How DBT Helped in Labor (TW)

This is a bit more of a personal post and has been an ongoing struggle to write.   Up until this month I felt like as a therapist it was unprofessional to write such an intimate blog post.  A student at DBT Path is also pregnant due in a few days and I felt like it would really helpful to share my birth experience with her.  The more I thought about it, started to write then stopped the more I realized it is not unprofessional to write a personal blog post, but rather professional and sincere to share what might be a post that is helpful to others.   Here we go- My Birth Story and how DBT Skills Kept Me Sane

TW- Although I do not get into medical detail, this can be uncomfortable to read for some.

Once I found out I was pregnant I was on what I called the “hippie mom bandwagon.”  I researched doulas in my area and had narrowed down my birthing options to two; home water birth and hospital water birth.  After talking it over with some “hippie mom,” friends I decided the latter provided some reassurance just in case something happened I wouldn't need to travel in the snow last minute in to the hospital.  Little by little my plan came together through talking to close friends, discussing it with my Midwife, endless blog posts, scientific articles and of course good ole’ Google.  I was to have a water birth as well as a four page birth plan I printed off a site that sold organic baby products.  I spent hours preparing for this event; creating a You Tube playlist of both calming mindfulness and upbeat songs for the big push.  I included You Tube videos of DBT skills I planned on using as I packed my hospital bag of herbal medication, lavender and healthy snacks in a cooler. I was prepared at 34 weeks with 6 weeks to spare. I spent the last few weeks on a yoga ball, practicing breathing, taking evening primrose, drinking Red Leaf Raspberry tea (with local honey of course!) and watching more You Tube videos of natural birth than I thought possible.

At my 38 week appointment I had been suffering from an ongoing headache and my blood pressure was elevated, they re-tested and it remained high.  I had some blood drawn to test for preeclampsia and told to call back at 3 for results.  It was unlikely, but I might be induced soon.  I went home and called back.  That was New Year’s Eve and was told to relax, lie on my side, deep breathe and take some Tylenol.  The headache would not go away and I continued to check my blood pressure at home and it remained very high.   I called back the next day and told Labor & Delivery at my hospital that my blood pressure had hit 174/129 and was told to come in for an induction.  I was immediately admitted and told I was suddenly “very high risk,” and might have a seizure at any moment. 

My dreams of a water birth surrounded by the scent of lavender and mindfulness exercises was thwarted when I was put in some heavy duty blood pressure medication and told I was not able to leave the bed, eat or drink until I gave birth and 24 hours after that to continue to prevent seizures.  I took their medical advice (I did try talking them out of how serious it was to not avail) and began a hefty regime of medication.  The cure for preeclampsia is delivery and the OBGYN (buh-bye Midwife) was trying to get my son out ASAP.  The next few hours were a blur or ongoing medical check-ins, a one-on-one nurse, hunger and medication that made me sick to my stomach.  I was admitted at around noon and that night was being told I was not allowed the “hippie haven,” I created.   I panicked and kept thinking suddenly things would be different and I would wake up in the birthing pool to deep breaths and the smell of fresh baby.  

At 10pm that night I had a breakdown- I felt hopeless and skill less.  I had not planned for this and had no clue what to do. I felt like I was losing my sense of control by going along with the process of medical intervention.  My husband slept in the couch next to me in the dark, fresh off of his dinner of a soda and a Snickers bar while I sat and waited and mourned.  I cried, a lot and asked him to hand me the iPad.  I had not updated anyone on what was happening and was unable to see straight because of the meds.  The first thing I did was play my business partner, Debbie Corso’s Conveyor Belt exercise video knowing I needed to begin separating the racetrack of thoughts coming my way.  I shut my eyes and listened, creating buckets including “medical concerns,” “worst case scenarios” and the biggest bucket of them all “the unknown.” I listed to that video twice.   From that I was able to notice that my major fear was the unknown ahead of me and was able to use the Function of The Emotion and identify it as survival and work on Fact Finding- noting I was safe and being well cared for. 

I then decided I needed to Radically Accept the situation- it was beyond my control and the more I tried to fight it or continued to hope that I would wake up in a lavender tub it was not happening.  I cried some more, mourning this lose.  The OBGYN came in to check on me and asked what I wanted to keep in my birth plan- I was shocked.  My black or white thinking lead me to believe I had to give it all up.  I noticed using Wise Mind that I was thinking and acting very emotionally and not being skillful.  I re-drafted my 3 page plan into three important bullet points including having immediate skin to skin contact with my son.  This made me feel more in control of the situation even if I had not moved from the bed in 12 hours.   

I also noticed I was being less than kind to the nursing and other medical staff, partly due to side effects from the medication and a larger part was me being willful and grumpy.  The nurses had done nothing wrong and since I had one-to-one care they were actually being very kind and gentle.  When the nurse returned that morning I used GIVE to ask if I could have some ice since I was so parched and not allowed even water.  She checked with the doctor and I received two cups of joy.   With staff I also utilized Opposite Action and remembered to be kind to others even if I was not feeling well.  I knew I had a long day ahead of me since I was assured I would probably deliver my son next day and knowing I was unable to focus for very long on the iPad screen I googled mindfulness music and listened with my eyes closed until I fell asleep.   I utilized PLEASE skills as best I could and was able to get a few hours of sleep.  I also utilized Building Positive Experiences by trying my hardest to notice the positives; I was healthy and being well cared for, the staff was friendly and knowledgeable and most of all I was going to meet my son soon.    

For the next few hours I focused on Mindfulness and Distress Tolerance skills.  I self-soothed by holding the lavender in my hands and breathing it in as well as listening to some of my favorite songs.  I used the ice in the cup to remain focused, I utilized Mindfulness What skills to observe, describe and participate by releasing the pain with my breathes.  I utilized IMPROVE and took a vacation thinking of the summer’s I spent with my family as a child while it was snowing 6” outside, as well as encouragement by telling myself I can do this.  I utilized DEAR MAN with my husband by telling him to encourage me and even though he is squeamish he was able to help me cheerlead and validate my feelings.  I utilized Half Smile with staff in order to be in a place where I could get my needs meet and be kind to others.   Using Ride the Wave allowed me to handle the physical pain a bit better as well as some of the sudden changed in my treatment that had to be made for the safety of myself and my son.  Lastly I focused on an object in the final moments of labor, which the nurse initiated by telling me to look at her while I pushed.

At 10:17am my son, Javier was born to a set of parents who were able to make the best out of a less than pleasant experience.

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!

My Job: Dual Diagnosis Counselor at a Womens' Prison

Today's post is a little off topic, but today was the inmates graduation and being the emcee I posted about my nerves on Facebook and told my friends with an interesting response.  I have been working there for 8 months and it always seems to be an interesting topic to talk about with friends, family even strangers.  The reactions are mixed, but people have the same few questions so here goes.  If I seem vague it's because well it's a prison and although some information is open, certain some things are not.

• My job is Dual Diagnosis therapist, although not all my clients are what the program considers DD.  To them DD is MH medication+therapist+diagnosis of MH & Addiction.  The medication they can receive is not the same medication they often have Rx with their regular MH doctor.
• The programs main focus is substance abuse and they attend 16+ hours of group a week including cognitive skills, seeking safety, and process.  They learn a lot of skills for their recovery and must attend 2-12 step meetings a week.  
• We have a wait list of over one year most times, some of them are parole-board recommended- which translates that they need to complete the program.  
• The program is 6 months long.  There are reviews of their progress every 30 days- it's very time consuming.
• My caseload is about 20 people, although not all people graduate due to various reasons most are due to lying, manipulating and confidentiality.
• The "program" is all housed together- the rooms hold from 2-6 people, most are "2-man cells."
• We utilize a peer-support program which includes 10 "lifers," all which are murderers some of which have been incarcerated for 25 years.
• We are contracted by the state.
• A vast majority of these women have been the victim of horrific abuse as a child (often sexual,) abusive relationships, raped, started using substances around age 13 and have or in the process of losing their kids permanently.  Most would meet the criteria for PTSD.

