Tag: DBT

Therapy types explained: DBT, CBT, CPS, and others

Therapy types explained: DBT, CBT, CPS, and others

The fantastic news about the brain is that it can heal itself by talking with someone! And there is ample evidence to back this up.

The therapist or psychologist who works with your child or teen will use a type of therapy or “modality” based on their symptoms or diagnosis, because some work better for mood disorders, some work better for defiant children, some work better for borderlines, and so forth. (In thought disorders like autism and schizophrenia, talk therapy has limits. Those on the autism spectrum need specialized interactions due to their processing issues. Those on the schizophreniform spectrum need medication to think logically before starting

Therapy models. Each type of therapy follows a model, and five are covered in this article. Your child’s therapist must be trained and practiced in any model they use. Why? It’s a matter of quality control. A therapist who has fidelity to a model (adheres to protocol) will help the most people most of the time, because that model has data to prove that the majority will benefit–the ones in the center section of the Bell Curve. (Therapists include psychiatrists, psychologists, and psychotherapists with MSW (Masters in Social Work), LCSW (Licensed Clinical Social Worker) and other licensure.)

Therapy models

CBT – cognitive behavioral therapy
CBT works when the child can examine their own feelings and make sense of them—the “cognitive” part. They learn to understand what affects them and why. The therapist will guide your child to create a list of options for themselves for when they face the next stressful situation that pops up in their lives. CBT helps a person think their way out of the confusion and have plans in place for appropriate actions. It works for mood disorders and anxiety, and some thought disorders if person has ‘insight’ (able to notice when they are behaving or thinking irrationally). CBT is one of the most widely used therapeutic models because it works for people who are relatively stable but enduring a difficult life situation (divorce, medical illness, job loss, and other big stressors).

DBT – dialectical behavioral therapy
DBT is unusual in that it can help anyone for any reason! The term “dialectical” describes how a patient learns to hold two opposing truths in their mind and respond effectively to the discomfort and emotions this causes. DBT is the one therapy model that can work for people with borderline personality disorder, who are considered the hardest to treat. It also helps those with mood dysregulation, those who’ve thought about or attempted suicide, or those with uncontrollable and negative responses to the world, such as oppositional defiant disorder. DBT relies less on personal self-examination and analysis, and instead concentrates on self calming, tolerating stress without overreacting, accurately perceiving the nature of a conflict, and communicating with others appropriately. Anyone can benefit from DBT. Notice how commonly people hear bad news and immediately expect the worst, then act to address the worst possible outcome? Does your child do this, only to extremes?

EMDR – eye movement desensitization and reprocessing
The goal of EMDR therapy is to help a person process extremely distressing memories of trauma and mitigate their torturous subconscious influence so children and adults can adapt and cope when memories are triggered in the future. EMDR is used for people with PTSD (physical, sexual, or emotional abuse) and other traumas such as from war, accidents, and major disasters. The therapy process uses rhythmic stimuli as a distraction during the precise moments when the person relives the traumatic memory—eye movement back and forth (by following a swinging object or a therapist’s hand), clapping, or listening to tones switching from ear to ear through headphones. The person does not have to talk about the horrible memory, so EMDR is less stressful—so important for a trauma survivor! EMDR works but there are no acceptable explanations. It is based on a belief that the memory and associated stimuli of the event must be processed to remove it from “an isolated memory network” where it creates havoc.

Parents as therapists

There are two proven models of therapy that are taught to parents to practice with their children in the home. Like the other models, they don’t work for every child, but they work for most children with a certain range of behaviors, rages, resistance, and physical violence, which can be caused by ODD, ADHD, and depression/bipolar disorders.

