i walk the line borderline personality disorder presentation by summer brunscheen, ph.d., lp, hsp,...
TRANSCRIPT
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I WALK THE LINEI WALK THE LINEBorderline Personality Borderline Personality
DisorderDisorderPresentation by Presentation by
Summer Brunscheen, Ph.D., Summer Brunscheen, Ph.D., LP, HSP, LMHCLP, HSP, LMHC
Central Iowa Psychological ServicesCentral Iowa Psychological Services319 Lincoln Way319 Lincoln WayAmes, IA 50010Ames, IA 50010515-233-1122515-233-1122
[email protected]@iowacounseling.com
I walk the line: Johnny Cash
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Personality DisordersPersonality Disorders
PD’s enduring, pattern of inner experience PD’s enduring, pattern of inner experience and behavior that deviates markedly from and behavior that deviates markedly from the expectation’s of an individual’s the expectation’s of an individual’s culture, culture,
Pervasive and inflexiblePervasive and inflexible Onset in adolescence or early adulthoodOnset in adolescence or early adulthood
PD PD patternspatterns can be dx as young as age 5! can be dx as young as age 5! (chaotic, disorganized, bizarre, annihilation (chaotic, disorganized, bizarre, annihilation anxiety)anxiety)
Stable over time, leads to distress or Stable over time, leads to distress or impairment (Axis II “is” vs. Axis I “acts”)impairment (Axis II “is” vs. Axis I “acts”)
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Personality DisordersPersonality Disorders
Cluster BCluster B Antisocial, Borderline, Histrionic, Antisocial, Borderline, Histrionic,
Narcissistic (dramatic, emotional, erratic)Narcissistic (dramatic, emotional, erratic) BPD affects:BPD affects:
2% of the general population2% of the general population 10% of an outpatient population 10% of an outpatient population 20% of an inpatient population, 20% of an inpatient population, 74% of people diagnosed with BPD are 74% of people diagnosed with BPD are
femalefemale
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Borderline Personality Borderline Personality DisorderDisorder
BPD is often comorbid with ADHD, BPD is often comorbid with ADHD, addictive DO’s, and mood disordersaddictive DO’s, and mood disorders
People with BPD are often poly-People with BPD are often poly-substance abusers/self-medicating substance abusers/self-medicating (avg 4.5 medications)(avg 4.5 medications)
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BPD per DSM-IV-TR (4 of BPD per DSM-IV-TR (4 of 9)9)
Frantic efforts to avoid real or Frantic efforts to avoid real or imagined abandonmentimagined abandonment
Unstable, intense interpersonal Unstable, intense interpersonal relationships, alternating between relationships, alternating between love and hatelove and hate
Identity disturbance, unstable sense Identity disturbance, unstable sense of selfof self
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BPD per DSM-IV-TR (4 of BPD per DSM-IV-TR (4 of 9)9)
Impulsiveness in at least 2 areas Impulsiveness in at least 2 areas that are potentially self-damagingthat are potentially self-damaging spending, spending, sex, sex, substance use, substance use, shoplifting, shoplifting, reckless driving, reckless driving, binge eating, binge eating, cuttingcutting
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BPD per DSM-IV-TR (4 of BPD per DSM-IV-TR (4 of 9)9)
Recurrent suicidal behaviorRecurrent suicidal behavior least likely to attempt when emotionally least likely to attempt when emotionally
upsetupset 8-10% suicide rate8-10% suicide rate Higher among those with SAHigher among those with SA 400 times the rate of general population400 times the rate of general population 800 times the rate found in women 15-34800 times the rate found in women 15-34 5-7 DSM characteristics = 7% suicide rate, 5-7 DSM characteristics = 7% suicide rate,
8 = 36% suicide rate so check, document, 8 = 36% suicide rate so check, document, and increase interventionsand increase interventions
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BPD per DSM-IV-TR (4 of BPD per DSM-IV-TR (4 of 9)9)
Affective instability (rarely last more than Affective instability (rarely last more than a few hours, even more rarely more than a few hours, even more rarely more than a few days)a few days)
Chronic feelings of emptinessChronic feelings of emptiness Inappropriate, intense anger or lack of Inappropriate, intense anger or lack of
control of anger, frequent displays of control of anger, frequent displays of temper, constant anger, recurrent temper, constant anger, recurrent physical fightsphysical fights
Transient stress-related paranoid Transient stress-related paranoid ideation, severe dissociative symptomsideation, severe dissociative symptoms
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Additional Additional CharacteristicsCharacteristics
Disturbance in Self conceptDisturbance in Self concept Low Social Functioning/Unstable Low Social Functioning/Unstable
interpersonal relationshipsinterpersonal relationships Negative affect/Labile affectNegative affect/Labile affect Dichotomous thinkingDichotomous thinking
