suicide.
Bipolar disorder is difficult to diagnose in children because symptoms often mirror other issues, for example: ADHD, conduct disorder, or alcohol and drug abuse issues. Bipolar disorder can, however, occur alongside these other issues, so it’s important to see a professional skilled in recognizing the affectations of various mental health disorders. Treatment for bipolar disorder requires the use of medication, but because the effectiveness in children isn’t as well researched, it’s wise to take note that children may respond differently to medications than adults. NIMH recommends children and adolescents take the “fewest number and smallest amounts of medication possible to help their symptoms,” additionally noting the danger in stopping any medication without the advice of a physician.
Pay attention to any side effects, and immediately tell the treating physician if you recognize new behaviors. Remember: the treatment for bipolar disorder is based upon the effective treatment of adults, which typically applies the use of mood stabilizers like lithium and/or valproate to control symptoms of mania and act as a preventative to the recurrence of depressive episodes.  Still, treatment of children and adults is still being researched. At this time, “NIMH is attempting to fill the current gaps intreatment knowledge with carefully designed studies involving children andadolescents with bipolar disorder.”  Further, scientists continue to perform studies looking at different types of psychotherapy, which would support the pharmaceutical treatment used in children and teens.  
Please see below for links to additional information (note, I also used some of these as reference for this article.)
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