CPS – collaborative problem solving
CPS can be learned by anyone to manage an intensely frustrated child who goes into uncontrollable fits or tantrums, and the parent can do nothing to calm them down. The fits may last hours, and must run out of steam on their own. Afterwards, the child is often remorseful. Why? Their brain is “chronically inflexible” and has difficulty with the unexpected, switching from one situation to another or one plan to another. Using CPS, a parent doesn’t enforce rules per se, but negotiates with child so that they together come up with a win-win solution. This is very counterintuitive! The parent does not give away their authority, but offers the child an acceptable choice. For example, if a child can’t get a red jacket because there aren’t any in their size, and they must have red (!), the parent asks the child if they want to order one and wait 2 weeks, or if they will accept another color. This seems fair to the child because they have a say, and much easier on the parent because the child accepts the outcome they’ve chosen.

PMT – parent management training
PMT refers to a proven intensive educational program for parents to teach them skills for managing extremely difficult children, especially those with ODD. PMT helps parents assert consistency and predictability at home and in school, and promote positive social behavior in their child. The parents are also trained to change their own behavior towards their child, and taught how to analyze different home/school situations, “then apply moment-to-moment positive reinforcement or punishment” (called interventions) based on what is happening. The punishments are humane, such as taking time outs. It is hard on the parents, but works for children with serious behavior problems in addition to ODD: Conduct disorder, ADHD, and autism spectrum disorders.

What makes a good therapist? Because multiple models are out there, a really skilled therapist will figure out which model your child needs once they get to know them, and they will apply parts of different models depending on your child’s individual challenges. That same skilled therapist will also be a cheerleader for your child, helping them feel good about themselves (and you), helping them discover their talents, and helping them to stay committed to their need for self-care. This is the very definition of a good therapist! Therapy is hard to take for anyone, but your child will trust a good therapist if they feel they have their best interests. Chemistry is important. If your child doesn’t like the therapist or make progress, it’s worth spending the time to find someone else who’s a better match. If the therapist has professional ethics; they will recognize they are not a fit and recommend someone else.

I know of a 10-year old child whose therapist dragged out appointments for a year with zero progress or results. From the start, the child didn’t like her and simply refused to talk with her. And this child, now 11, refuses any therapy because “it’s boring and a waste of time.” What an unfortunate consequence!

How you know you have a good therapist. A good therapist will be able to discover something valuable that brings light on your child’s situation after the very first session. They should ask you for background information about your child, and listen to you when you talk about recent problematic situations. They cannot talk to you about your child’s therapy, but they can encourage you to partner with them, and should recognize your need (your family’s need) for your child to function as normally as possible. You can ask to have therapy together with your child if its appropriate. If the therapist can’t connect meaningfully with your child after a few weeks, ask them about this. If you have any doubts about the therapist, share them, and expect to have a thoughtful, respectful explanation.

Which therapy is best for your child?

Seek a therapy provider with knowledge of all of them, and with experience treating children and teens. Ask about a specialty when you make the initial contact, and ask about a model you think fits your child’s behaviors (based on their descriptions). You can get a one-time assessment from a therapist for an opinion on which model to use. The best way to find a good therapist is through personal referrals: your child’s doctor or psychiatrist, support groups, school counselors, and other parents.

Brace yourself for borderlines

Brace yourself for borderlines

Are you ready to bang your head on a wall?  Do you want to abandon your child in the wilderness?  Are you praying for the day they turn 18, when you can change the locks on your doors?  Children with borderline personality disorder (BPD) bring out the worst in everyone around them.

A borderline child or teen is not a “drama junkie” on purpose.  There brain is primed to overreact.

Yes, BPD kids really believe that others are out to get them, and that all their problems are someone else’s fault.  They are appalled that others mistreat them horribly.  They are insulted and defensive when they detect criticism, even when there isn’t any.  They can never be pleased, and it’s always about them.  Most exasperating for you, they turn from monstrous, to sweet and charming, and back to monstrous in an instant.

“Does this explain why I can go from 0 to 60 in two seconds?”
–17-year-old girl when told she was diagnosed with borderline personality disorder

Especially confusing, a borderline teen can be very engaging and affectionate… sometimes at random, and sometimes when they want something.  They will also turn on the charm to embarrass you in front of others (such as in family therapy).  Since they seem so wonderful to other people, you are asked why you get upset at your clearly wonderful child.  People often recommend that you take care of your own issues instead.