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Additional Additional CharacteristicsCharacteristics
Cognitive DisturbancesCognitive Disturbances Unrelenting crisesUnrelenting crises Active passivityActive passivity Expressively SpasmodicExpressively Spasmodic
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Additional Additional CharacteristicsCharacteristics
SplittingSplitting Self-Perpetuating Intrapsychic and Self-Perpetuating Intrapsychic and
Interpersonal ProcessesInterpersonal Processes Counter Separation ManeuversCounter Separation Maneuvers Impulsive behaviorsImpulsive behaviors
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Additional Additional CharacteristicsCharacteristics
Sleep DisordersSleep Disorders Intimacy TerrorIntimacy Terror Catastrophic ThinkingCatastrophic Thinking ManipulativeManipulative Functional FailuresFunctional Failures
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Differential DiagnosisDifferential Diagnosis
GET A REALLY COMPLETE GET A REALLY COMPLETE ASSESSMENT (including past treatment ASSESSMENT (including past treatment history)history)
Mood DisordersMood Disorders BPD: Bipolar = QUICK mood changes, when BPD: Bipolar = QUICK mood changes, when
depressed is still impulsive, bipolar shifts are depressed is still impulsive, bipolar shifts are neurological, BPD shifts are environmental neurological, BPD shifts are environmental (can see what is triggering the mood shifts)(can see what is triggering the mood shifts)
BPD: Depressive Suicidality = BPD BPD: Depressive Suicidality = BPD motivated by wish to gain sympathetic and motivated by wish to gain sympathetic and binding response, depressive motivated by binding response, depressive motivated by despair and hopelessnessdespair and hopelessness
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Differential DiagnosisDifferential Diagnosis
PTSDPTSD Eating DisordersEating Disorders Substance AbuseSubstance Abuse From other PD’sFrom other PD’s
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Tools for AssessmentTools for Assessment
Clinical interview: Clinical interview: historical patterns, historical patterns, relationship patterns, relationship patterns, suicide attempts/self harm, suicide attempts/self harm, psychotic symptoms, psychotic symptoms, abuse historyabuse history
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Tools for assessmentTools for assessment
Self-Report (Interview) Instruments: Self-Report (Interview) Instruments: Diagnostic Interview for Borderline Diagnostic Interview for Borderline
Personality Disorders-Revised, Personality Disorders-Revised, Structured Clinical Interview for DSM-Structured Clinical Interview for DSM-
III-R Personality Disorders, III-R Personality Disorders, PAI, PAI, Borderline Personality Inventory, Borderline Personality Inventory, Objective Behavioral IndexObjective Behavioral Index
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AssessmentAssessment
Self Harm InventorySelf Harm Inventory Beck Scale for Suicidal IdeationBeck Scale for Suicidal Ideation Suicide Probability ScaleSuicide Probability Scale MMPI-2MMPI-2 RorschachRorschach MCMI-IIMCMI-II
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Suicide AssessmentSuicide Assessment
Previous suicidal attempts, lethal in Previous suicidal attempts, lethal in naturenature
SpecificitySpecificity Level of commitmentLevel of commitment Availability of instrumentsAvailability of instruments Level of impulsivityLevel of impulsivity Substance useSubstance use Social support availabilitySocial support availability
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Self Harm Behaviors: Self Harm Behaviors: Attempts to “kill the pain”Attempts to “kill the pain”
Cutting: e.g. Cutting: e.g. arms, legs, arms, legs, stomach (80%)stomach (80%)
Bruising (24%)Bruising (24%) Burning (20%)Burning (20%) Head banging Head banging
(15%)(15%) Biting (7%)Biting (7%)
SpendingSpending GamblingGambling Substance AbuseSubstance Abuse PromiscuityPromiscuity ShopliftingShoplifting Reckless drivingReckless driving Binge eatingBinge eating
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Self harm behaviorsSelf harm behaviors Gestures, threats, attempts, Gestures, threats, attempts,
parasuicidal acts, self-mutilation parasuicidal acts, self-mutilation As a way to communicate distressAs a way to communicate distress 90% show self-destructive behavior 90% show self-destructive behavior
in the broad sensein the broad sense 75% have at least 1 self-damaging 75% have at least 1 self-damaging
act, act, 75% of acts occur b/n 18-45 years 75% of acts occur b/n 18-45 years
oldold
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Self harm behaviorsSelf harm behaviors
We have three pain systemsWe have three pain systems SharpSharp Hot/coldHot/cold BluntBlunt
Can find out what the “just right” Can find out what the “just right” sensation is and then do cognitive sensation is and then do cognitive construction of WHY do itconstruction of WHY do it
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Self harm behaviorsSelf harm behaviors
Presence of self-injurious behaviors Presence of self-injurious behaviors doubles the likelihood of suicidedoubles the likelihood of suicide
