Tag Archives: Dialectical Behavior Therapy

#WeekendCoffeeShare for June 16, 2018

I have seriously been meaning to write more and have had a few ideas floating around my head. Someohow though I could never find the energy or motivation to actually sit down and write a post. This week, a lot happened, so it’s about time I join in Alli’s #WeekendCoffeeShare again.

If we were having coffee, first I’d tell you all about the visit to a few possible new day activities places last Monday. There were four places that I would be visiting: a day center like the one I go to now, an industrial workshop, an arts place and a farm. The care consultant explained about each place and said the farm was pretty large and low-support, so I would most likely not be able to do much there. I don’t like industrial work, so I turned that one down too. The arts place, we did visit, but it didn’t turn out to be suitable. They mostly do textile arts, painting and drawing there, none of which I can do. They also do ceramics, which I can do but don’t usually like. It was also rather crowded and noisy there.

The day center consists of four groups, two of which are relatively high-support. I was shown around these two groups. The first one, which is the highest-support one, seemed really suitable. They have arund a 1:5 staff/client ratio, which is similar to my current group and is doable for me. The group seemed a little more structured than my current group. They go for walks regularly. They also have a garden with some swings and a rocking lounger. The center has a sensory room near this group. I spoke to one of the staff for this group, who happened to have seen me at the horseback riding school a few times. You see, some people from this day center go horseback riding there too. They also go swimming every other Tuesday. I assume this is only for peoople for whom a volunteer buddy can be found, but I hope that should I transfer here, I can do this too.

I was up front about the fact that I could have meltdowns if my irritability isn’t acknowledged and dealt with on time. I think though that if I transfer here, the consultant from the Center for Consultation and Expertise (CCE) can help us figure out a good support plan.

We also visited the other group, where people do mostly table-based activities. This group was a little more crowded and lower-support and I like walking and sensory activities more than table-based tasks. I ultimately chose to try out at the first group. On June 25 and 26, I’ll be spending the mornings there. We’ll be evaluating this on the 26th. I have decided to wait to potentially transfer till we’ve spoken to the CCE consultant on July 31.

I can’t convey through writing how excited I am about this possible new opportunity. I really hope it works out. Transportation may be an issue, but I have my hopes up that this will be sorted out.

Next, I’d be sharing about my next session of dialectical behavior therapy (DBT) with my nurse practitioner. It was good. We discussed rational, emotional and wise mind. Wise mind is like intuition, the integration of emotion and reason. One of the goals of DBT is to get into wise mind more often.

Last week, I had called the on-duty nurse at the psychiatric unit because I was close to a crisis due to feeling very lonely. I had initially felt really bad about having called, because loneliness is a common reason for me to land in near-crisis and need to call them. My nurse practitioner validated me, saying I don’t have their phone number for no reason.

If we were having coffee, I’d share about my weight loss this past week. I lost 1.5kg in just over a week. Now this evening we went to an all-you-can-eat restaurant, so I’ve probably gained it back, but I’ll lose it again soon enough. I also met the recommended daily step goal (10,000 steps) again on Wednesday.

What have you been up to lately?

#WeekendCoffeeShare for June 3, 2018

Welcome to this week’s #WeekendCoffeeShare. I’m a little late this week, as yesterday my husband and I spent most of the day at my in-laws and I didn’t have my computer or external keyboard for my phone with me, so I could barely type. So grab a cup of your favorite drink and sit with me as I write about this week. I’ll have a cup of green tea instead of coffee even though it isn’t terribly late here yet.

On Saturday last week, I finally went onto the scale again. I hadn’t weighed myself in a few weeks. As I feared, I had gained weight, but even more than I expected. I’d gained 2kg. I was so angry with myself. I mean, yes, we’d eaten pizza three evenings that week, but that couldn’t possibly explain such a huge weight gain. My husband tried to reassure me, saying I was probably constipated. This may be so, as the next day I’d gained another 800 grams. Tomorrow marks one year since the start of my weight loss journey and I’m afraid I will not reach my goal of having a BMI under 30. Then again, last January, I did reach this goal already and stayed at that weight all through early May.

On Sunday evening, the Center for Consultation and Expertise (CCE) coordinator E-mailed me and my support coordinator. As we’d had the meeting with her on the 15th of May, she’d planned on discussing my case on the following Monday but hadn’t realized this was a bank holiday. She had eventually discussed me with her colleague and had decided to ask a consultant to focus assessment on my needs and wishes rather than on a diagnosis. On Tuesday, she E-mailed us again to let us know she’d found a suitable consultant and we’d be contacted again to set an appointment for a first meeting.

