How to Find a (Good) DBT Therapist

One of the most common e-mails I receive at DBT Path is asking for a referral for DBT counselors in their areas.  It can find like a needle in a haystack to even find a DBT counselor let alone one you connect with.  Don’t fret there are options out there and some don’t involve leaving the house.

1.  Behavioral Tech

The Good:  This list is of those formally trained though Behavioral Tech.

The Bad: Many DBT Therapists are not trained through Behavioral Tech (myself included) and it includes mostly DBT Clinics over individual counselors.

2.  Google

The Good: It’s simple and it might bring up therapists who willing to do sliding scale or starting a practice than those who pay to be on search sites.

The Bad: It’s google, so anything with “DBT+ Phoenix” will come up, including a band called Drive By Truckers.

3.  Good Therapy

The Good: Easy to use search engine just for therapists.  You can search for DBT-specific therapists and see short bios and pictures.

The Bad: Same as with other search engines for therapists, they pay for the advertisements so small practices might not advertise.

4.  Psychology Today

The Good: This is the top site for searching- more listings and more detail in profiles.

The Bad:  Same as good therapy regarding therapists paying for their listing.

5.  Live Person

The Good: It’s online, via e-mail or make a phone appointment so stay in your PJs also some therapists profiles say “live now,” which means if you want to talk to someone at 3am they might be someone there (it’s not crisis counseling.)  Therapists do not pay to be listed and they have reviews.

The Bad: Many people like face-to-face therapy and the prices are a bit steep if you are looking for ongoing help.  There are also less than 10 DBT Therapists listed right now.

6.  Look for a non-DBT Therapist.  : I know this seems weird, but hear me out on this.

     The Good:  Many counselors who are not DBT Therapists are still great counselors.  If you are looking for help      with trauma and sharing diary card/homework accountability, a non-DBT Counselor might be a great fit.  Yes,      you won’t talk DBT the whole time, but you might get great non-DBT coping skills.  This opens up the number      of local Mental Health Professionals exponentially.

     The Bad: It’s not DBT-oriented.

So now you have some names and numbers of DBT Therapists so where to start?  There are many articles on how to find a “good” therapist.  This site has a great list of what to ask so I am going to focus on what to ask a “DBT Therapist.” 

I put “DBT Therapist” in quotes for a reason.  There are many great therapists that have some training on DBT and list DBT in their profiles, but then don’t have much knowledge of it.  Many of the search sites have check boxes and I think many therapists get “click happy.”  I am not saying these are not great therapists, but if you are looking to talk DBT, review diary cards and talk skills these counselors might not be a good fit.  Here’s a list of what to as a “DBT Therapist to ensure they are DBT Counselors:

·         Give them a ring, not an e-mail.  Sounds sneaky but try to catch them a bit off guard so their answers are not prepared even if they end up calling you back.

·         Take the free meet-and-greet.  If you are searching someone in person, most offer an initial consultation on person or on the phone- take them up on it and be prepared with questions.  Consider this a job interview and you are the boss!

·         What training do you have specific to DBT?

·         How many clients who have (your diagnosis or primary issue) have you used DBT skills with?

·         Have you ever facilitated a DBT group?

·         Are you familiar with DBT Diary Cards?  Emotion Regulation 1a worksheets?

·         How familiar are you with specific skill?  Heck name a few major skills (i.e. Wise Mind and Opposite Action) and see if they can keep up.

You are the consumer and deserve the best- be assertive!  Ask for exactly what you want to work on.  If you are struggling with relationship issues and past trauma issue start the conversation with, “I am working on relationship issues and handling past trauma that is interfering with my life.  I am looking for more accountability and skill building one-on-one.  I have found wise mind, radical acceptance and mindfulness most effective and could use more depth in my learning of these skills.”  A good therapist who isn't well versed in DBT will re-direct you to someone else.

No matter which way you go, if you need help be EFFECTIVE and find it!

Family and Loved Ones with Emotional Regulation Issue Seminar

A week from today Sunday 9/29 from 4-5:30PST Debbie Corso from Healing from BPD, myself and guest Dr. Perry Hoffman from NEA BPD (National Education Alliance for Borderline Personality Disorder) will be facilitating an global seminar for family and loved ones of those with Emotional Regulation Issues.  We will be talking about how loved ones can help, what resources are available to both clients and their families and have an open Q&A session.  

There are 2 days left to get the discounted price.

If you have any questions e-mail dbtpath@gmail.com

Ask Any DBT or BPD Questions This Weekend!

Hi All,

Quick note.  This weekend I will do a Q&A on twitter.  Feel free to ask me any questions about DBT or BPD.  Tweet them @apazma, DM me to be anonymous, e-mail or leave them in the comments below.  I will re-post all questions (minus names) here after I am done.

Great way to get some professional information!

Profiles of Borderline Personality Disorder: Tess Smith

Misdiagnosis and Invalidating Environment

Tess Smith was diagnosed with Borderline Personality Disorder in 2006 after 16 years of treatment for dysthymia, anxiety, and obsessive compulsive disorder.  A misdiagnosis that resulted from her lack of trust in adults as a child, and miscommunication with therapists as an adult. "In 2006 my primary diagnosis was BPD in addition to depression, anxiety and OCD. I started seeing a therapist when I was 14, it took many years for them do diagnose me correctly because I didn't trust anyone enough to admit I was a cutter.  Growing up mental illness was not anything we talked about in my family. When I was first diagnosed (with depression, anxiety, and OCD) my mother didn't want to discuss it or even look into it. She told me I was “in control of my feelings” and I “just needed to get better”, so for many years it was a dark secret. I hid it from everyone, I didn't talk about it, and I sure didn't look for others like me. There’s a lot of shame in a mental illness diagnosis."  

Tess's secret kept her sick and her environment growing up was very invalidating, "my father died when I was 12, he was sick for years so growing up I wasn't close to any adults. We weren't able to ever express how we were feeling, it was always very important to look perfect. There were several situations in which I felt I had been lied to and my trust betrayed. I never felt like I could trust my mom, and her reaction to my initial mental illness diagnosis made it clear she wasn't going to be very supportive.” Tess's secret mental health issues continued throughout her teen and early adult years, " In my teens I never felt like I could talk to anyone about what I was doing without them telling my mother... and when I became an adult, no one ever came out and asked me if I was a self injurer."  It has taken Tess a long time to get to where she is today, “22 years of off and on therapy and prescriptions for Prozac, Wellbutrin, Remerol, Ambien, Xanax, Clonazepam, and Trazadone."

BPD and Stigma

In 2006 Tess found little information about her diagnosis online, "I had never heard of it... and when I found out what little there was out in the mainstream media about it - it wasn't easy to wrap my head around.   The movie everyone knows is Fatal Attraction... no one wants to be that crazy chick... and accepting the diagnosis is one of the hardest things - but the first step I think in getting better."  

Treatment & Hope

When she was diagnosed in 2006, she was referred to Dialectical Behavioral Therapy.  Unfortunately, the first class was full, then there weren't any that met her work schedule, and then she lost her insurance coverage.  When she again had coverage to attend DBT classes, she couldn't get time off of work to go. At that point Tess took her treatment into her own hands, "I did my own research and thank gods for the internet in 2011 because it gave me access to self help and the DBT tools I needed to at least get going. This is a long term thing… something I will have to manage for the rest of my life. Has it improved? YES! Simple skills I was able to find online have helped me when interacting with everyone and in almost every situation. My personal relationships have improved and are more stable and I find myself willing to put a little more of myself out there, in order to improve life. I do continue to take Prozac to alleviate the symptoms of anxiety and depression, but use DBT skills to manage my Borderline Personality Disorder."

Relationships

Along with Tess's new coping skills, she is also developing friendships, "I'm very careful with whom I let get close... I've surrounded myself now with a handful of friends who I depend on.  I'm better with some distance though... I don't talk on the phone or hang out - I text, IM online... I don't go out.  I am more comfortable when I can control my environment and who I am with.  I don't seem to have conventional relationships...I've been married 4 times, and the longest relationship I've ever had is with my cat."

Ongoing Struggles

For Tess the hardest part of her BPD diagnosis is the emotional dysregulation, "my rapid and intense mood swings. I go from loving the ground you walk on to 'I can’t stand the sound of you breathing' in 2 seconds flat.  It’s hard for me to pin-point what I'm feeling, and then I have to figure out why I'm feeling it... every swing is an internal dialogue.  It’s hard to just 'be'… it seems like I’m always trying to figure out what I’m feeling and if it’s appropriate.  I feel tired a lot."  

Successes

For Tess getting the right diagnosis made a big difference, "it helped because I finally knew what I needed to do. My life was always on reset about every 4 years; a new address, new husband, and a new job. I didn't feel like I could be anywhere for very long without destroying everything. I had a stressful job, the diagnosis made me realize that maybe I liked what I was doing but not the position I was in, because it was just too demanding. I’m not built for that kind of long term exposure to stress. I now have a career in the same type of industry, but my day to day is very different. My interpersonal skills have improved, and I'm able to communicate what it is I want - instead of just being upset about not getting what I need. This whole time it’s been like being lost... and then getting a GPS.”