Suicidal behavior NOT necessarily Suicidal behavior NOT necessarily related to comorbid depressionrelated to comorbid depression
Self harm acts often start as self-Self harm acts often start as self-punitive measures or ways to control punitive measures or ways to control affect then take on increasing affect then take on increasing awareness and purpose of awareness and purpose of controlling otherscontrolling others
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Research into the Cause Research into the Cause of BPDof BPD
Psychoanalytic/Psychological/Psychoanalytic/Psychological/Developmental ModelsDevelopmental Models
Trauma (Abuse) ModelTrauma (Abuse) Model Interpersonal/family psychological Interpersonal/family psychological
modelsmodels Genetic/biological modelsGenetic/biological models
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Therapeutic Therapeutic ApproachesApproaches
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Management contextManagement context
Interventions done TO the clientInterventions done TO the client Competency desired (not designed to create Competency desired (not designed to create
self internal change)self internal change) Reduce chaos, avoid worsening, manage Reduce chaos, avoid worsening, manage
crises, try to correct distorted relations with crises, try to correct distorted relations with helping systemshelping systems
Use when history of: failed tx, worsening in Use when history of: failed tx, worsening in tx, abusing the system, no motivation for txtx, abusing the system, no motivation for tx
Use when the individual is not your Use when the individual is not your psychotherapy clientpsychotherapy client
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Therapeutic ApproachesTherapeutic Approaches
Dialectical Behavior TherapyDialectical Behavior Therapy Medications: Medications:
MAOI’s, SSRI’s, TCA’s, Neuroleptics, MAOI’s, SSRI’s, TCA’s, Neuroleptics, Lithium Bicarbonate, Anticonvulsants, Lithium Bicarbonate, Anticonvulsants, Opiate Antagonists, Benzodiazepines Opiate Antagonists, Benzodiazepines
Psychodynamic ApproachPsychodynamic Approach Interpersonal Psychotherapy Interpersonal Psychotherapy Cognitive PsychotherapyCognitive Psychotherapy
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Therapeutic approachesTherapeutic approaches
Psychoanalytic Approach Psychoanalytic Approach Cognitive Analytic TherapyCognitive Analytic Therapy Relapse PreventionRelapse Prevention Group PsychotherapyGroup Psychotherapy Psycho-Educational TherapyPsycho-Educational Therapy Family TherapyFamily Therapy
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Dialectical Behavior Dialectical Behavior TherapyTherapy
developed by developed by Marsha M. Marsha M.
LinehanLinehan
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DBTDBT
Developed in the 1970’s by Marsha Developed in the 1970’s by Marsha Linehan and colleaguesLinehan and colleagues
Originally designed to treat suicidal Originally designed to treat suicidal behaviorsbehaviors
The only currently Empirically Validated The only currently Empirically Validated Treatment for BPDTreatment for BPD
Long term therapy not short term: best if Long term therapy not short term: best if in both individual and group DBT therapyin both individual and group DBT therapy
faculty.washington.edu/linehan
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Goals of Skills Training Goals of Skills Training in DBTin DBT
Behaviors to Increase (Skills)Behaviors to Increase (Skills) MindfulnessMindfulness Distress toleranceDistress tolerance Emotion RegulationEmotion Regulation Interpersonal EffectivenessInterpersonal Effectiveness Walking the Middle Path/Finding the Walking the Middle Path/Finding the
BalanceBalance
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Goals of Skills Training Goals of Skills Training in DBTin DBT
Behaviors to Decrease Behaviors to Decrease (Problems)(Problems) Confusion about yourselfConfusion about yourself ImpulsivityImpulsivity Emotional InstabilityEmotional Instability Interpersonal ProblemsInterpersonal Problems Adolescent & Family DilemmasAdolescent & Family Dilemmas
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DBT AssumptionsDBT Assumptions
You are doing the best you can.You are doing the best you can. You want to improve.You want to improve. You need to do better, try harder, You need to do better, try harder,
and be more motivated to change.and be more motivated to change.
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DBT AssumptionsDBT Assumptions
You may not have caused all of your You may not have caused all of your own problems but you need to solve own problems but you need to solve them anyway.them anyway.
The lives of suicidal & depressed The lives of suicidal & depressed adolescents are painful as they are adolescents are painful as they are currently being lived.currently being lived.
It will generally be more effective for It will generally be more effective for you to learn new behaviors in all the you to learn new behaviors in all the important situations in your life.important situations in your life.