My support coordinator had also inquired about getting long-term care funding for me. Whether this is possible, depends on whether my blindness is the primary reason for my care or my mental health or autism. If it’s blindness, I may get long-term care funding, whereas if it’s autism or mental illness, I definitely won’t. Long-term care funding would enable me to move to supported housing for the disabled or get more support while living with my husband.

On Thursday, I had my first session of dialectical behavior therapy (DBT) with my new nurse practitioner. DBT was originally developed for treating people with borderline personality disorder (BPD). It’s usually group therapy. Though I do have BPD traits, I’m also autistic, which means that group therapy would be hard for me. I therefore do the DBT individually. I had already started DBT with my community psychiatric nurse, who left recently. My nurse practitioner, who took over from her, proposed to start at the beginning of the therapy manual again. We only managed to work through the first page, which details the goals of DBT. There are four skills domains on which I’ll work: mindfulness, emotion regulation, interpersonal effectiveness and distress tolerance.

I also realized as I was talking to my nurse practtitioner how angry I still am at the psychologist from the institution who kicked me out almost with no after care last year. My nurse practitioner did the intake interview for this team with me last year and mentioned how he and the psychiatrist got a totally different impression of me than said psychologist had painted. The psychologist had diagnosed me with dependent personality disorder for claiming care I supposedly didn’t need. She removed my autism diagnosis. The nurse practitioner and psychiatrist saw pretty soon that I’m not dependent at all. Yes, I need a lot of support, but that’s due to my disabilities (including autism), not low self-esteem. In fact, I just realized how this psychologist had in fact broken my self-determination. I don’t feel safe to ask for help much now and am a lot more passive than I was when I had this dependency diagnosis. My nurse practitioner validated my feelings, in fact saying that the reason for the CCE involvement is in part the poor after care this psychologist had arranged for.

On Friday, I went adaptive horseback riding again. Angie, my horse, was scared of a car passing by and attempted to go on the run while I sat on her back. This was terrifying. Thankfully, I managed to keep seated on her back. She was quickly calmed down again, but I was shocked for a bit aftwards. So was the girl who held the horse. Thanfkully, the instructor always walks beside my horse because of my blindness, so the girl wasn’t on her own. I still had fun horseback riding.

I’ve yet to think of what I want for my birthday at the end of the month. I will have to look at sensory toy shops for inspiration. I’m also thinking of starting up the soap making craft again, so maybe I’ll ask for supplies for that.

What have you all been up to this past week?

Increase in My Antidepressant Dose: Is It Working?

Tomorrow, I will see my psychiatrist for a medication review. Last month, the dose of my citalopram, an SSRI antidepressant, was increased. Do I truly feel it helps?

When I started on the higher dose of citalopram, I had no idea what to expect. I’d originally been prescribed this medication in September of 2010 and had never had its effecacy evaluated. I seem to remember I was put on citalopram after the dose of my Abilify had been increased twice in a few months’ time and I was still very irritable. Abilify is an atypical antipsychotic commonly used for irritability and emotional dysregulation of all kinds. Citalopram is primarily used for depression and anxiety, but it can also help with emotional dysregulation, or so I seem to remember my psychiatrist having said.

Even before I started on my higher dose of citalopram, my mood started to lift a little, possibly because of anticipation. Once I started on the higher dose, my mood remained relatively good for a short time. Things were looking up in the day activities department, so that also helped.

One thing I have clearly been noticing, is that I’m more active. I have less need for sleep during the day. I am also a little more motivated and inspired to get things done. Though I obviously did’t complete the #AtoZChallenge, I did write far more regularly on this blog last month than i’d done in almost two years before.

Another positive that I’ve noticed is that I am more able to keep myself from engaging in self-destructive behavior. I do still have urges, but I’m more able to reach out for help first.

Though these are all very positive changes, I must say that if I’m truly honest, my depressed mood is still the same if not worse. Same for my irritability. I still experience this feeling as though a heavy weight is on my shoulders. I still get agitated very easily. I still experience suicidal thoughts.

Then again, these are most likely more symptoms of emotional regulation issues rather than major depression. Unfortunately, there’s no medication that targets these specifically. I won’t have my first appointment with my new treatment coordinator till the 17th, and I assume we won’t be diving back into dialetical behavior therapy right then. I try to use the skills I’m learning through self-help groups and apps, but it’s all rather hard.

Emotions: Dealing with Emotion Regulation Issues #AtoZChallenge

Welcome to day 5 in the #AtoZChallenge of random reflections. For my letter E post, I focus on emotions. In this post, I’ll explain what it is like living with emotion regulation issues and how dialectical behavior therapy helps. Both I and my treatment team prefer the term “emotion regulation difficulites” over “borderline personality disorder traits”, as my emotion regulation issues are likely in part due to my autism. Also, borderline personality disorder is very stigmatized. Now I know the solution to that is not to avoid the term, but I do feel I’m not the “classic” borderline.

First, I have difficulty understandign my own emotions. This is called alexithymia and is relatively common in autistic people. I can usually tell whether I’m feeling “good” or “bad”, but not whether “good” is joy or love or “bad” is anger, sadness, etc.

I feel “bad” far more often than I feel “good”. This may be because I suffer with depression too. I however tend not to express my depression as sadness. Rather, I express all “bad” feelings as irritability. Over the years, I have gotten slightly better at knowing when I’m genuinely angry and when it’s another feeling that I express as irritability.

In dialectical behavior therapy (DBT), the treatment I follow for my emotion regulation difficulties, we learn to counteract emotions by acting opposite to how the emotion “makes” us act. For example, one skill that I’m trying to practice is to half-smile, accepting the situation as it is even if I don’t like it. I initially thought that acting opposite to emotion was acting cheerful whenever a cheerful mood was expected. For example, I’d greet my husband enthusiastically when he’d come home even though I still felt like crap. Now I know that you’re not supposed to “fake it”, but that acting opposite from your initial impulse might help you achieve your goals. For exaple, if I feel like crap and want to stay in my room all the time, it may be more effective if I reach out to my husband instead.

Dialectical behavior therapy also teaches me about the misconceptions about emotions I may have. One of them is that some emotions are just stupid and shouldn’t be felt. Another is that emotions come up for no reason at all. In fact, emotions all happen for a reason and as such have value. Now that I write this, I realize this is the strongest argument against fake cheerfulness. It is important to acknowledge an emotion without judging it, but also without dwelling on it too much. Mindfulness, as such, is the first skill of DBT.

Changes

This week has been rather eventful and yet, nothing really did happen. A lot of changes are on the horizon for me, yet nothing has really changed yet.

First, I found out a few weeks ago that next week, my primary day activities staff will be leaving the day center. It is great for her, as she’ll embark on a new and challenging path in her career. For me though, it’s quite hard. Some of my other staff and family have been askign whether I mind at all, since I’ve been struggling at day activities and she was the one who filed the incident report that led to my day activities hours being cut. Yes, I do mind, since despite this, I like this staff a lot.

Then on Thursday, I found out that my CPN is leaving too. It’s also to embark on a new and challenging path in her career, but it’s sad nonetheless. My CPN and I have had quite a few misunderstandings over the ten months so far that we’ve worked together. However, I’ve noticed that I did make progress. It seems odd, since both my husband and my psychiatrist have been commenting on how I didn’t get far on the DBT course yet and it’s apparently my CPN’s fautl. Apparently, she should be limiting my bringing up only indirectly related topics.

I know the nurse practitioner who will be replacing her already from my intake interview last year. It is a slight disadvantage that he’s male, but other than that, I think I could get along with him just fine. However, it’s still a bit stressful that so many people are leaving at the same time. After all, my nurse will also be taken off my case. We’re not yet 100% sure who will be replacing her.

On Friday, I had a meeting with my psychiatrist. We discussed my progress on the DBT course, my medication and I mentioned I’ve been rather depressed lately. I did say it’s been going on for half a year already, so if I can hold it together for that long, it must not be that bad. She ignored this comment and proposed to increase the dose of my citalopram from 20 to 30mg. It’s a bit scary, since I’ve been on 20mg ever since 2010 with no med review whatsoever and I didn’t even know why I’d been prescribed it. IN this sense, I like it that my psychiatrist did ask to see me in a month’s time for an evaluation. I really do hope the med increase will help with mood improvement.

Cuts to My Day Activities Hours

And again I really didn’t get to write as much as I’d like to have done. The past week was quite busy. I had my first session of movement therapy on Tuesday and a meeting with my nurse on Thursday. Actually, I would’ve had a session with my CPN, but she’s off sick. I was so grateful that my nurse asked whether I wanted an appointment with her instead, as I really needed to talk.

I’ve not been doing well lately. I’m very irritable and easily overloaded. I switch a lot between being completely in my “rational mind” and feeling terribly emotional. I try to use my DBT skills, of course. Not that I’ve come far on the formal DBT course I do with my CPN, but I’ve been doing it by myself. I do an okay job when I’m not overwhelmed, but once overwhelmed, all my skills go out the window.

I mostly find that I can’t handle this huge, gaping split between my (verbal) IQ and my emotional, practical and behavioral functioning. At day activities, this is becoming more and more problematic. The staff are telling me that my irritability upsets the other clients, who are “like a baby” and can’t understand. I tell them that I don’t understand stuff myself, either, but because I’m not intellectually disabled, I should somehow be able to be more capable.

Because I’m too much of a handful, my day activities are being reduced. I won’t get additional home support in exchange. This upsets me greatly. It feels as though, when I need more help the most, I’m punished for it by getting less. Again, the main reason is my IQ, because other people with significant behavioral challenges at my day activities, get more care.

“We don’t do psychiatry.” That’s my day activities staff’s reasoning for cutting my hours when I’m too irritable. The other staff even mentioned finding me another place to go. I don’t know where. I mean, day activities for mentally ill people cater mostly to those with psychotic disorders. I have experience with that and I run into the same crap I get here there. After all, people with schizophrenia can’t help reacting to their voices either.

For clarity’s sake, I’m not saying that people with severe intellectual disabilities or those with actively psychotic schizophrenia should just be able to hold it togehter. I know they can’t, but I can’t always hold it together either.

I know my staff try their best. The staff who decided to cut my day activities hours, got angry when I told her they’re expecting too much out of me. I know she’s never worked with a person of at least average intelligence who still has signiificant sensory issues and challenging behavior. I know the manager probably told her to prioritize her main focus group, ie. those with severe intellectual disabilities. It’s interesting that she refers to the other clients as “the clients”, not “the other clients”, when she talks to me.

However, I can’t keep from being reminded of all the great lengths to which the staff go to accommodate their other clients with challenging behavior. For one person, a staff goes to his group home to provide him day activities one-on-one. Two at my group get several hours of one-on-one too. I don’t ask for that, but I don’t ask for the other extreme, ie. being cut off my hours, either.

My Experience With Therapy and Counseling #Write31Days

31 Days of Mental Health

Welcome to day 23 in the #Write31Days challenge on mental health. Today, I’ll focus on another question in the 30-day mental illness awareness challenge. For day 23, the topic is your opinion on therapy. I will share my experiences of therapy and my opinion on various approaches. I have decided to include both traditional psychotherapy approaches and non-verbal approaches.

I had my first experience of therapy as a child, when I had four sessions of play therapy. I didn’t like the therapist, didn’t have insight into my problems, and four sessions obviously wasn’t enough to garner any results. In hindsight, my play behavior did show my problems with rigid thinking, emotion regulation and behavioral control. For example, I’d throw out the dollhouse dolls with purple hair because “people don’t have purple hair”. I also preferred to play with toys that allowed me to show anger, such as toy guns. One vivid memory I have is of me trying to overflow the water tray. The therapist did show me why it wouldn’t work, but I tried anyway.

My first experience with verbal therapy was when I was nineteen and attending the rehabilitation center for the blind. Once again, I didn’t like the therapist, who appeared a bit inpatient towards my difficulties adjusting to blindness and misunderstanding of my social ineptitude. She tried to offer practical advice, while I felt I needed to process the rollercoaster ride that my life had become. Of course, time constraints – I had only about twelve sessions -, prevented us from going deeper.

During my first sixteen months in the psychiatric hospital, I didn’t have a psychologist. I did do movement therapy, which helped me greatly to release my emotional tension. It was here that I learned to rate my distress level – I came up with a system myself. Thhat being said, when later people asked me to rate my distress level, I was often stuck. This moveement therapist I had at the acute ward was one of the more helpful therapists I’ve had.

At the resocialization ward, I tried cognitive-behavioral therapy for a bit. It hardly worked, because I and my therapist agreed I had good reason to be anxious. Then, when I was diagnosed with DID and PTSD, the therapist pushed me to try EMDR, but I resisted. I didn’t have that severe PTSD symptoms, after all, and did have quite a bit of trouble with self-regulation and dissociation.

When I moved to my current institution, I got diagnosed with BPD. My therapist’s expertise was schema-focused therapy, an approach I’d wanted to use for a while. Unfortunately, it didn’t work out. The therapist told one of my parts, who hides her inner weakness behind a stubborn attitude, that she’s a “punitive parent” and needs to disappear. I strongly feel that each part of my personality has a function, so this dismissive attitude didn’t fit me well. Besides, though I learned some from the book the therapist recommended, most of the information was just a bit too abstract.