Even though their manipulation and upheaval is relentless, strive for compassion.  Trust me, your borderline child will suffer more than you in every important aspect of life.  They make a mess of their relationships because of their anger, instability, substance abuse.  Their clingy behavior is annoying.  They drive away good friends, hate them for leaving, and then suffer from loneliness and depression.  They make a mess of their jobs, often fired or forced to resign, and bounce from one to another… and they don’t understand why it happens to them.

For goodness sakes, why?

When playing a game that requires teamwork, the brain of a normal person shows activity in the bilateral anterior insula.

 

The brain of a borderline person, when playing the teamwork game, showed no activity whatsoever.

A study published in 2008 in Science showed that brain activity in people with borderline personality disorder was abnormal—their brains lack activity in the ‘cooperation’ and ‘trust’ regions, called the bilateral anterior insula.  Borderline personality patients do not have an internal, natural sense of fairness and social norms, and little to no level of trust.

Statistics

One research study reported that borderline personality disorder occurs as often in men and women, and sufferers often also have other mental illnesses or substance abuse problems.  (In my personal observations over many years, teenagers with borderline personality disorder are often diagnosed with bipolar disorder.) Another study reported, “The disorder occurs in all races, is prevalent in females (female-to-male ratios as high as 4:1), and typically presents by late adolescence.”  It is estimated 1.4 percent of adults in the United States have this disorder.

In infants:  the children who were later diagnosed with borderline personality were more sensitive, had excessive separation anxiety and were moodier. They had social delays in preschool and many more interpersonal issues in grade school, such as few friends and more conflicts with peers and authorities.

In teenagers:  they are more promiscuous, aggressive and impulsive, and more likely to use drugs and alcohol. Cutting and suicide are more common.  “…research shows that, by their 20s, people with the disorder are almost five times more likely to be hospitalized for suicidal behavior compared to people with major depression.”

 

Evidence for hope

“Trying to Weather the Storm” (excerpt)
Shari Roan, September 07, 2009, Los Angeles Times

“Borderlines have the thinnest skin, the shortest fuses and take the hardest knocks.  In psychiatrists’ offices, they have long been viewed as among the most challenging patients to treat.

“But almost 20 years after the designation of borderline personality disorder, understanding and hope have surfaced for people with the condition and their families.  Advances have been made in recent years.  Researchers from McLean Hospital in Massachusetts studied 290 hospitalized patients with the condition over a 10 year period:  93 percent of patients achieved a remission of symptoms lasting at least two years, and 86 percent for at least four years. Published in The American Journal of Psychiatry, the research argues that once recovery has been attained, it appears to last.

“Having a relative with BPD can be hell,” says Perry D. Hoffman, president of the National Education Alliance for BPD http://www.borderlinepersonalitydisorder.com.  “But our message to families is to please stay the course with your (child) because it’s crucial to their well-being.”

Treatment

“What Therapy Is Recommended for Borderline Personality Disorder in Adolescents (13-17 years)?”(excerpt)
Mary E. Muscari, PhD, August 9, 2005, http://www.medscape.com/viewarticle/508832

Psychotherapy is the primary treatment of BPD, specifically long-term dialectical behavior therapy (DBT), which helps the person attain and maintain lasting improvement in their personality, interpersonal problems, and overall functioning.  DBT appears to be the most effective.  It focuses on coping skills, so patients learn to better control their emotions and behaviors. This may be complemented with medications that help with mood stability, impulsivity, psychotic-like symptoms, and self-destructive behavior.

There are several appropriate therapies in addition to DBT, and all share common elements:  1. The bond between the patient and therapist is strong.  2. Therapy focuses on the present rather than the past, on changing one’s behavior patterns now regardless of how patients feel about the past or if they see themselves as victims.

On DBT:  I recommend this straightforward self-help lesson to get started learning the concepts and skills:  http://www.dbtselfhelp.com/html/dbt_lessons.html.