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DBT AssumptionsDBT Assumptions
There is no absolute truth.There is no absolute truth. It will generally be more effective if It will generally be more effective if
you and your family would take you and your family would take things in a well meaning way rather things in a well meaning way rather than assuming the worst.than assuming the worst.
You cannot fail in DBT.You cannot fail in DBT.
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DBT SkillsDBT Skills
DialecticsDialectics Finding the middle pathFinding the middle path ValidationValidation
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AcceptanceAND
Change =Middle Path
Acceptance Change
DialecticsDialectics
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Dialectics:Dialectics:Finding the Middle Path- Finding the Middle Path-
BalanceBalance
Holding on too tight
Forcing independence
GIVING YOURSELF/YOUR ADOLESCENT GUIDANCE, SUPPORT,AND RULES TO HELP YOURSELF/YOUR ADOLESCENT FIGUREOUT HOW TO BE RESPONSIBLE WITH YOUR/THEIR INCREASED
FREEDOMAnd at the same time
SLOWLY GIVING YOURSELF/YOUR ADOLESCENT GREATERAMOUNTS OF FREEDOM AND INDEPENDENCE WHILE ALLOWING
AN APPROPRIATE AMOUNT OF RELIANCE ON OTHERS
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Learning to think dialectically: Learning to think dialectically: Practice Practice
ID the dialectic statement:ID the dialectic statement:
a) No one ever listens to me.a) No one ever listens to me.
b) People are always available to me and listen to b) People are always available to me and listen to whatever I feel.whatever I feel.
c) Sometimes I do not feel listened to and it is c) Sometimes I do not feel listened to and it is very frustrating.very frustrating.
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Learning to think dialectically: Learning to think dialectically: PracticePractice
ID the dialectic statement:ID the dialectic statement:
a) I may not have caused all of my problems, a) I may not have caused all of my problems, but I need to solve but I need to solve them anyway. them anyway.
b) It is not my fault that I have these problems so b) It is not my fault that I have these problems so I am not going to even try.I am not going to even try.
c) All of my problems are my own fault.c) All of my problems are my own fault.
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ValidationValidation
What is validation?What is validation? Validation Validation communicates to another personcommunicates to another person
that his or her responses (feelings, thoughts, that his or her responses (feelings, thoughts, actions) make sense and are actions) make sense and are understandable understandable to youto you in a particular situation. in a particular situation.
Acknowledgement (observing & describing Acknowledgement (observing & describing nonjudgmentally) “I can see that you are really nonjudgmentally) “I can see that you are really upset now”upset now”
Acceptance: “I know you are upset.” “I am upset”.Acceptance: “I know you are upset.” “I am upset”.
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ValidationValidationREMEMBER:
VALIDATING IS NOT NECESSARILY AGREEING
VALIDATING DOES NOT MEAN THAT YOU LIKE WHAT THE OTHER PERSON IS DOING, SAYING, OR
FEELING
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Validation/Invalidation Levels Validation/Invalidation Levels and Typesand Types
ValidationValidation Basic attention, listening, Basic attention, listening,
ordinary non-verbalsordinary non-verbals Reflecting or Reflecting or
acknowledging the other’s acknowledging the other’s disclosures; what she/he is disclosures; what she/he is thinking/feeling/wanting; thinking/feeling/wanting; or functionally responding or functionally responding to her/him by answering or to her/him by answering or problem-solvingproblem-solving
Articulating/offering ideas Articulating/offering ideas about what the other about what the other might want/feel/think, etc., might want/feel/think, etc., in an empathic way; in an empathic way; helping the other clarify; helping the other clarify; asking questions to help asking questions to help clarifyclarify
InvalidationInvalidation Not paying attention, Not paying attention,
distractible, changes, distractible, changes, changes subject, anxious changes subject, anxious to leave or to end the to leave or to end the conversationconversation
Not participating actively, Not participating actively, missing ordinary missing ordinary conversational validation conversational validation opportunities, not opportunities, not providing evidence of providing evidence of tracking the other person; tracking the other person; functionally unresponsivefunctionally unresponsive
Telling the other person Telling the other person what she/he DOES what she/he DOES feel/think/ want, etc. even feel/think/ want, etc. even when the other provides when the other provides contradictory statements; contradictory statements; or telling what she/he or telling what she/he SHOULD feel/etc. SHOULD feel/etc.
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Validation/Invalidation Levels Validation/Invalidation Levels and Typesand Types
ValidationValidation Recontextualizing the Recontextualizing the
other’s behavior; putting other’s behavior; putting more positive spin on it; more positive spin on it; acceptance because of acceptance because of history; reducing the history; reducing the negative valence.negative valence.