Now to the questions people have most often:

• I always feel safe- the rare time I don't is when I am with general population and someone s cursing or yelling at someone else.  There are physical fights- but rarely .  There has been 1 in the 8 months I have been there, and I don't think there was more than one prior.
• The "lifers" and inmates in general are not scary or mean.  Part of it is because they in some way need the program to parole or stay out of another more-strict.more dangerous unit (or they have an extra 2 years+ typically.)
• Some do recovery- this is probably the #1 question.  Some come back.  We don't know statistics on how many, but I would assume half of them relapse on substances with in first 2-3 years.  If they relapse they often go to a different program, rather than repeating this one although we have had a few come back 5 years later.
• Half of my co-workers are in recovery, my boss has 33 years and my co-worker has 13 years clean! We had a counselor pass this year and she has 13 as well, she died due to complications from her Hep C she contracted at age 17 using heroin.
• It's very, very stressful- these women have been through so much and get "caught up" in what we call "prison bullshit," relationships, manipulation and lying to staff.  A lot of my time is spend in crisis mode, especially in the beginning of the 6 months.  
• I cry, I try not to and most of the time I am fine.  They write an autobiography about halfway through and share it with the group- it's all triggering.  Some stories don't affect me so much and then there are a few that keep me up at night, make me cry or change the way I look at the inmate.  These women have such strength and perseverance and their stories are so tragic.  
• We can't hug!  Nope, no touching on shoulder, no embracing at all.  This is a strict rule and could lead to termination.  It is difficult and un-natural at times, especially when someone comes to be on-on-one and tells me their child died in the streets selling dope or there mom has terminal cancer.  Life goes on while they are in jail and they often feel and are powerless.I am called by my last name only
• Yes, they eat crap.  Carb and calorie heavy food is the norm around here. They are allowed to work out at times and watch videos during the day.  There really isn't healthy options and most gain weight while incarcerated. Food is a commodity and is traded like cash.
• There are drugs in the prison.  Seems strange, but like all institutions there are drugs.  Most often it's Rx drugs that another inmate "cheeks" and sells, but there is also narcotics.
• 3" toothbrushes, and other strange things (to me) are used as if it's normal.  They are allowed to purchase (or someone purchases it for them) certain products these mostly include non-name brand lotions and such.  They are not allowed make-up (they use paint,) nail polish, headbands, etc.  Many still have them though.  A "full size" toothbrush that is easily 15 years old can go for $25.

That's all I can think of off-hand, I am open to answering any questions as I often think people think I work in one of those "reality" TV shows that fill prime-time TV now.  Here's a secret- the inmates in one of those shows is told to yell obscenities and appear aggressive for the cameras...I know I have 3 people in my group that were on it!

**Trigger Warning: There is a movie Sin By Silence (trailer here) which is a documentary about abused women who kill their husbands.  It's very sad, and triggering but very empowering as they work to change California laws and get out**

Dealing with trauma issues with BPD

Although the DSM IV-r criteria for Borderline Personality Disorder does not include trauma, it is often a common thread in those with the disorder.  Often on Twitter I see a tweet started with "TW" (trigger warning) before something that may be triggering, it's a safety boundary for many in the BPD community.  In DBT we strictly enforce the rules about saying things that can be triggers, sometimes those who don't have BPD don't realize how harmful what they say can be, sometimes people try to stir up some drama and some are so disconnected from their trauma they don't understand how someone could be hurt by what they are saying.

Adults with borderline personality disorder (BPD) showed excessive emotional reactions when looking at words with unpleasant meanings compared to healthy people during an emotionally stimulating task, according to NIMH-funded researchers. They also found that people with more severe BPD showed a greater difference in emotional responding compared to people with less severe BPD. The study was published in the August 1, 2007, issue ofBiological Psychiatry. [source]

This week myself and a client came to the conclusion that talking about her trauma only continues to hurt her more than help her.  Creating a boundary became necessary since other clients continue to push her to speak about the horrific trauma thinking that like them she needs to "get it out and give it away." In group she announced this decision and the overall look was puzzled, so we decided to allow questions as this appeared to go against everything they have been taught since being in therapy.  The questions were in 3 categories; 1) doesn't keeping it in, keep us sick? 2) How does talking about it make it worse? 3) So what are you going to talk about then?  The group decided to respect her boundary, although they were skeptical.  I decided to not go into the details of Borderline Personality Disorder since the client had told me she was not comfortable with that.

