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Monday, August 14, 2017

Understanding Borderline Personality Disorder

borderline personality disorderFriends and family members of individuals with borderline personality disorder often feel frustrated, unsafe and confused, the cause of these emotions being the erratic and abusive behavior of their loved ones. People frequently mistreat individuals with borderline personality disorder, which only exacerbates their symptoms. The first step to treating individuals with BPD and learning how to have effective healthy communication is having compassion and awareness of the challenges of living with BPD.

Borderline personality is often misdiagnosed so it is important to understand the diagnostic criteria, and have an evaluation with a mental health professional.

According to the DSM-5 (diagnostic statistic manual) a person must present with five or more of the following in order to meet the diagnostic criteria for BPD.

1. Desperate efforts to avoid real or imagined abandonment.
2. A pattern of unstable relationships switching between extremes of admiration and hatred.
3. Unstable self-image.
4. Impulsivity in at least two areas that are potentially self-damaging (such as spending, sex, substance abuse, reckless driving or binge-eating).
5. Repeated suicidal behavior and threats or self-harm.
6. Erratic mood swings.
7. Chronic feelings of emptiness.
8. Intense anger or difficulty controlling anger.
9. Temporary, stress-related paranoid ideation or dissociative symptoms.

One of the main symptoms of borderline personality that impacts all individuals who are diagnosed is intense personal dysregulation. That means this person experiences rapid intense mood fluctuation, have immense difficulty grounding themselves or being able to accurately view reality.

The cause of borderline personality disorder is still unknown however there is a strong correlation between experiences with childhood trauma (sexual, physical or emotional abuse) and developing BPD. The rates of co-occurring disorders such as substance use disorders, eating disorder and depression are incredibly high among individuals with BPD as well.

It has been proven that the most effective course of treatment for borderline personality disorder is long-term treatment with a focus on behavioral modification. In this treatment individuals will learn how to correct maladaptive behavioral patterns, healthy communication and boundaries, tools for emotional regulation, and skills in order to achieve autonomy.

Friday, August 4, 2017

Treatment of Complex Trauma

treating complex traumaIn cases involving complex trauma, treatment providers may find themselves exposed to some of the enigmatic and challenging cases they will face throughout their careers. Take, for example, cases of trauma that stem from early childhood; the resulting biopsychosocial problems, defenses, and maladaptive coping skills have been in place for many years and will be thoroughly engrained in a person’s system. Individuals with childhood trauma commonly present with blatantly negative views of self and others, as well as intense physiological and emotional distress, and feelings of anger, low self-esteem, distrust, shame, and self-loathing. Often, these individuals exist in survival mode, which becomes ingrained in their psyche, even when life becomes less perilous or strained. In addition, many of these individuals fluctuate between being flooded with intense emotions, to being completely detached and dissociated from them. To top it off, individuals with complex trauma histories often feel like outsiders, feel incredibly alone and misunderstood, and can’t seem to fit in with others (often leading to further abuse in adolescent years in the form of bullying).

According to the DSM-V, there are several events that may be defined as traumatic. These events may involve death or threat of death, interpersonal traumatization, and threats to the integrity of the self and personal development (APA, 2013). Complex trauma is often repeated, lending to the complexity of the trauma, which often exists in layers. In addition, complex trauma may be related to a person’s very identity, further resulting in damage to the sense of self, safety, and hope.

According to child psychiatrist Lenore Terr, two main types of children’s trauma exist (that also apply to adults). