When not to use DBT skills: Conference highlights on treating anxiety disorders (with Melanie Harned, Ph.D. and Katheryn Korslund, Ph.D.).

This last week I was able to attend a wonderful conference on exposure-based treatments. Exposure therapy is basically this: If you are confronted with objects, sensations, or memories that you are afraid of over and over again eventually your fear of them goes down. Exposure is used to treat anxiety disorders such as panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. According to the conference presenters, 60-85% of anxiety-disordered clients who receive exposure therapy show clinically significant improvement.

One example of exposure treatment is for people who have panic attacks. Panic attacks generally include a range of symptoms such as a racing heart, shortness of breath, fear about going crazy or dying, numbness and tingling, feeling flushed, and intense physical sensations. In essence, when people have panic attacks they are often afraid of having more panic attacks. For instance, when a person runs a short distance, they may get out of breath (naturally!). Not so naturally, however, they may become flooded with anxiety that this is yet another panic attack coming on. Therefore they go out of their way to avoid anything that includes a racing heart, shortness of breath, or physical sensations associated with exercise. Perhaps this includes feeling their heart beat or feeling their breath. Therefore they may avoid any activity (or any emotion!) that involves physical sensations.

Exposure treatment for panic disorder involves facing and experiencing physical sensations. This is known as interoceptive exposure. For instance, clients are asked to participate in activities that create the feeling of not getting enough air in the lungs. Classic examples may include running up a staircase, breathing through one nostril through a straw, spinning around in a chair, or hyperventilating on purpose. (Hey, when I was in graduate school, we had to do all the above with our classmates!).

The important thing that makes exposure treatment work is that the person has to be alive, awake, attentive- and not under the influence of drugs, medications, or alcohol- to make it work. NO CHEATING!!! This is actually a time NOT to use DBT distracting skills. The point is that a person’s brain has to experience the situation differently when the person is exposed to the feared stimulus. Anxiety will go up- initially- and then it will go down. Otherwise the brain never learns! The new learning is experienced, and this makes all the difference in the world. No amount of rational cognitive problem solving is going to convince your brain otherwise.

This conference gave me new food for thought, allowed me to visit old material that I haven’t seen in a while, and was an excellent and thorough overview of exposure treatment for trauma (including when not to use it!). I will keep chewing on this food for thought- and definitely keep you posted.

Are clients with Borderline Personality Disorder too needy? Follow up thoughts from attending the NEA BPD conference.

This past week I attended a conference hosted by the National Education Alliance for Borderline Personality Disorder. Dr. Alan Fruzetti presented on Dialectical Behavior Therapy and Dr. Anothony Bateman presented on Mentalization Based Treatment (an alternative treatment for BPD). Then they both did a “role play” of a session (with the same client and same presenting concerns)- each demonstrating the theory and application of the treatment they represented. It was a wonderful opportunity to see two very skilled clinicians at work.

During the role play, the acting client identified a great deal of difficulty when her boyfriend suggested that he did not want to “cuddle” with her- as he wanted to “take things slowly.” She expressed a great deal of distress about this situation- including thoughts of suicide.

At the end of the role play, Dr. Fruzetti asked the audience if they believed that the client was “too needy.” Several people raised their hands. He then suggested that he did not believe the client to be “too needy.”

I really appreciated that he did this- mainly because of the stigma in the field around borderline personality disorder and neediness. Having, wanting, needing, or desiring things in the first place has somehow been interpreted as pathological and problematic- and gets punished. (“It should not be as it is. You should not be as upset as you are.”) It also seems to defy self-acceptance. Clients often have some deal of difficulty sorting out confusion regarding self-experience (ie, not feeling real, confusions about experience and feelings, acting or behaving in ways that are inconsistent with intentions). It seems that pathologizing the wanting only makes things more confusing- and creates more problems- and I regret that it is so common in the mental health field to do so.

Being clear about what is wanted is a sign of improvement. Knowing adaptive and effective ways of getting it involves skill. Attacking oneself for wanting or desiring something in the first place is not an effective way of solving a problem. In addition, attacking oneself for wanting or needing things in the first place reinforces this idea that reality should not be as it is. Accepting how things are also involves acceptance of oneself- even though wanting something very badly can be painful.

DBT: How emotion impacts thinking, self, and relationships

One of the theories behind DBT is that emotions interfere with other aspects of functioning. If emotional arousal is high it has the capacity to interfere with thinking, experience of self, actions, and relationships. This may be especially true for people that are sensitive to emotions, experience emotions as strong and intense, and have difficulty getting emotional arousal down.

For instance, if you are feeling extremely threatened you may have a tendency to argue, attack, avoid or withdraw, attempt to problem-solve or fix by ruminating on past or recent interactions. You may become preoccupied with the event(s) in which you became threatened in the first place. When your thoughts become preoccupied with the threatening situation, it is hard to be “in-the-moment” in other areas of your life. (For instance, it is really hard to “be” with friends when your attention is clearly somewhere else).

Because people sometimes behave in out-of-control ways when they are under emotional threat, a person may experience him or herself as out-of-control of undesirable actions. Actions (ie, self harm, breaking things, picking a fight, getting drunk, attacking, saying mean things, avoiding people) may temporarily reduce or control strong emotions, but most of the time lead to unwanted long-term consequences.

People who have difficulty with strong emotions often believe that emotions “come out of nowhere.” When emotions “come out of nowhere”, it is difficult to predict when they will show up. If a person can’t predict when emotions show up, and if strong emotions lead to out-of-control type actions (or interactions!)- a person will not experience a high degree of self-control. This may lead to confusion about experience, difficulty organizing or “knowing” oneself, or problems following through on tasks or activities. Intentions may not get carried out because 1) emotional arousal is already high 2) when emotional arousal is high, the person has a lower tolerance or threshold for new emotional stimuli 3) the environment will continue to make demands/ expect things of a person. Thus, one’s attention and energy can be so pre-occupied that one may lose all sense of purpose and direction.

When emotions control a person’s life, it becomes clear that relationships are impacted negatively. Avoiding, arguing, withdrawing- or picking up the pieces after a big fight- can be a painful business that can threaten to destroy or strain relationships over time. Interactions that evoke strong emotions, invite people to take a strong stand on something despite disagreement in the community, or pursue goals and dreams may be easier to avoid altogether. In some cases, attacking or threatening other people may be a short-term way to avoid unwanted situations, losses, or other painful stuff.

Mindfulness is considered to be a “core skill” in DBT. As abstract as it sometimes sounds, the concept of mindfulness has to do with the ability to be centered, grounded, attentive, “real”, and connected. Mindfulness has to do keeping all the impinging emotional extremes manageable. One of the purposes of being mindful is to decrease confusion about oneself. “Knowing oneself” is a benefit of showing up, paying attention, and taking notice. It is extremely hard to do, takes a lot of hard work, and can be really frustrating to “get”. It is also really hard to think of how it applies, and can take considerable patience in terms of getting it “work.” It really does work, though!

Pros and cons of diagnosis

Pros:

  • People feel understood, “not crazy”, and a sense of being helped by a professional -that can put a label on a cluster of symptoms, experiences, or problems. Being understood reduces anxiety and helps people feel connected and hopeful.
  • In some instances, specific diagnosis can help people identify empirically supported treatments that have a good track record for symptom reduction and decreased pain. For instance, exposure and response prevention treatment works for obsessive-compulsive disorder.
  • If you meet criteria for a diagnosis, it could be argued that your treatment is medically necessary and thus qualifies you for insurance reimbursement.
  • Psychological assessment and testing can help determine adequate treatment for erratic behavior. Assessment may differentiate psychosis, dissociation, brain damage, dementia, impairment from psychoactive substances, and/or cognitive limitations. Getting clarity on a diagnosis may be helpful in making referrals to appropriate providers, getting educational or vocational assistance, and getting appropriate medication.

Cons:

  • There are stigmas attached to having a “psychiatric disorder” when pain and suffering is ordinary and understandable. To the uneducated public, “having” a mental illness, having mental problems, or being known for psychiatric problems can be stigmatized and confused with psychosis and violent behavior. Labels and stigmas can also be a detriment down the road when applying for licenses and certain jobs that require intensive screening.
  • In one of my first classes in graduate school I was taught that diagnosis is not valid (ie, it doesn’t accurately “capture the essence” of that which is trying to be captured) nor is it reliable. In other words, different interviews with different clinicians would not yield the same results. Trends in diagnosis vary in terms of popularity, educational influences, and controversy and biases within the field. Structured interviews such as the SCID (structured clinical interview for DSM disorders) or psychological assessments (such as personality testing or the Beck Depression Inventory) can increase accuracy for diagnostic criteria, but can be time consuming and in some cases quite costly.
  • Labels don’t explain causes. I can’t recall the number of times I hear people (colleagues included) explaining behavior through descriptions of behavior. In the great rhetorical scheme of things, being depressed because you act depressed and acting depressed because you are depressed doesn’t really account for depression- nor does it get you to stop being depressed.
  • Putting a label on something doesn’t necessarily mean that you will be helped, or that any given psychotherapist will know how to treat “what you have.” Psychotherapists should ethically refer when they are not familiar with “what you have”, but bear in mind that clinicians all have their own approaches, own theories, and own biases about “what you have.” (Thankfully, some of them also have niche areas.) Bear in mind that there are a wide variety of factors that go into getting treatment for “what you have” including factors related to research and economy.

If you are curious about diagnostic criteria, you are welcome to visit  http://www.behavenet.com/capsules/disorders/dsm4TRclassification.htm.

Dialectical Behavior Therapy and the real deal: Multiple layers, multiple players

Dialectical Behavior Therapy is a very complex treatment- I think more so than the public realizes. Organizations that are adherently providing Dialectical Behavior Therapy services generally need to include individual psychotherapy, DBT skills groups, psychopharmacology consultation if needed, DBT consultation team meetings for the providers of DBT, and 24-hour on call pager availability. They should subscribe to assumptions about clients and therapists, be knowledgeable about research findings and publications, have a regular mindfulness practice, adhere to the 24-hour rule, and have a structured format for sessions which include diary cards, behavior chain analysis, and priority targets for treatment.  “Adherent” DBT treatment requires a pretty good grasp of not only the skills, but ways to teach and generalize skills to contexts outside of treatment based on functional analyses of behavior. DBT was originally designed to treat repeat suicide attempters. It has since been utilized to treat eating disorders, substance use, incarcerated populations, couples, families, older adults, adolescents, developmentally disabled clients, “difficult-to-treat” clients, and clients who don’t tend to benefit from “treatment as usual.” Because it has become so popular, clinicians have utilized DBT training to work with clients who are not so “severe”.  However, in general it is known for being a tough treatment for a tough population that involves tenacity for getting clients to change while at the same time maintaining compassionate acceptance.

DBT has been criticized because it is so complex- it is certainly difficult to implement and takes considerable effort and energy to maintain. DBT is generally practiced in settings in which there are multiple providers- popular settings include hospitals, VA programs, research clinics, day programs, community mental health centers, and prison systems. Private outpatient clinics that primarily provide adherent DBT exist, but seem to be less prevalent. DBT in many of these settings means getting treatment from trainees (they may not be licensed) – but treatment is more accessible as trainees cost less money.

Doing adherent DBT from a mental health and business perspective takes multiple players with multiple talents. If money isn’t coming from research grants or the business isn’t a non-profit, mental health clinicians have to be funded in some manner. In order for all the components of DBT to be in place, someone in the organization needs to attend to business, administration, and organizational matters. They need to make sure that the business is sustainable and profitable. Someone needs to be taking care of legal matters, such as employment law, hiring/firing of employees, considering mission statements and the direction of the organization, enhancing compliance with insurance company requirements (such as claim filing and tracking), and making sure that practice is ethical and HIPAA compliant. Like any business, someone needs to take care of marketing, referral sources, attracting clients, and providing good customer service. Due to the complexity of DBT, having a solid understanding of the treatment can take years, lots of good supervision, and a grasp of how to do not only individual psychotherapy- but group treatment and crisis coaching. It involves finding and supervising clinicians who are invested in doing the treatment, are willing to be available at all times by pager, are interested in taking on high risk clients, and who can sustain their own lifestyles in which they don’t get burned out or overwhelmed. In addition, if the clinic or program desires to have evidence of effective treatment, the clinic may have to employ someone with a research background to work on data collection and outcome measures. Like any person with strengths and weaknesses, it makes sense that having multiple players with multiple talents is needed for very complex and “adherent” DBT treatment- and that not all clinicians (or business administrators, or researchers) are created equal.

What I have to offer is unique because I have a strong background in group therapy and DBT and I love doing groups. My DBT training did not offer a strong background in groups, group therapy, group dynamics, and the general implications for structuring and maintaining groups. However, I was able to get this training in graduate school. Therefore, I have a stronger basis for offering DBT skills groups. What I love about DBT groups is that I can offer valuable content that can be flexibly adapted to the needs of my groups while giving my clients opportunities for shared experiences.