The end question was then "Ms. Paz, how is she going to work on her trauma issues without talking about it?"  I spoke about working on how the trauma affects you now; relationship issues, boundaries, PTSD symptoms and focusing on coping skills and grounding techniques instead of living in the past.  The group was still unsure about this plan as it goes against what they have (thought) they have known for most their life.  HEre are some ways to work on your trauma without talking about the trauma [source]

1. Tell yourself that you are having a flashback  

2. Remind yourself that the worst is over.  The feelings and sensations you are experiencing are memories of the past.  The actual event has already occurred and you survived. Now it is the time to let out the terror, rage, hurt, and/or panic.  Now is the time to honor your experience.  

3. Get grounded.  This means stamping your feet on the ground to remind yourself that you have feet and can get away now if you need to.  (There may have been times before when you could not get away, now you can.)  Being aware of all five senses can also help you ground yourself.  

4. Breathe.  When we get scared we stop normal breathing.  As a result our body begins to panic from the lack of oxygen.  Lack of oxygen in itself causes a great deal of panic feelings; pounding in the head, tightness, sweating, feeling faint, shakiness, and dizziness.  When we breathe deeply enough, a lot of the panic feeling can decrease.  Breathing deeply means putting your hand on your diaphragm, pushing against your hand, and then exhaling so the diaphragm goes in.  

5. Reorient to the present.  Begin to use your five senses in the present.  Look around and see the colors in the room, the shapes of things, the people near, etc.  Listen to the sounds in the room:  your breathing, traffic, birds, people, cars, etc.  Feel your body and what is touching it: your clothes, your own arms and hands, the chair, or the floor supporting you.  

6. Get in touch with your need for boundaries.  Sometimes when we are having a flashback we lose the sense of where we leave off and the world begins; as if we do not have skin.  Wrap yourself in a blanket, hold a pillow or stuffed animal, go to bed, sit in a closet, any way that you can feel yourself truly protected from the outside.  

7. Get support.  Depending on your situation you may need to be alone or may want someone near you.  In either case it is important that your close ones know about flashbacks so they can help with the process, whether that means letting you be by yourself or being there.  

8. Take the time to recover.  Sometimes flashbacks are very powerful. Give yourself time to make the transition form this powerful experience. Don't expect yourself to jump into adult activities right away.  Take a nap, a warm bath, or some quiet time.  Be kind and gentle with yourself.  Do not beat yourself up for having a flashback.  

9. Honor your experience.  Appreciate yourself for having survived that horrible time.  Respect your body's need to experience a full range of feelings.  

10. Be patient.  It takes time to heal the past.  It takes time to learn appropriate ways of taking care of yourself, of being an adult who has feelings, and developing effective ways of coping in the here and now.

 Stay safe.
AP

Boundary Garden

Those with Borderline Personality Disorder struggle with healthy boundary setting.  From my perspective this is part of their black/white, all/nothing thinking.  Sometimes it's obvious when someone has poor boundaries. The story I always tell to describe what poor, or low boundaries look like is this personal one from when I was 15 years old.  I had just walked off the city bus to walk to go home, as did another classmate I had not seen before.  It was the first week in school, so I guessed she might be new.  I began talking to her, figuring if nothing else it would give me someone to walk home from school with.  Our walk and only conversation lasted 8 minutes and in it she told me her mother had killed herself, she was now living with her father, he didn't know how to cook, was "icked" out buying her tampons, she had an array of mental health issues, told me what medications she was on and showed me scars from when she tried killing herself a few months back.  My radar went into the red danger zone and I immediately knew this was not someone I would want to be friends with, even if it was 16 minutes a day round trip.

Those with all/nothing thinking struggle with making, having and often keeping friends for this primary reason; "they are either my all-time best friend or my worst enemy."  This was a quote from a client, whom I didn't at the time know much about BPD to diagnosis.  I have my clients create boundary gardens to illustrate this point and have a visual for where their friends lay.  Below is the outline of the garden I have them fill in.