What would Tess like those without Borderline Personality Disorder to understand about those who do have it? "I’d like them to know that we don't mean to be cruel. It’s a protective mechanism that's a knee jerk reaction - we don't aim to hurt you.  We can seem distant or self-absorbed… if you get burned you pull away and it looks/seems like were lashing out. I think the main underlying issue of BPD is that we grew up in an environment we didn't feel safe in, and no one ever taught us coping skills - so we made our own."

"I used to think having a mental illness made me weak... I felt emotions more than other people and it made me different. I've learned now to look at it as a source of strength, my perspective has changed. With tools, friends, and willpower - I am strong enough to get better."

Why I needed a Twitter-cation

After being away from Twitter, other social media and MIA from e-mails for a week, I returned this Sunday to peak back out and say hello.  I also decided to write a brief explanation of why I needed a break from anything besides my 9-5 job.

The Bad:

• As a Counselor on twitter, it's hard to continue to be engaged.  I often felt like I worked 8 hours then came home and kept working on twitter; interacting and (hopefully) helping with people with mental illness.
• My passion for helping people became overwhelming and I was staying up late to finish a conversation, complete a blog post of think about someone on twitter.
• The (TW) ongoing suicide, self harm or pro-eating disorder posts; as a Counselor in person if someone is going to hurt themselves there are things I can do and feel powerful and in control.  On twitter, especially with the high rates of those with BPD and self-harm/suicide I feel hopeless and ignoring certain people or posts was still not preventing me from sleepless nights or thinking I should have done something to help at 2am.
• My 9-5 job is very, very stressful.  If you are unaware I work as a Dual Diagnosis Counselor in a Women's Prison.  Until this evening at 8pm, I was 6 months behind on filing- now I am 2. 40 hours a week doesn't cover the workload and I mostly refuse to stay much later for my own sanity leaving me with heaps of work that sits, stresses me out then gets noticed by the boss.
• I have "too much compassion," this might sound weird, but I begin feeling too much for people (maybe the honest words is co-dependent) and I was struggling with drawing a boundary.
• Having boundaries is difficult online for me, and I found myself not being able to say no to the many requests for help.
• Essentially I was not going a good job of self-care and didn't feel like I was ever "off the clock."

Moving Forward:

• Although I will be back on twitter, I am going to set some self-limits on how often I am on.  Checking twitter while I do my 9-5 is no longer going to happen. Just morning, evening and maybe a check in during lunch.
• I will continue with the contests (I really enjoy it) but need to figure out some online format that is simple for me to track.  I will not be mailing books out, as that turned out to be more expensive than I presumed as well as it taking 4 weeks. The last contest probably took 6 hours to tally, choose, order, mail, track and in one case even re-order.
• I plan on continuing to respond to DM's from those I know, or answering brief questions, I am no longer responding to people in crisis- but refer elsewhere for their help.
• If anyone posts about suicide or anything I feel I can not handle, I will *edit* Report to Twitter to follow and possibly re-tweet for others to help, but not give support myself and not engage in any "therapy-like" behavior.  If the same person has ongoing SI or ED chat, or continues to post pictures I will "block" them for my own safety.
• I will continue the BPD Interviews, but only set-up one a week.  If it takes 6 months to get them all done, so be it.
• I will be in bed by 10pm if I have work early the next morning, midnight if I do not.  
• I will drink 6-8 glasses of water and weekly Vitamin D supplements.
• I will eat better, consume less caffeine and spend more time playing with the dog than hitting refresh.
• I will stop from extending myself too far and pull away before I feel overwhelmed.  
• If I need to take a break, I will not beat myself up or feel like I let anyone down.
• I will read a book every 2 weeks to once a month.  These books will not ALL be mental health or addiction literature.
• I will be more gentle with myself.
• I will remind myself that I am not a masterpiece, but a work in progress.

Profiles of Borderline Personality Disorder: David O'Garr

After hitting a writer block earlier this week, I spoke to a fellow counselor about my work with DBT and that I specialize and take an interest in Borderline Personality Disorder.  As is often the case, my fellow counselor was stunned that my specialty was the one diagnosis she avoided working with "at all costs."  Being I speak with those with BPD on Twitter daily, I thought a simple way to change the stigma of "Borderlines" would be to do interviews with people with BPD and put a face with the diagnosis.  I was surprised when I put the ABP out and got 6 responses in a few hours.  The interview also took longer than I expected, but I hope to have 2 profiles out a week for the next month or two.

Being Misdiagnosed

Without further ado, I present David O'Garr, male age 29 years old and from Canada.  David is very open and honest in his life, and writes a blog about his struggles with BPD.  David comes from a large blended family, that were invalidating, although he remains close with his mother. Before his BPD diagnosis he felt jerked around by the Mental Health community, "It got to the point that every time I talked to a doctor they just wanted to prescribe me something else, and I kept saying that this isn't working we need to do something else. But instead of referring me to someone, they just kept telling me that the waiting lists for psychiatrists was too long and it wouldn't' help me."  He was diagnosed in March 2011 with BPD, Generalized Anxiety Disorder, Dysthyia and ADHD Inattentive Type. after 17 years of being diagnosed with depression and on a variety of antidepressants, "I was on meds off and on from 11 - 28  none of them worked."  David found out he had Borderline Personality Disorder after knowing something was amiss for years last March, after waiting almost 2 hours to see a Psychiatrist , "he spent 20 minutes with me, told me I had BPD, referred me to a different Psychiatrist and sent me on my merry way.  So I left there, not knowing up from down, not knowing what BPD actually was, basically thought I was being told that I was not a real person pretty much.  That everything I thought was me was a lie...And to top it all off, I felt disrespected, not listened to, and treated like I didn't actually matter."   

The Hardest Part: Romantic Relationships

As David read about the diagnosis he felt unsettled, "Well the first things I were reading was that it was most often diagnosed in women and gay men.  Which made me feel that the diagnosis was actually wrong, that the treatment of it in the medical field was actually sexist and misogynist in nature (I'd say homophobic, but homophobia also has it's roots in misogyny.)  That we were basically being treated for 'hysteria'  I also came across a lot of blog posts by men stigmatizing women with BPD.  Which was a bit heart breaking to read as well."  David is one of only 3 men, I have meet with the Borderline Personality Diagnosis, "I've also been basically written off in discussion and debates, and told well he's a 'borderline' so not worth engaging with.  It's actually those things that have made me really scared of being in a relationship.  That I would be seen as being 'psychotic' 'crazy' and 'clingy' and I have seen how I've been in relationships and it scares me."  David states he struggles with romantic relationships the most, having BPD, "I find love to be the hardest and most difficult emotion to regulate...It's the intimate relationship thing.  I want nothing more then to find a partner, settle down, create a home and a family for myself.  Get a dog, maybe adopt kids.  It's funny I actually wrote a piece about this not too long ago, about dating with BPD after some pretty crappy experiences this summer.  I have actually been really upfront with guys about what I'm like or I try to be before I had my diagnosis I have said like 'I feel things larger then life, it it's difficult for me to dial it back.' After my diagnosis, I explain what my diagnosis is, and what it meant."  "That I have no interest in dating someone, but if you're perusing me you need to know this, because I can't handle someone who is just going to run the first time I get triggered  and fly off the handle about something.  I get a lot of, 'that's okay', 'I'm still interested' 'I like you for you', or we'll work through it.  But then the first time they're confronted with me being angry and pissed off they totally and utterly just cut me off..tell me I'm melodramatic and they don't have time for that."   

"I pretty much hold that Marilyn quote pretty near and dear to my heart after my experiences: “I'm selfish, impatient and a little insecure. I make mistakes, I am out of control and at times hard to handle. But if you can't handle me at my worst, then you sure as hell don't deserve me at my best.”  Actually it's funny because I usually break it to them with that quote. It's like, do you know what this means? Do you know what this actually means? I think a lot of people use that quote because they think it applies to them, but I think that quote applies to people with BPD so much more.  We can totally be out of control and selfish and impatient, but we can also be so completely and utterly selfless and our ability for empathy and compassion I think is amazing too.  That we have bad things and good things, and our good ones really make it worth it.  If you can give us the time to prove that. 

Support

"I have an awesome support system.  My roommate, which I wish I could love romantically because it would make my life simpler.  He's an amazing man, he has his faults too, but when I freak out he just lets me do it and either walks away or goes out, and then when I done I usually apologize to him for having to see that and he just shrugs and we watch TV or a movie, or play video games.  There's also my mother, who's a big PFLAG mom, she's also trying very hard to learn what BPD is all about and doesn't quite get it yet.  And my best friend, who I am able to talk about pretty much anything and everything with.  She's been there for me through a lot of my life, and is really the strongest part of my support network."

Stigma

David would most like to change people's opinion of the diagnosis, "I wish people would understand the part about how difficult it is for us to deal with just every day.  The ups and downs of our emotions are a roller coaster and a lot of times we can't deal and really just want to get off the ride...That being melodramatic isn't us being vindictive or malicious, but a result of us trying to cope and ride the wave of emotions without having the tools to do it in a way that meets the limitations of acceptable behavior or the 'status-quo' of our pretty backwards society.  That being clingy, is me trying to be connected, and all I need is reassurance that you respect that, that you still care and you do want me.  That once I'm reassured, you can do whatever you want, within limits of course."  Exactly, the funniest thing is that it's that first part of the relationship that's the hardest, because that's when I need the most reassurance once the trust is built, and I know you're not going to leave, is when I know I'm more relaxed, but I can never get to that stage."

Getting Better

David has mostly utilized CBT therapy, although he found DBT group more helpful, "Well did a lot of CBT which I found unhelpful because none of my therapists really seem to understand what I was going through.  And I've had a few.  But still the same methods were applied over and over again, and I got really good at talking around my therapists, to the point where I have finished treatment with multiple therapists with them saying I didn't need anymore treatment...I got so good at telling people what they want to hear, that I just said it because I felt frustrated with them.  Then I have taken a six week DBT crash course and I found that REALLY helpful, and I am now just waiting for the year long treatment."

When asked what David has learned about himself since this journey began for him at age 11, "I have learned a lot.  I have learned not to change myself for other people, because once learning about that as a symptom I started catching myself doing that.  I have found that medications can help if you start taking the right ones.  I have found that I don't always need to be right, and my need and want to be just stemmed from my need and want to be accepted."

Are Mentally Ill People Dangerous (TW)

Let me start off by stating four quick points:

• What happened in Newtown, Connecticut was a tragedy.
• The following view is not to discuss why? how? who is to blame or gun control.
• The following post uses facts and intellect rather than blanket statements and accusations.
• It is written by a well-educated adult whose career and education serves as a platform to form the following viewpoint.

I'd ban ALL guns for convicted criminals and ANYONE with ANY mental health history whatsoever.
— Piers Morgan (@piersmorgan) December 14, 2012

Along with this tweet, after finding out the news I found myself with a whole slew of people stating the shooter "must be mentally ill/sick/psychotic," and a guesses of his diagnosis from laymen as well as some news casters, as well as Piers Morgan, who tweeted the above tweet to his nearly 3 million followers.

So are those with mental illness more dangerous than those without? Are those with mental illness more violent? 

The answer may seem obvious to the general public, given the popularity of movies, TV shows and books in which mentally unbalanced individuals are portrayed as homicidal maniacs. Three-quarters of Americans view mentally ill people as dangerous, according to a 1999 study in the American Journal of Public Health. Another 1999 study from the same journal found that 60% of Americans believed patients with schizophrenia — a condition characterized by disordered thought processes, paranoid delusions and auditory hallucinations — were likely to commit violent acts.

But while the data show that people with certain psychiatric problems do commit violent crimes at a higher rate than those who are seemingly healthy, the vast majority of homicides, arsons and assaults are perpetrated by people who are not considered severely mentally ill.

What's more, other factors, such as unemployment, divorce in the last year and a history of physical abuse, are better predictors of violent behavior than a diagnosis of schizophrenia, according to a 2009 study in the Archives of General Psychiatry.

"If a person has severe mental illness without substance abuse and history of violence, he or she has the same chances of being violent during the next three years as any other person in the general population," the study found. (source) (many more sources here)

So simple, the big question is solved, now let's look at the negative impact this lie-telling and guessing game causes:

The discrimination and stigma associated with mental illnesses stem in part, from the link between mental illness and violence in the minds of the general public (DHHS, 1999, Corrigan, et al., 2002).  The effects of stigma and discrimination are profound. The President’s New Freedom Commission on Mental Health found that, “Stigma leads others to avoid living, socializing, or working with, renting to, or employing people with mental disorders - especially severe disorders, such as schizophrenia. It leads to low self-esteem, isolation, and hopelessness. It deters the public from seeking and wanting to pay for care. Responding to stigma, people with mental health problems internalize public attitudes and become so embarrassed or ashamed that they often conceal symptoms and fail to seek treatment (New Freedom Commission, 2003).” (source)

So telling lies, jumping to conclusions and assuming violence is perpetrated in increasing numbers by those whom are mentally ill, hurt those who are mentally ill creating this ongoing stigma that mental illness equals danger.  So why does the general population think those with mental illness are dangerous?

"Characters in prime time television portrayed as having a mental illness are depicted as the most dangerous of all demographic groups: 60 percent were shown to be involved in crime or violence" (Mental Health American, 1999).  "Most news accounts portray people with mental illness as dangerous" (Wahl, 1995).  "The vast majority of news stories on mental illness either focus on other negative characteristics related to people with the disorder (e.g., unpredictability and unsociability) or on medical treatments. Notably absent are positive stories that highlight recovery of many persons with even the most serious of mental illnesses" (Wahl, et al., 2002). (source)

How can those in the public eye become honest with their viewers instead of perpetuating lies and stereotypes?

 Choose your words wisely: Learn about the impact your words can have on those with mental illnesses.   Words are very powerful. 

