TIPS & TOPICS
Volume 3, No.2
In this issue
– SUCCESS STORIES
– Until Next Time
Can you imagine being with nearly 20,000 psychiatrists at the Annual Meeting of the American Psychiatric Association meeting? As I was getting educated this week, the people of Atlanta, Georgia haven’t seen so many shrinks in the one place for years. Here are a few SAVVY tips I gleaned from an informative session on Borderline Personality Disorder. The speakers didn’t actually word their information this way. You are getting their points filtered through my particular prism:
- Not every client who frustrates you and splits the team is a “borderline”. There are specific dimensions of personality function that define Borderline Personality Disorder (BPD), so use “borderline” carefully.
Here is one cluster of dimensions that was presented:
–> Dysphoric affect – such as depression, helplessness, loneliness, emptiness, anxiety
–> Disturbed cognition – depersonalization, derealization, hallucinations etc.
–> Impulsive behaviors – such as verbal outbursts, assault, cutting behavior, substance abuse
–> Troubled relationships – very dependent, entitled or manipulative behavior, masochistic etc.
Symptoms in each of these four domains must be present at the same time to qualify for BPD in the model used in the Revised Diagnostic Interview for Borderlines (DIB-R). Using this cluster of symptoms results in a somewhat smaller and more homogeneous group of BPD people, than if using the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV).
Dr. Larry Siever, Director of the Special Evaluation Program for Mood and Personality Disorders at Mt. Sinai School of Medicine in New York outlined the dimensions of BPD in a similar yet different way:
–> Consequences of traumatic stress – people who may have a predisposition to be more emotionally vulnerable are negatively affected by trauma in their early years
–> Affective dysregulation – difficulty controlling anger or feelings of loneliness and depression
–> Impulsivity – cutting behavior, substance abuse, abrupt termination of therapy
–> Dissociation/self injurious behavior (SIB) – lost time; suicidal behavior.
DSM-IV notes a pervasive pattern of the following areas that begins by early adulthood and is present in a variety of contexts:
–> Instability of interpersonal relationships
–> Instability of self-image
–> Instability of affects
–> Marked impulsivity
Bottom Line: Take care to not quickly label, in a dismissive manner, difficult and frustrating clients as “borderlines”.
Zanarini MC, Gunderson JG, Frankenburg FR, Chauncey DL: “The Revised Diagnostic Interview for Borderlines:Discriminating BPD from Other Axis II Disorders” J Personal Disord. 1989;3:10-18.
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) Washington, DC, American Psychiatric Association.
- Rather than feel hopeless about people with BPD, almost 90% of clients experience a remission of their BPD; and almost 80% of clients with BPD attain good psychosocial functioning.
Mary Zanarini, Ed.D., Director of the Laboratory for the Study of Adult Development at McLean Hospital in Belmont, Massachusetts, told about a study that tracked the ten-year course of 290 former inpatients. All the patients were carefully diagnosed with BPD and were interviewed every two years to assess their symptomatic and functional status. Over 93% of the surviving patients were re- interviewed at all five follow-up sessions. Rather than feel hopeless about people with BPD, almost 90% of clients experience a remission of their BPD; and almost 80% of clients with BPD attain good psychosocial functioning.
In the study, a “remission” was defined as no longer meeting criteria for BPD for two years. A “recurrence” was defined as meeting criteria for BPD for two years, after meeting the criteria for remission in a previous follow-up period.
Dr. Zanarini highlighted two hopeful findings that expanded on the work of her original study:Rather than feel hopeless about people with BPD, almost 90% of clients experience a remission of their BPD; and almost 80% of clients with BPD attain good psychosocial functioning.
–>Remissions were common and they increased over the course of the ten years – 88% experienced at least one two year period when they met no criteria for BPD. But a tenacious 12% did not experience even one remission.
–>Recurrences of BPD were relatively rare among the patients who experienced a remission of BPD – only 17.6% had a recurrence; almost 80% of patients with BPD attained good psychosocial functioning over the course of the ten years.
“Psychosocial functioning” was specific and defined as at least one emotionally sustaining relationship with a friend or romantic partner and both a good vocational performance and a sustained vocational history.
Bottom Line: The prognosis for most, but not all, patients with BPD is better than previously recognized.
Zanarini MC, Frankenburg FR, Hennen J, Silk KR: “The Longitudinal Course of Borderline Psychopathology; 6- Year Propsepctive Follow-Up of the Phenomenology of Borderline Personality Disorder” Am J Psychiatry. 2003; 160:274-283.
- There are levels of BPD that translate into stages of treatment.
Marsha Linehan, Ph.D. of Dialectical Behavior Therapy (DBT) fame presented a whirlwind overview of her over thirty years of work that grew out of developing services for highly suicidal clients with BPD. She outlined four levels of BPD and the corresponding stage of treatment goal for each level:
–>Level 1: severe behavioral dyscontrol – Stage 1 treatment goal: behavior control
–>Level 2: “quiet desperation” – Stage 2 treatment goal: nontraumatic emotional experiencing
–>Level 3: problems in living – Stage 3 treatment goal: ordinary happiness and unhappiness
–>Level 4: incompleteness – Stage 4 goal: freedom and capacity for joy
For many who work with people with BPD issues, Stage 1 treatment is what often consumes a lot of clinical effort and energy. In order to move from severe behavior dyscontrol to behavioral control, there are behaviors to decrease and skills to increase.
–> Life threatening behaviors
–> Therapy-interfering behaviors
–> Quality-of-life interfering behaviors
–> Interpersonal effectiveness
–> Emotion regulation
–> Distress tolerance
Bottom Line: Treatment for people with BPD can become overwhelming as both client and clinician “buttons” can so easily be pushed. Having some structure of levels of BPD and the related stages of treatment provide a sense of direction and hope.
Linehan MM: “Cognitive-Behavioral Treatment of Borderline Personality Disorder” New York, Guilford Press, 1993.
Linehan MM: “Skills Training Manual for Treating Borderline Personality Disorder” New York, Guilford Press, 1993.
These SKILLS tips can apply more broadly than just working with BPD:
- Use inpatient and residential treatment carefully and judiciously for people with BPD in crisis.
For some people there are benefits of a 24-hour treatment setting in the midst of a crisis. For others with BPD and other personality vulnerabilities, these same benefits can be liabilities and more detrimental to them. A safe place to sleep and eat, away from the stress of the outside world, can re-create a psychological “womb”. Such 24-hour care can precipitate regression as old and early needs for nurturance are aroused.
Equally as strong as needs for nurturance are fears of abandonment. There is mistrust and anticipated rejection. 24-hour settings trigger a lot of inner turmoil. This kind of client has strong urges to control the expected rejection and abandonment. It is as if the client is saying to herself: “This safe and secure setting is so fulfilling and I have wanted this nurturance all my life. But if I can’t count on this continuing and I will be emotionally abandoned anyway, I at least want to be in control of the rejection.”
The sudden fluctuations in mood, interactions and the alliance with such BPD clients partly arise from these conflicted dynamics. These are the clinical implications:
–> Keep the inpatient or residential stay as brief as possible to limit the degree of regression.
–> Focus the inpatient stay on preparing the client for return as soon as possible to the real world. Use the safe milieu to practice cognitive and behavioral strategies which increase the confidence of the client and family that he or she is safe enough to continue recovery in the community. For example, ask: “What can you think about and do differently next time there is a crisis and you have an impulse to cut yourself?”
You might say:
“This brief stay in the inpatient unit or residential program is to practice some ways to cope with this and any other crisis without hurting yourself or others. We won’t be working on all the things that are important to talk about when you continue care in an outpatient setting. This will not be a stay to get a total emotional makeover, nor to understand and solve all the issues and concerns of your life to be happy. But we will hang in with you to think about, and do whatever it takes to help you cope in the community as soon as possible. That is where the real ongoing work will be done, not here. So let’s think about what you could do differently to cope with another crisis like this one.“
- Be careful about reinforcing suicidal behavior.
Imagine if every time a person becomes suicidal the response is to move from a stressful environment to a safe, caring treatment environment. The client quickly learns to see themselves as unable to cope in the community, and that all that will work is to have others take over control of them and their environment. So the next time a similar crisis arises, guess where the person thinks of first to go as a way to cope and get relief?
Most clients know this: that if they’ve run out of money and want to get off the streets, or get relief from the stresses at home or the street, the surest way to get to a 24 hour setting is to present depressed and suicidal. (That is not to say that everyone who presents suicidal is not really suicidal, or that we should never hospitalize people who are suicidal.) But when hospitalization and intense treatment is always the first option, it reinforces this as the main coping and relief mechanism.
Marsha Linehan suggested that with a Dialectical Behavior Therapy approach, the message is that hospitalization and intense treatment is the last option if at all, but certainly not the first option. Compared with treatment-as-usual, DBT reduces the prevalence and medical severity of parasuicide episodes, therapy dropout, and inpatient psychiatric days.
You might say:
“I really understand that life feels hopeless and depressing right now and that it seems that death is the best and only option. But I am glad you are here talking to me, because that tells me a part of you actually has hope that it might not actually be the only option for you. So let’s work on how to explore all the options, not just the death one, and I will hang in with you in that process. There is no magic in an inpatient stay. It will not solve all the problems right now; and it may even delay solutions and make things worse. So let’s think together on what we can do to focus on active functioning in the community and to get on with the part of you that found life worth living and brought you to reach out for help. You wouldn’t have called me if you wanted to die, as you know I don’t help people die. But you do know I want to be there for you to help you live. Thank-you for reaching out and asking me to help you live. Now let’s get on with focusing on that.“
Linehan MM, Tutek DA, Heard HL, Armstrong HE: “Interpersonal Outcome of Cognitive Behavioral Treatment for Chronically Suicidal Borderline Patients” Am J Psychiatry. 1994; 151:1771-1776.
I am a frustrated radio or TV talk show host, news anchor, and radio advertising voice. Where did that little self-revelation come from you may ask? My hotel in Atlanta was just a few blocks from the world headquarters of Cable Network News (CNN), which is viewed by millions all over the world every day. So I couldn’t resist the tour of CNN that has four growing divisions – CNN Headline News; CNN USA; CNN International; and CNN for Spanish countries.
Part of the tour took us to a mock CNN news studio complete with news desk, weather map, camera and teleprompter just like the real thing. The tour guide asked for a volunteer to sit at the news desk and read the news looking into the teleprompter and camera for the audience to see on the TV monitor. You guessed it!
For one brief moment I got to scratch the itch of a frustrated news anchor and read a news item. It was fun and I did well according to the applause of everyone and the personal comments of several people on the tour.
A few years ago, I hosted two, half-hour shows on our local cable TV network and had a great time interviewing couples about “What Works in Relationships?” Jay Leno and David Letterman’s jobs are safe, but a few viewers in Davis, California had a good time watching. Then there was the demo tape I made in a recording studio as part of class in radio advertising and voice-over work (as they say in the business). After learning about radio advertising, you never listen to the radio in quite the same way after that class.
So what’s the point?
I enjoy my work and it is rewarding to gain competence and effectiveness in my career. It is gratifying to help others grow in that same way. But every now and then, it’s rejuvenating to stretch and fantasize a little about what also might be— what could be—if I were to actually break out of the mold I have cast for myself in my work life. Why not believe in yourself, explore more, forge some new neural pathways in your brain? How about pursuing in a more focused way, some of those hobbies you’ve pondered, but never found time for? Or what about those entrepreneurial ideas that could mean a small business on the side? Or why not try out in a talent show, or actually go up on the Karaoke stage one night?
Don’t give up your day job just yet. But there may be many more itches to scratch than what is the box you have put yourself in so far.
“This is David Mee- Lee for CNN. Goodnight.”
If you want to tune into a large group of people interested in issues related to dual diagnosis, consider joining the Co-Occurring Dialogues Discussion List – send an e-mail to email@example.com.
Recently on the listserv there has been brisk discussion about person-first language. It encourages viewing clients and patients as being much more than the embodiment of their diagnosis (alcoholic, addict, schizophrenic, sociopath etc.) Instead, person-centered language sees a father, mother, brother, sister, son or daughter who happens to have to deal with a schizophrenic disorder, or a substance use disorder, or an alcohol problem, or a depression illness.
One member of the listserv struck a contrary note however, and indicated that he was at least one addict who did not feel the least stigmatized by the word “addict.” In fact he was very proud of the fact that he had been able to manage his addiction for some 18 years and planned on doing so for years to come. He for one felt more irritated by the person- first language than the word “addict.”
As I was following this debate about terminology, I noticed the following heartfelt response that puts the issue in a developmental perspective. With his permission, here is what Don wrote:
“Your response moved me. I am recovered also. I use that term in the sense that it was used in the Introduction to the Big Book. Identity as a recovering alcoholic was really important at the outset. And as I moved into the field, whether someone else I was working with was recovered was really important to me. But at some point, I realized I was working with someone and didn’t know whether he was recovered or not and it didn’t seem to matter much — bottom line. He was skilled and effective and I could see that he could teach me as well as grow with me. As it turned out he was not recovered — never had the disorder I have.
At about that point, I also realized that my primary identity as an association to my disorder was not nearly as important. I seemed to be emerging into a new world where the challenges and opportunities were not defined by my disorder. My disorder was less consuming, and the challenges and opportunities were more the every day just plain human kind.
Things to think about. To my many friends that are professionally trained and experienced but without the personal experience with the disorder — realize the assumption of that initial identity as primary is really important for some people. And that primary identification may endure for their lifetime.
To my” recovered” friends, recovery for me has been a process of growth and change. And how I view and identify myself a year from now may be different from that perception right now. Hopefully it will be a more aware, “weller” person — more engaged productively in life. And hopefully less bound to the particular recovery path that worked for us — and more accepting of the different recovery paths now available.
Just a thought.
Don Phillips, Retired after 27 years in addictions treatment and the Employee Assistance field.
Until Next Time
Thanks for reading this month. I hope you found something helpful in this TIPS and TOPICS for your work and life.