When to hospitalize

  • In an emergency – when your child has serious suicidal thoughts or an attempt, and/or is in imminent danger to others.
  • In long-term residential care – when your child has persistent suicidal thoughts, is unable to participate in therapy, has a life-threatening mental disorder (e.g. bipolar), continued risk of violent behavior, and other severe symptoms that interfere with living.

Other treatment a borderline may need:

  • Treatment for substance abuse.
  • Therapy that focuses on violent and antisocial behaviors, which can include emotional abuse or physical abuse, baiting, bullying, and sexualized behaviors.
  • Therapy that focuses on trauma and post traumatic issues when an adolescent loses their sense of reality.
  • Reduce stressors in the young person’s environment.  Most adolescents with BPD are very sensitive to difficult circumstances, for examples: an emotionally stressful atmosphere at home; teasing in school; pressures to succeed or change; consistent rules; being around others who are doing better than them, etc.

What parents and caregivers can do

With a partner or spouse:  Maintain a united front.  Communicate continually to stay on the same page when managing your child and setting limits.  Have each other’s back even if you’re not in full agreement.  Always take disagreements out of earshot of your child.  Any disagreement they hear will be used against you.

Maintain family balance.

Keep your energy in balance so you can maintain your family's foundation.  Too much spent on your child affects everything else your family needs to survive.
Keep your energy in balance so you can maintain your family’s foundation. Too much spent on your child affects everything else your family needs to survive.

 

Keep things relaxed.  If you need to set boundaries and apply pressure, do it only to maintain  appropriate behaviors and reminders for self-calming.  Let other things go.

Use praise proactively.  Borderlines crave attention and praise.  When they deserve it, pour it on thick.  And pour it on thick every single time they demonstrate good behavior and positive intention.  One can’t go too far.  When an argument or fight comes up, search your memory banks for the most recent praiseworthy thing they did or said, and bring it up and again express your gratitude and admiration.  This does two things:  it reinforces the positive;  and it redirects and ends a negative situation.

Become skilled in DBT and help your child stay in the here and now.  Keep up the reminders that enable them to stay in the moment, to take those extra few seconds to think things through before reacting.

  • Did your friend really intend to upset you?  It sounds like they were talking about something else.
  • The delay wasn’t planned just to make you mad, perhaps you were just frustrated by being asked to wait, and it was no one’s fault.
  • The tear in your jacket isn’t a catastrophe.  It is easily fixed and I can show you how.

Prevent dangerous risk taking – Teens with borderline personality are exceptionally impulsive and prone to risky behavior.  Consequently, parents should consider:

  • Tightly limiting cell phone use, email, texting, and access to social networking sites
  • Using technology to track their communications (this is legal), or disabling access during certain time periods
  • Reducing the amount of money and free time available
  • Searching their room (this is also legal)

A couple I know fully informed their borderline teen that all internet activity would be tracked, as well as cell phone calls.  The father also installed cameras in the home, at the front and back doors, in plain sight.  Nevertheless, his son continued with bullying and hurtful behavior towards siblings right in front of those cameras, and he would get caught and pay consequences repeatedly.  His persistence in the face of obvious monitoring became a great source of private amusement for his parents–humor really does provide relief.
–Margaret

Be patient – You are unlikely to receive the child’s respect, love, or thanks in the short-term.  It may take years.  But be reassured that your child will thank you for your firm guidance and limits once he or she matures to adulthood.

Other characteristics of BPD

Signs and symptoms of BPD may include significant fear of real or imagined abandonment; intense and unstable relationships that vacillate between extreme idealization and devaluation; markedly and persistently unstable self-image; significant and potentially self-damaging impulsivity (spending, sex, binge eating, gambling, substance abuse, and reckless driving); repeated suicidal behavior, gestures, or threats; self-mutilation (carving, burning, cutting, branding, picking and pulling at skin and hair, biting, and excessive tattooing and body piercing); persistent feelings of emptiness; inappropriate anger or trouble controlling anger; and temporary, stress-related severe dissociative symptoms or paranoid ideation.