• When we say someone is "crazy" or "that's totally mental" we're perpetuating stereotypes.
• Avoid the verb "suffers" when discussing mental illness. Instead, choose, "lives with mental illness" or "is affected by mental illness."
• Use "person first" vocabulary. When we say a person is schizophrenic, we make their mental illness fully define their identity. Instead, be clear that this is a disease that individuals manage and live with -- "He is living with schizophrenia."
• There are many phrases and terms; "crazy," "nuts", "psycho", "schiz", "retard" and "lunatic" that may seem insignificant, but really aren't.
• While there may be times when it is too challenging or simply not possible to politely correct someone else's insensitive use of language, you can always watch your own. (source)

How can those with mental illness begin changing the stereotype of mental illness?  Bring Change to Mind is an organization started by Glen Close, who's sister has Bipolar Disorder and nephew Schizoaffective about changing the stigma.  Here are the 6 ways to help: Take the Pledge, sharing your story, spread the word, donate, download the toolkit (which has helpful handouts regarding awareness), walk to raise awareness (source)

So what can we do now to begin healing, newscasters, talking heads, normal people, heck even Piers Morgan could use a hug right now?  Susan Pivers is a Buddhist Public Speaker whose work focuses on meditation and self-awareness.  She wrote this wonderful piece including a meditation for this incident (source)

Lastly I want to end with this quote from Fred Rogers, better known as Ms. Rogers:

“When I was a boy and I would see scary things in the news, my mother would say to me, "Look for the helpers. You will always find people who are helping.” ― Fred Rogers

My Personal DBT Diary Card

I was thinking today while on Twitter that although I do talk about some personal items (mostly my mischievous dog and cooking skills) and I have shared Why I become a Therapist, I have not shared how DBT has helped me.  I currently do not meet any criteria for any DSMIV-r diagnosis, but learning about and teaching DBT has helped me immensely in my life.  Here is a list of the most (and least) common used skills:

Mindfulness: I use this almost daily, so much so during stressful times at work, sometimes while in group that clients have "caught" me suddenly re-positioning myself to do some grounding/square breathing.  This most often happens when someone shares their autobiography or I am dealing with my own personal issue and need to re-focus on the task at hand.  I also use mindfulness when doing paperwork, the dreaded part of counseling.  After 4 hours of Utilization Reviews, "square breathing" and "observe and describe," helps me focus on the task.

HOW Skills: I use these when I come in every Monday to a stack of sheets to file, a slew of notes from clients stating "I need to talk to you ASAP," as well as an occasional bombardment of someone in my office at 7:30am with an urgent issue, that needs to be solved fast.  The HOW skills allow me to non-judgmentally (instead of yelling, freaking out or catastrophizing,) one-mindfully and effectively assess the situation.  In short it helps me to remain calm and prioritize: pick group sheets off floor, quick organize, turn on computer while I read the client notes to me, prioritize highlighting and placing anything urgent on top of pile in front of computer, check e-mails, respond quickly if necessary or it is something short that I don't want on my to-do list, continue working on paperwork to do first (I create a to-do list on Saturdays for Monday.)

Distress Tolerance- Sensations:  All the time in group or one-on-ones I use this skill in very basic ways, sometimes it's as simple as fiddling with a Styrofoam cup I randomly keep in my office, rolling the toilet paper (we don't have the luxury of tissues in prison) into small balls or noticing the heat from the computer on my left leg.

Improve the Moment: Mints, I keep a larger round container in my office and although they are great for some breath refreshing post-lunch I often use it to Improve the Moment.  Simply popping a spearmint piece in my mouth for a few seconds vastly improves whatever I am doing and it also gives me a reason to get out of the chair and look away from the computer for a bit.

Wise Mind: In the prison, we refer to it as "I over E" (intellect over emotion) and use it as a cognitive skill.  I use this all the time, and encourage my clients to do the same.  For example I am now able to notice my ears getting hot, my heart racing before the feelings of anger or panic.  I am able to think very concrete and remind myself almost instantly "this too shall pass."  A close friend/counselor told me she spoke to her anxiety, and for me that seems a little odd, I do talk to my feelings saying things like "This is anger right now, you feel betrayed, upset, sad and disrespected  and this will stop.  Is it valid? What DBT skill can I do to Improve the Moment? What is my best option for being most effective right now. This too shall pass."

Can you tell what days are more stressful and which days I have off?

I am going to stop here, as I could probably list 20 instances in he last 5 days I used DBT skills.  There are some I struggle on still as well:

PLEASE: I try to sleep 8 hours, but stress and the late night anxiety ("I need to remember to pack a lunch tomorrow? Where are my brown shoes? Can I wait until Saturday to wash the dog? Do we have enough OJ for breakfast?") often keeps me up and I find myself staying up to do fun things only to regret it in the morning.