This therapist left in 2014 and I’ve had a new psychologist for a little over a year now. With her, I focus on supportive counseling and rehabilitation. I find this is most constructive. I do hope that, in the future, I can get some formal psychotherapy again. I have a dialectical behavior therapy self-help book, which is quite interesting. Then again, I find it hard to make a long-term commitment to sticking to one thing to focus on. That is probably the main thing keeping me from engaging properly in psychotherapy.

(Not So) Busy: Looking at the Roots of My Fatigue

This week at the spin cycle, the writing prompt is “busy”. I am not technically very busy. I do not work, after all, and am not in full-time school. I still have enough time to sleep, although I sleep often at the wrong moments. During the day, that is.

That being said, you might believe it would be easy to incorporate new requirements into my schedule. Exercise three times a week. Go to the educational department at my institution to study for 90 minutes twice a week and study for an extra hour on Sundays. Write a blog post everyday Monday through Friday. Yet why don’t I accomplish this?

It’s probably that I feel too overwhelmed. It’s not necessarily that there’s not enough hours in the day, but that there are too many requirements on my mind at the same time.

I also, of course, do have limited energy. I don’t know why, but it’s probably one of those symptoms of the aches and pains of daily living. What I mean is, I don’t have a physiological explanation for it, but it’s there nonetheless.

I am not busy as a bee most of the time. Sometimes, I have more energy and tend to put my day full of activities. It seems I’m almost normal then. Right now, I feel far from normal. I feel exhausted while I’ve hardly even done much of anything.

When I once read part of a book about medically unexplained chronic health symptoms, the author presumed there were two causes of these types of symptoms (other than of course an unknown physiological ailment). Some people tended to push through and do too much, while others tended to give up and do too little. On the surface, I appear to be fiercely in the second category. After all, even on days when I feel as though I push through, I don’t do nearly as much as a healthy person my age. I still don’t work or go to school full-time and I don’t care for a family.

However, it seems to me like I do have issues with dividing my limited energy correctly, pushing through on days when I feel lots of energy and giving up on days when I feel little. Psychological treatments of mental illnesses like bipolar disorder, which include fluctuations in energy levels, teach the exact opposite. Dialectical behavior therapy for borderline personality disorder also teaches acting opposite to one’s state of mind. Could it be that I, too, need to rest when I feel energetic and push through when I feel fatigued?

I know that conventional treatment of chronic fatigue syndrome follows this line of thought. Now I don’t claim to have CFS, and I don’t mean to say that this line of treatment is correct for those who do have CFS. What I mean is that it could be helpful for me.

Everyday Gyaan

Emotion Regulation Skills for BPD Sufferers

In the Netherlands, borderline persoanlity disorder is sometimes also called emotion regulation disorder. There were in fact psychiatrists advocating for this name change in DSM-5, but it didn’t happen. Indeed, I myself notice that emotioon regulation problems are, besides having little sense of self, the most prominent symptom of my BPD. Tonight, I noticed how being told that I had to ask a fellow patient to help me with something minor rather than a staff member, set into motion a train of emotions and behaviors that I now realize, at least to some extent, was uncalled for.

Learning to regulate emotions does not mean stuffing them. Rather, it means observing and describing your emotions, decreasing your vulnerability to negative emotions and increasing positive emotions. Identifying what emotion you are feeling is usually the first step, and it can be especially hard. Many people, even those without mental illness, learn that certain emotions are not allowed, so they convert them into others. I for one often act angry when I’m sad or overwhelmed. However, all emotions have value.

Changing emotions requires first observing them without judgment, then letting go of them through for example mindfulness. Mindfulness allows you to experience the coming and going of emotions like a wave. In mindfulness, you shouldn’t try to block or suppress an emotion or try to keep it around. Rather, let emotion run its natural course.

This does not mean acting on emotions the moment they come up. We are not our emotions. Therefore, another step in emotion regulation is choosing whether to act upon your emotion. This seems impossible at first – at least, it does for me -, which is why mindfulness is important. When you have chosen to challenge an emotion, some therapies, like dialectical behavior therapy (DBT), explicitly teach acting opposite from the emotion. The most useful example of this I’ve heard is from a woman who suffered from bipolar disorder. When she was sliding into depression, she was encouraged to become active, while she was encouraged to take it slow when she was climbing towards mania. Other therapies, like rational emotive therapy, emphasize the fact that an emotion doesn’t come out of the blue, and encourage sufferers to challenge the thoughts that lead to their emotions. I believe that challenging cognitions may be best done when emotions are not overflowing you.