Normalizing other’s Normalizing other’s behavior given present behavior given present circumstancescircumstances
Empathy, acceptance of the Empathy, acceptance of the person in general; acting person in general; acting from balance about the from balance about the relationship; not treating the relationship; not treating the other as fragile or other as fragile or incompetent, but rather as incompetent, but rather as equal & competent.equal & competent.
Reciprocal vulnerability/ Reciprocal vulnerability/ self-disclosure in context of self-disclosure in context of the other’s vulnerability, & the other’s vulnerability, & the focus stays on the other the focus stays on the other personperson
InvalidationInvalidation Agreeing with other person’s Agreeing with other person’s
self-invalidation when self-invalidation when behavior makes sense in behavior makes sense in terms of history & could be terms of history & could be spun differently; increasing it spun differently; increasing it negative valencenegative valence
Criticizing other’s behavior Criticizing other’s behavior when it is reasonable or when it is reasonable or normative in present normative in present circumstancescircumstances
Patronizing, condescending, Patronizing, condescending, &/or contemptuous behavior &/or contemptuous behavior toward the other; treating the toward the other; treating the other as not equal or other as not equal or incompetent; character incompetent; character assaults/ over-generalizing assaults/ over-generalizing negatives.negatives.
Leaving the other person Leaving the other person hanging out to dry; not hanging out to dry; not responding to his/her responding to his/her vulnerable self-disclosures, vulnerable self-disclosures, thereby assuming a more thereby assuming a more powerful position.powerful position.
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Mindfulness Handout 1Mindfulness Handout 1
Taking Hold of Your Taking Hold of Your Mind:Mind:
Reasonable Mind
Emotional Mind
Wise Mind
States of Mind
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DBT SkillsDBT Skills
MindfulnessMindfulness Emotional MindEmotional Mind Analytical MindAnalytical Mind Wise MindWise Mind HOW skillsHOW skills WHAT skillsWHAT skills
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DBT skillsDBT skills
Distress ToleranceDistress Tolerance Crisis SurvivalCrisis Survival
ACCEPTSACCEPTS Self-SoothingSelf-Soothing IMPROVE the momentIMPROVE the moment Thinking of Pro’s and Con’s (ST and Thinking of Pro’s and Con’s (ST and
LT)LT)
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Remember…Remember…
ACCEPTANCE OF REALITY IS NOT ACCEPTANCE OF REALITY IS NOT EQUIVALENT TO THE APPROVAL EQUIVALENT TO THE APPROVAL
OF REALITYOF REALITY
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Coping with Urges & Feelings:Coping with Urges & Feelings:Why Bother Why Bother
Coping with emotional pain is important Coping with emotional pain is important for three main reasons:for three main reasons: Pain is a part of life & can’t always be Pain is a part of life & can’t always be
avoided.avoided.
If you can’t deal with your pain, you may act If you can’t deal with your pain, you may act impulsively.impulsively.
When you act impulsively, you may end up When you act impulsively, you may end up hurting yourself or not getting what you want.hurting yourself or not getting what you want.
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Radical AcceptanceRadical Acceptance
Suffering is not accepting painSuffering is not accepting pain Acceptance is:Acceptance is:
Letting go of fighting realityLetting go of fighting reality Turning suffering you can’t cope with Turning suffering you can’t cope with
into pain you can cope withinto pain you can cope with Acceptance is NOT approvalAcceptance is NOT approval
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Acceptance MythsAcceptance Myths
Three myths about acceptance:Three myths about acceptance: If you refuse to accept something, it will If you refuse to accept something, it will
magically change.magically change.
If you accept your painful situation, you If you accept your painful situation, you will become soft & just give up (or give will become soft & just give up (or give in)in)
If you accept your painful situation, you If you accept your painful situation, you are accepting a life of painare accepting a life of pain
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WillingnessWillingness
Cultivate a willing response to each Cultivate a willing response to each situationsituation Willingness is Willingness is doing just what is doing just what is
neededneeded in each situation. It is focusing in each situation. It is focusing on effectiveness.on effectiveness.
Willingness is listening very carefully to Willingness is listening very carefully to your your wise mindwise mind, acting from your inner , acting from your inner selfself
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(Over) Willfulness(Over) Willfulness
Replace willfulness with willingnessReplace willfulness with willingness Willfulness is Willfulness is sitting on your handssitting on your hands when when
action is needed, refusing to make changes action is needed, refusing to make changes that are needed.that are needed.
Willfulness is Willfulness is giving upgiving up.. Willfulness is the Willfulness is the opposite of “doing opposite of “doing
what works”what works”, or being effective., or being effective. Willfulness is trying to Willfulness is trying to fixfix every situation. every situation. Willfulness is Willfulness is refusing to toleraterefusing to tolerate the the
moment.moment.
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DBT SkillsDBT Skills
Emotion RegulationEmotion Regulation Reducing vulnerability: STRONG skillsReducing vulnerability: STRONG skills Increase positive emotionsIncrease positive emotions Opposite ActionOpposite Action
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Short List of EmotionsShort List of Emotions
LoveLove HateHate FearFear JoyJoy ShameShame
GuiltGuilt AnxietyAnxiety LonelinessLoneliness AngerAnger FrustratioFrustrationn
SadnessSadness ShynessShyness BoredomBoredom SurpriseSurprise NumbnesNumbnesss
ConfusioConfusionn
CuriositCuriosityy
SuspiciousnSuspiciousnessess RageRage InterestInterest
DepressioDepressionn
WorryWorry HopelessnesHopelessnesss
IrritabiliIrritabilityty
PanicPanic
JealousyJealousy OptimisOptimismm
EmbarrassmEmbarrassmentent PainPain SympathySympathy
Research suggests all emotions can be categorized by the 7 basic emotions
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The Interaction of Emotions The Interaction of Emotions With Thoughts & BehaviorsWith Thoughts & Behaviors
Actions
Thoughts about the event
Body Reactions
Emotions about event
Event
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Taking Charge of Your Taking Charge of Your Emotions:Emotions:
Why Bother? Why Bother? Taking charge of your emotions is Taking charge of your emotions is
important because:important because: Suicidal & depressed adolescents often Suicidal & depressed adolescents often
have intense emotions, such as anger, have intense emotions, such as anger, frustration, depression or anxiety.frustration, depression or anxiety.
Difficulties controlling these emotions Difficulties controlling these emotions often lead to suicidal & other self-often lead to suicidal & other self-destructive behaviors.destructive behaviors.
Suicidal & other self-destructive actions Suicidal & other self-destructive actions are often behavioral solutions to intensely are often behavioral solutions to intensely painful emotions.painful emotions.
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Pleasant Activities ListPleasant Activities List
Make a list of fun, SAFE, things you Make a list of fun, SAFE, things you can do to DISTRACT, SELF-can do to DISTRACT, SELF-SOOTHE, increase positive SOOTHE, increase positive emotions, lower negative moods, can emotions, lower negative moods, can be opposite actionsbe opposite actions
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Opposite ActionOpposite Action
Step 1Step 1 Figure out what emotion you are Figure out what emotion you are
experiencing. You may need to do step experiencing. You may need to do step 2 first if this is difficult.2 first if this is difficult.
Step 2Step 2 Determine the action urge, in other Determine the action urge, in other
words, what you feel like doing.words, what you feel like doing.
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Opposite ActionOpposite ActionAction Urge for the 7 Basic Action Urge for the 7 Basic
EmotionsEmotions
EMOTIONEMOTION ACTION ACTION URGEURGE
InterestInterest ----------------------------------------------
ExploreExplore
SadnessSadness ----------------------------------------------
WithdrawWithdraw
AngerAnger ----------------------------------------------
AttackAttack
ShameShame ----------------------------------------------
HideHide
FearFear ----------------------------------------------
Run/AvoidRun/Avoid
LoveLove ----------------------------------------------
ApproachApproach
JoyJoy ----------------------------------------------
Being ActiveBeing Active
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Opposite ActionOpposite Action
Step 3Step 3 Ask yourself, “Do I want to reduce this emotion?”Ask yourself, “Do I want to reduce this emotion?”
It is very difficult to actually do Opposite Action if you It is very difficult to actually do Opposite Action if you are not genuinely interested in changing the emotion. In are not genuinely interested in changing the emotion. In some situations a person might have a negative emotion some situations a person might have a negative emotion that he or she would prefer not having, but does not that he or she would prefer not having, but does not want to change, as in grief at the loss of a loved one.want to change, as in grief at the loss of a loved one.
Set 4Set 4 Figure out the emotion’s opposite action.Figure out the emotion’s opposite action.
Step 5Step 5 This involves actually doing Opposite Action all This involves actually doing Opposite Action all
the way.the way.
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Opposite ActionOpposite Action
EmotionEmotion ActionAction Opposite ActionOpposite Action
Afraid/FearAfraid/Fear Run/AvoidRun/Avoid ApproachApproach
AngerAngerAttack/Attack/Judgmental Judgmental ThoughtsThoughts
Gently AvoidGently Avoid
SadSad WithdrawWithdraw Get ActiveGet Active
ShameShame HideHide ApproachApproach
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DBT skillsDBT skills Interpersonal EffectivenessInterpersonal Effectiveness
Keeping a good relationshipKeeping a good relationship GIVE skillsGIVE skills
Getting someone to do what you wantGetting someone to do what you want DEAR MAN skillsDEAR MAN skills
Keeping your self-respect Keeping your self-respect FAST skillsFAST skills
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Ask for Something? Ask for Something? Say No to Something? (Cont)Say No to Something? (Cont)
In order to decide whether to ask for In order to decide whether to ask for or say no to something, the things one or say no to something, the things one needs to consider include:needs to consider include: PrioritiesPriorities CapabilityCapability TimelinessTimeliness AuthorityAuthority RightsRights RelationshipRelationship
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What Stops You From Achieving What Stops You From Achieving Your Goal? Your Goal?