DEAR MAN: I am good with this one up until the end, negotiate is what trips me up.  I do think part of it is due to the power dynamic working in a prison where my word is the final word most of the time.  I am very assertive, but when it comes to moving an inch, I sometimes personalize and I often get stubborn.

So that's my best/worst list.  What skills do you utilize most often? Which ones are you struggling/still working on?

BPD and Relationships

In group I have my clients work on the Power and Control Wheel numerous times in the 6 month program.  I think it is really important for those with mental illness and addiction issues to be able to identify what is abuse.  The most interesting part is when I ask them to identify ways in which they were the abuser and used the P&CW against someone else.  It's harder to come to grips with, but a few are vocal about using abuse against someone else, most of the examples are holding children as pawns, physical abuse, comments about a man's sexual performance to belittle him and cheating as a way to demean him.  I bring this up because as I have been considering writing about Borderline Personality and Romantic Relationship, but everyone I try- I get distracted and a more optimistic blog idea pops up.

Until I read "A Woman With BPD Explains Her Actions in Romantic Relationships"  by the author of Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder. In it she has the very honest and personal account of someone with BDP who explains her past relationships and the abusive tactics she has used:

• Purposely broken a gift you gave me 
• Flirted with several other people at a time or having a crush on others while I'm still dating you
• Said some of the most cutthroat things you've ever heard .
• Talked about suicide even though I know it hurts you
• Pulled a "Dr. Jekyll and Mr. Hyde"
• Pushed you away then pulled you right back
• Started an argument out of nowhere

The author of the article goes into depth about why someone with BPD would act this way, most of it boils down to the fear of abandonment as well as mood swings that can cause quick fluctuations of love and hate. Reminds me of I Hate You--Don't Leave Me: Understanding the Borderline Personality.  And yes according to the Power and Control wheel the above 7 bullet points could be broken down like this:

• Purposely broken a gift you gave me Intimidation & emotional abuse
• Flirted with several other people at a time or having a crush on others while I'm still dating you Intimidation & emotional abuse & using coercion and threats
• Said some of the most cutthroat things you've ever heard emotional abuse & isolation & minimizing, denying and blaming
• Talked about suicide even though I know it hurts you emotional abuse & using intimidation & isolation & using coercion and threats & denying, blaming and minimizing
• Pulled a "Dr. Jekyll and Mr. Hyde" emotional abuse 
• Pushed you away then pulled you right back emotional abuse, denying, blaming & minimizing
• Started an argument out of nowhere emotional abuse, minimizing, denying and blaming

So that's the bad news, those with BPD are often the abusers (not saying they are not as often abused) in romantic relationship.  And it may sound like a broken record, but there are ways to get better and once again this is why boundaries are so important. So what steps can be taken to have healthy relationships?  Here is a great article from BPD Central with the 10 Essential Limits for Romantic Relatonships:

The 10 Essential Limits

Keep in mind that a limit is not about rules or telling the other person what to do. You can't control their behavior; you can only control your own. Limits are based on your personal values and about what you will do to take care of yourself. For more information about limits, what they are and what they're not, and how to set and observe them, see my book The Essential Family Guide to Borderline Personality Disorder.

1. No mindreading. Your job is verbalize your own thoughts, feelings, concerns and preferences. By contrast, assuming you know the other person's thoughts and motivations (e.g., "You think that.." or, "You did this/said this because....") is almost always guaranteed to get you into trouble. Mindreading is one of the biggest obstacles to effective communication; it is invalidating, provocative, and almost always based on misinterpretations.

2. Build routines of taking a time out when things begin to get heated. People who are furious simply can't think straight; their brain is so focused on their feelings that logic gets thrown out the window. This is especially true with BPs and NPs. You can test this yourself. Think about something you said in the moment of anger that you regretted the next day (or week).

Talk about time-outs at a calm before they are needed, letting your partner know how this will work and assuring him or her that you two will come back to finish the discussion when you are both calmer. (Your partner, of course, has the option of initiating a time out too.) Find a safe place that is sacrosanct to you where no one else can enter when you need to be alone.

Early exits when either of you is beginning to feel a temperature rise prevents unsafe, hurtful mistakes--verbal as well as physical. Take the pot off the stove by removing yourself early on from a situation you may not be able to handle calmly.

3. Regularly do things you both enjoy and share positive reactions to your partner. The two of you need positive shared time and interactions to keep the relationship connection solid.

Positivity makes relationships worth having. The more appreciation, agreement, affection, playfulness, attention, etc you offer each other, the sunnier your relationship will be.  And the more you give, the more you'll get.