  • Chronic depression: Depression results from ongoing feelings of abandonment.
  • Inability to be alone: Chronic fear of abandonment also leads to these adolescents having little tolerance for being alone. This results in a constant search for companionship, no matter how unsatisfying.
  • Clinging and distancing: Relationships tend to be disruptive due to the adolescents’ alternating clinging and distancing behaviors. When clinging, they may exhibit dependent, helpless, childlike behaviors. They over idealize he person they want to spend all their time with, constantly seeking that person out for reassurance. When they cannot be with their chosen person, they exhibit acting-out behaviors, such as temper tantrums and self-mutilation. Distancing is characterized by anger, hostility, and devaluation, usually arising from discomfort with closeness.
  • Splitting: Splitting arises from the adolescents’ inability to achieve object constancy and is the primary defense mechanism in BPD. They view all people, including themselves, as either all good or all bad.
  • Manipulation: Separation fears are so intense that these adolescents become masters of manipulation. They will do just about anything to achieve relief from their separation anxiety, but their most common ploy is to play one individual against another.
  • Self-destructive behaviors: The behaviors are typically manipulative gestures, but some acts can prove fatal. Suicide attempts are not uncommon yet usually happen in relatively safe scenarios, such as swallowing pills at home while reporting the deed to another person on the telephone.
  • Impulsivity: Poor impulse control can lead to substance abuse, binge eating, reckless driving, sexual promiscuity, excessive spending, or gambling. These behaviors can occur in response to real or perceived abandonment.

 

Drawn from:
Risk taking adolescents: When and how to intervene (excerpt)
David Husted, MD, Nathan Shapira, MD, PhD , 2004
University of Florida College of Medicine, Gainesville

– – – – – – – – – –

How am I doing?  Please rate this article at the top, thanks!

–Margaret

The blessings and curses of schizophrenia – A father’s view

The blessings and curses of schizophrenia – A father’s view

This guest article is by Don Moore.

Some families are presented with the dual dilemmas of dealing with a child that is both gifted and troubled.  Such is the case with my daughter who in spite of her schizophrenia nearly ended up on the popular television show American Idol.

Most fathers would be quite pleased if children came with owner’s manuals.  Mind you, the great majority would not read the manual, but prefer to use their own experiences and logic to determine appropriate actions in parenting.  Owner’s guides would be a fine reference resource to look up how things were to be done after trying their own thoroughly contemplated actions before resorting to some sort of predetermined remedial action.

Particularly in American society, a Man’s perspective is to reason out and come up with solutions to problems they encounter or to follow a set of requirements at their employment to retain their job.  Sure, there are exceptions, especially for those who pursue artistic endeavors, but even these can often be reduced to techniques, learned, practiced and then applied.  (More about men’s approaches to parenting is here:  For men who raise troubled kids) 

Like many other parents and especially fathers, my work revolves around the repair of things and when I first encountered my daughter’s difficulties with life, I followed an approach of analyze, find a solution and apply a remedial fix to my interactions with her.

Much of Western medicine follows this thought process as well; study the problem, recommend a treatment and magically the problem will be gone.  The real problem is that this simplified view does not reflect the nature of the underlying problem with many mental health issues.  An especially difficult disorder to use this approach with is schizophrenia.  Because we define this illness as a set of behaviors and characteristics and each person can have or not have many of the characteristics, the approaches that I followed in dealing with my daughter’s situation were woefully inadequate as well as misguided.

In fact, most of my approach to dealing with my daughter would have been ineffective with just about any teenager, much less one suffering from hearing voices and disjointed thinking.

If the point of reference that you are using to deal with a child with schizophrenia is that the child is somehow concerned with what effect their behavior will have upon you, you are sadly mistaken.  This is precisely what I thought when I would painfully explain why some task had to be done, like load a dishwasher.  If she could not complete the task, it was obviously because she was trying to agitate me and I responded by becoming agitated and angry at either her lack of compliance with my instructions or the poor quality of her efforts.  As the behavioral difficulties became more serious my frustrations escalated accordingly.  The escalations were equally ineffective.