Here is an example of one filled in for someone who has low boundaries,

After I have the clients fill in the garden I ask a few questions; which section has the most people in it? Why are people in old brush and not out of the garden? Is there anyone who has been moved towards the old brush or into roses since starting therapy/group/recovery?  It's a great starting point for creating and enforcing boundaries.  I also have the clients put lines where they would like to move people, for example, "my step mom and I have had a better relationship the last few years since she stopped drinking, so maybe it's time to have her as a violet," or "My brother is a close friend now, but I think he has been stealing money from my purse, so maybe we need more distance and he needs to be moved to Geraniums."

It doesn't solve their boundary issues, but it gives them a starting point and a nice visual to begin working on.

Why I Became a Therapist?

This week a client in my group asked me how old I was.  I didn't even think before responding "29."  All the Graduate School training about boundaries and "turning the question" to "Why is that important to you?" went out the window quickly.  Later in the day when another person (not in my group) said "you are only 29!" I realized maybe I shouldn't be answering questions about my private life.  Then I meet with my one Borderline Personality Disorder client and hand her the DBT manual and give her the overview of DBT and say to her "DBT is collaborative between myself and you, so come directly to me with any questions you have."  I set up a weekly time to see me and walk back to my office thinking..."collaborative."  DBT is very collaborative and much time is spent on the relationship of both the client and the facilitator (individually and as a team.)  I remember using some personal examples in a DBT group a few years ago and made huge strides with my own "issues" facilitating DBT.

I tell you all this to share with you the question I get asked most often by clients, "What made you decide to become a Counselor?"

It was my last year in Undergrad and I was about to graduate with a degree in Legal Studies, had taken the LSAT's and was about to apply to Law Schools

Just like DBT, there is no black and white and no one answer for this question, but here's how the formula worked for me:

20% My own personal issues, without getting into too many details I had experienced my own trauma in my life as an adolescent and had been through therapy at age 10 for this as well as a few bouts of depression and anxiety in my young adulthood.

20% This was a few years after 9/11 and was still deeply affected by it (still am, if I am being honest with myself.)  I was a participant in a PTSD study from a major university where I took PTSD tests at intervals for a few years and although I never got results, with 1 psych class under my belt knew I probably meet the criteria.

60% My room mate at the time, was my best friend for 10 years when we moved in together at age 22.  I had known her family had a huge mental health history, including a grandfather whom killed himself as well as  a mother whom was unable to work and debilitated by even the smallest tasks.  After a few years (and a lot of therapy) we decided it would be a great idea for us to live together in Manhattan.  Things went well for almost 6 months and then she essentially "cracked,"  without getting into details she became psychotic  thought I was trying to kill her, would accuse me of things I didn't do, and attempted to take her life with pills.  (Remarkably she is fine now, turned out to be a rare blood disorder and she takes medication for it and has not had any issues since.)

I took a Psychology class my 2nd to last semester to fulfill a requirement and the more I thought about applying to Law School, the bigger the stack of unfinished applications sat.  I clearly had a lot of resistance to the path I had created for myself in Junior High School when I first thought about Law School.  The Psychology class had me hooked from day one; the professor was a PhD student studying Criminal Psychology and worked at Riker's Island, one of the largest men's prisons in the U.S.  I immediately choose my plan of attack; I cornered her after class and asked her questions about what she did.  Her job at the prison was to assess male inmates to determine if they could stand trial.  After 1 hour, in which I completely took over the conversation and violated her boundaries I decided that is what I wanted to do.  A few hours later I was at home googling what education I needed.  Within a month I told the boyfriend I was moving to Portland, Oregon (he did come with me-although it didn't work out,) enrolled in 3 extra psychology classes and had 3 very part-time volunteer jobs in order to meet the application requirements.

I currently work at the states only women's prison, as the Dual Diagnosis counselor in a unique intense 6-month program focused on addiction and criminality.  It is amazing to think to yourself "How did I get here?" and I am glad I took a leap of faith 8 years ago.

Here is a picture of me packing/driving/moving across country (again) to Michigan, where I am now.