Lack of skillLack of skill You actually don’t know what to say or how You actually don’t know what to say or how
to act.to act. Worry thoughtsWorry thoughts
You have the skill, but your worry thoughts You have the skill, but your worry thoughts interfere with doing or saying what you interfere with doing or saying what you want.want.
EmotionsEmotions Can’t DecideCan’t Decide EnvironmentEnvironment
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Questions? Comments?Questions? Comments?
[email protected] 515-233-1122515-233-1122
Thank you for coming!Thank you for coming!
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ReferencesReferences American Psychiatric Association. (2000). American Psychiatric Association. (2000).
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Barnes, R. (1985). Women and self-injury. Barnes, R. (1985). Women and self-injury. International Journal of Women's Studies, 8(5),International Journal of Women's Studies, 8(5), 465-475.465-475.
Batty, D. (1998). Coping by cutting. Batty, D. (1998). Coping by cutting. Nursing Nursing Standards, 12(29),Standards, 12(29), 25-6. 25-6.
Beck, A.T. & Freeman, A. (1990). Beck, A.T. & Freeman, A. (1990). Cognitive Cognitive therapy of personality disorderstherapy of personality disorders. New York: . New York: Guilford. Guilford.
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ReferencesReferences Bockian, N.R., Villagran, N.E., & Porr, V. (2002). Bockian, N.R., Villagran, N.E., & Porr, V. (2002).
New hope for people with borderline personality New hope for people with borderline personality disorder: Your friendly, authoritative guide to the disorder: Your friendly, authoritative guide to the latest in traditional and complementary solutions. latest in traditional and complementary solutions. New York: Three Rivers Press. New York: Three Rivers Press.
Brodsky, B. S., Cliotre, M, & Dulit, R. A. (1995). Brodsky, B. S., Cliotre, M, & Dulit, R. A. (1995). Relationship of dissociation to self-mutilation and Relationship of dissociation to self-mutilation and childhood abuse in borderline personality childhood abuse in borderline personality disorderdisorder. American Journal of Psychiatry. American Journal of Psychiatry, 152,, 152, 1788-92.1788-92.
Cauwels, J. (1992). Cauwels, J. (1992). Imbroglio: Rising to the Imbroglio: Rising to the challenges of borderline personality.challenges of borderline personality. New York: New York: W.W. Norton.W.W. Norton.
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ReferencesReferences Clarkin, I.F., Yeomans, F.E., & Kernberg, O.F. Clarkin, I.F., Yeomans, F.E., & Kernberg, O.F.
(1999). (1999). Psychotherapy for borderline Psychotherapy for borderline personality disorderpersonality disorder. New York: John Wiley.. New York: John Wiley.
Cowdry, R. W. & Gardner, D. L. (1988). Cowdry, R. W. & Gardner, D. L. (1988). Pharmacotherapy of borderline personality Pharmacotherapy of borderline personality disorder: Alprazolam, carbamazepine, disorder: Alprazolam, carbamazepine, trifluoperazine, and tranylcypromine. trifluoperazine, and tranylcypromine. Archives of General Psychiatry, 45(2),Archives of General Psychiatry, 45(2), 111- 111-119.119.
Crawford, M. J., Turnbull, G., & Wessely, S. Crawford, M. J., Turnbull, G., & Wessely, S. (1998). Deliberate self-harm assessment by (1998). Deliberate self-harm assessment by accident and emergency staff -- an accident and emergency staff -- an intervention study. intervention study. Journal of Accident and Journal of Accident and Emergency Medicine, 15(1),Emergency Medicine, 15(1), 18-22. 18-22.
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ReferencesReferences Dawson, D. & MacMillan, H.L. (1993). Dawson, D. & MacMillan, H.L. (1993).
Relationship management of the borderline Relationship management of the borderline patient: From understanding to treatment.patient: From understanding to treatment. New New York: Brunner/Mazel.York: Brunner/Mazel.
Favazza, A. R. (1998). The coming of age of self-Favazza, A. R. (1998). The coming of age of self-mutilation. mutilation. Journal of Nervous and Mental Journal of Nervous and Mental Disease, 186(5),Disease, 186(5), 259-68. 259-68.