All of the difficulties came to a crisis point when my daughter left to attend a performing arts college in Minneapolis.  There her difficulties took on another level of seriousness and she returned home.  Under the care of a psychiatrist, some progress was made and my wife and I elected to take a class in dialectic behavioral therapy (DBT) for parents.  The class, in conjunction with some wise advice from her psychiatrist finally got me to see that her difficulties were from within her own mind and the best approach was to understand her behavior reflected her struggles to deal with her view of the world and were not based upon a master plan to disappoint or offend me personally.  DBT techniques allow you to understand the effect of delusions on the child’s behavior and instruct you to deal with the feelings that those delusions have on the child’s behavior. There is not an acceptance of the truth of the delusion, but there is an acceptance of how the person feels about the thoughts they have.  Having someone verify their feeling about the delusion (It must be frightening to believe the government is using thought control on everyone) without accepting the truth of the idea helps the person modify their response to the delusional thought.

Once there is an understanding of the thought issues facing the person with schizophrenia, there is hope that the narrative that their brain has created for their existence in the world can be refocused to include new ways of viewing the world and how they are to interact with those around them.  Proposing alternatives to how they see the world is a method of getting them to rethink the ideas that they hold and readjust to a new way of behaving.  It is by no means as simple as an owner’s guide, but progress is possible.

Tracy and Emmy winner Joey Pantolino

In my case, the treatments my daughter received helped considerably at first and she was able to make a journey to American Idol tryouts, meet the famous judges in person and come one audition from actually being on the television show.  You can see her story in the February 2006 SZ Digest magazine http://www.schizophreniadigest.com/e107_plugins/szproducts/images/articles/2006_spring_story1.pdf  or at my website, www.matersofthemind.info .

Another aspect of mental illness that seems to be misunderstood is the wide range of seriousness and variation with symptoms.  My family has been both fortunate and unfortunate.  My daughter has been blessed with a set of skills in singing that brought her national recognition for her efforts with American Idol, but did not ultimately reward her with employable skills or remediate her disease.  There are others with schizophrenia with truly exceptional talents who find jobs and recovery.  There are also those who struggle with more serious symptoms.  Whatever the course of your loved one’s illness, there is some measure of comfort in seeking and finding skills that will help in dealing with the issues that are confronting them.  Not the least of these skills are understanding the emotional turmoil that the person feels in dealing with their view of the world and helping them deal with the issues surrounding that view.

Tracy and Senator Gordon Smith (wrote and passed mental health legislation)

During her American Idol experience, my daughter wrote and recorded a song entitled “I am Not Alone.”   There is no reason that any family or person should be alone in their efforts to deal with their condition.  While it may sometimes feel lonely, seeking out resources and learning about the experiences of other people with similar challenges will help in your efforts to create not an owners’ manual but a guide to help you understand alternatives while you seek a better path to follow.  You may not cure the disease, but you can respond better to the challenges you face in your own journey.

–Don Moore

I offer deep gratitude to both Don and Tracy for sharing their remarkable experiences

Margaret

Parent to Parent Guidance

Parent to Parent Guidance

Margaret Puckette is a Certified Parent Support Provider, and helps parents with tailored advice for raising their troubled child, teen, or young adult. She is a parent who understands that parents and families need realistic practical guidance for maintaining their lives without stress. Margaret has coached and mentored families for over 20 years. She is an author & speaker, and believes parent & family support is essential. Mentally healthy parents with the right skills raise mentally healthy children.

You Can Handle This.

You Can Handle This.

You are not alone. Your situation is no one's fault. Behavior disorders are disabilities!
Troubled children need a very different parenting approach than 'normal' kids.

Care for yourself first, then set new goals:
1. Physical and emotional safety for all
2. Acceptance of the way things are
3. Family balance, meet the needs of all
4. One step at a time, one day at a time

Practical Guide for Parents

Practical Guide for Parents

A guide with practical steps for reducing stress at home and successfully raising a troubled child. You use the same proven techniques as mental health and other professionals. It starts by taking care of your wellbeing first, then taking an entirely different approach to parenting.
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