4. Focus on what you can do to improve situations rather than criticizing each other. And if you do feel it could be helpful to say something to your partner about what she or he has been doing, offer it as feedback, not as a criticism or complaint. People with personality disorders take criticism very badly, so it doesn't work to change their behavior.

Instead, learn ways to bring up your concerns without being critical and triggering the other person's defenses (well, as much as you can for a person with BPD/NPD). To give feedback offer a when-you statement, as in, "When you xyz, I feel abc"). Especially avoid the phrase, "You make me feel."  That's blame.

Remember that it's not your job to tell your partner what he or she should or shouldn't be doing. It is up to you to be honest about how you react as a consequence of your behavior. Your partner's concern for your feelings will tell you a lot about their capacity to show their love.

Just because you stop criticizing them won't stop them from criticizing and blaming you. With your own therapist or one of my books, formulate a strategy for how you will respond. My books go into this in detail.

5. Do not speak with contempt, ever. Studies have shown that couples who communicate contempt for each other are the most likely to break up. This principle is most important with regard to listening. Dismissive or eye-rolling as a form of listening dooms relationships.

6. No hostile touching; no putting hands on each other in anger. No threats or hurting property, either. Have a zero tolerance policy. Men, take any physical aggressiveness by your girlfriend or wife seriously; abuse of men is an underreported epidemic. Document, document, document, and be in communication with the police.

Never put your hands on your partner. Even if it is a mild pat, your partner may exaggerate it and make false abuse claims. You may end up in jail and unable to see your children.

7. Each person needs to have his or her own space, private time, and friendships as well as joint ones. Keep up with your friends and family and never become isolated. Isolation is the kiss of death to your confidence level, well-being, and sense of reality. Find at least one friend or counselor you can be honest with about what's going on. You need outside perspective, even if that threatens your partner.

8. Take responsibility for having and managing your own feelings, verbalizing your concerns and preferences, and being responsive to your partner's concerns and preferences.

9. Come to a mutual agreement about monogamy (or lack of) so you are honest and on the same page. Do not put up with infidelity (however you define it) that goes against your values. With infidelity, your sense of self-esteem will take a huge nosedive and your marriage will eventually be in name only. Again, formulate strategies with a therapist.

10. Work on problem-solving, not blame, and find win-win solutions so "Your-way" and "Their–way" differences lead to an "Our-way" solution that you both feel good about.

BPD and Medication

A counselor friend this week asked me the following question:  If there is no medication for Borderline Personality Disorder why are so many on medications?  Pretty valid question.

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

I have meet many people with BPD who have another diagnosis (or 5); Anxiety disorders, depression, PTSD, etc.  So for some people they are receiving medication for a separate disorder, which sometimes has overlapping symptoms.  For those of you who follow me on Twitter you know my issue with being people misdiagnosed with a plethora of other diagnosis, that gets added to each year when BPD is the only one.  Putting that aside I also think some people with BPD (especially those whom are newly diagnosed) are given Benzodiazaphines (I will save my opinion on that for another rant) to cope with the anxiety caused my BPD.

I work full-time in a prison, the female inmates are in a 6-month program, I find that month 1 everyone is knocking on my door about medications, someones their mental illness is valid often it is not (mostly due to drug use.)  Month 2-3 some mental health issues come to surface, as the program is intensive 20-hour a week therapy and people are now dealing with things they have stuffed for so long and they have a decent amount of clean time.  Right now my group is in month 3, what started as 11 on medication (out of 21) is now 5.  I asked the group why it has dwindled down significantly in 90 days.  The answers not surprising; 'we now have cog skills, I started journaling, grounding techniques, coping skills, I take to my bunkie about it.'  Many of these women are using skills over medication.*

So maybe medication is not available to you (Big Pharma will be another rant as well,) or maybe you are on medication and looking to gain more coping skills- here is a list of modes to get well for BPD:

• Dialetcical Behavioral Therapy Self-study material
• EMDR mostly used to handle trauma
• EFT (tapping)
• MBT used more in UK (Thanks to anon comment for the info)
• Social Support. Talk to others who may understand what you are going through. 
• Behavioral Activation. Engage in an activity that might take your mind off the stressful situation for a little while. 
• Relaxation Exercises. Practice a relaxation exercise, such as deep breathing or progressive muscle relaxation.
• Grounding. Practice grounding exercises that are designed to keep you "grounded" in the present moment, rather than caught up in replaying events in your head, worrying about the future or zoning out. 
• Mindfulness Meditation. Practice mindfulness meditation, which helps you to observe and describe your experiences without judging or rejecting them. 
• Active Problem-Solving. Consider the problem at hand: Is there a way to solve the problem directly? (source for 5-10)

*I am not saying medication may not be necessary for some