Favazza, A. R. (1996). Favazza, A. R. (1996). Bodies under Siege: Self-Bodies under Siege: Self-Mutilation and Body Modification in Culture Mutilation and Body Modification in Culture and Psychiatry, 2nd ed.and Psychiatry, 2nd ed. Baltimore: The Johns Baltimore: The Johns Hopkins University Press.Hopkins University Press.
Favazza, A. R. (1989). Favazza, A. R. (1989). Why patients mutilate Why patients mutilate themselvesthemselves. Hospital and Community Psychiatry. Hospital and Community Psychiatry..
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ReferencesReferences Favazza, A. R. & Rosenthal, R. J. (1993). Favazza, A. R. & Rosenthal, R. J. (1993).
Diagnostic issues in self-mutilationDiagnostic issues in self-mutilation. Hospital . Hospital and Community Psychiatryand Community Psychiatry. 44(2),. 44(2), 134-140. 134-140.
Gabbard, G.O. & Wilkinson, S.M. (1994) Gabbard, G.O. & Wilkinson, S.M. (1994) Management of countertransference with Management of countertransference with borderline borderline patients.patients. Washington, DC: Washington, DC: American Psychiatric Press.American Psychiatric Press.
Gunderson, J.G. (2001). Gunderson, J.G. (2001). Borderline personality Borderline personality disorder: A clinical guide.disorder: A clinical guide. Washington, DC: Washington, DC: American Psychiatric Press.American Psychiatric Press.
Gunderson, J.G. & Gabbard, G.O. (eds.) Gunderson, J.G. & Gabbard, G.O. (eds.) (2000). (2000). Psychotherapy for personality Psychotherapy for personality disordersdisorders. Washington, DC: American . Washington, DC: American Psychiatric Press.Psychiatric Press.
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ReferencesReferences Haines, J. & Williams, C. L. (1997). Haines, J. & Williams, C. L. (1997). Coping and Coping and
problem solving of self-mutilatorsproblem solving of self-mutilators. Journal of . Journal of Clinical PsychologyClinical Psychology, 53(2),, 53(2), 177-186. 177-186.
Haines, J., Williams, C. L., Brain, K. L., Wilson, G. Haines, J., Williams, C. L., Brain, K. L., Wilson, G. V. (1995). V. (1995). The psychophysiology of self-The psychophysiology of self-mutilationmutilation. Journal of Abnormal Psychology. Journal of Abnormal Psychology, , 104(3),104(3), 471-489. 471-489.
Hawton, K., Arensman, E., Townsend, E., Hawton, K., Arensman, E., Townsend, E., Bremner, S., Feldman, E., Goldney, R., Gunnell, Bremner, S., Feldman, E., Goldney, R., Gunnell, D., Hazell, P., van Heeringen, K., House, A., D., Hazell, P., van Heeringen, K., House, A., Owens, D., Safinosky, I., & Traskman-Bendz, L. Owens, D., Safinosky, I., & Traskman-Bendz, L. (1998). (1998). Deliberate self-harm: systematic review of Deliberate self-harm: systematic review of efficacy of psychosocial and pharmacological efficacy of psychosocial and pharmacological treatments in preventing repetitiontreatments in preventing repetition. BMJ. BMJ, , 317(7156),317(7156), 441-7. 441-7.
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recovery.recovery. New York: Basic Books. New York: Basic Books. Kernberg. O.F. (1975). Kernberg. O.F. (1975). Borderline Borderline
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Koenigsberg, H.W., Stone, M.H., Koenigsberg, H.W., Stone, M.H., Appelbaum, A.H., Yeomans, F.E., & Appelbaum, A.H., Yeomans, F.E., & Diamond, D. (2000). Diamond, D. (2000). Borderline patients: Borderline patients: Extending the limits of treatabilityExtending the limits of treatability. New . New York: Basic Books.York: Basic Books.
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ReferencesReferences Kreisman, J.J. & Straus, H. (1989). Kreisman, J.J. & Straus, H. (1989). I hate you, I hate you,
don’t leave me: Understanding the borderline don’t leave me: Understanding the borderline personality disorder.personality disorder. New York: Avon Press. New York: Avon Press.
Landecker, H. (1992). Landecker, H. (1992). The role of childhood The role of childhood sexual trauma in the etiology of borderline sexual trauma in the etiology of borderline personality disorder: Considerations for diagnosis personality disorder: Considerations for diagnosis and treatment.and treatment. Psychotherapy, Psychotherapy, 29, 29, 234- 234- 42.42.
Lester G. W. (2003). Lester G. W. (2003). Personality disorders in Personality disorders in social work and healthcaresocial work and healthcare. Nashville: Cross . Nashville: Cross Country University and Houston: Ashcroft Press. Country University and Houston: Ashcroft Press.
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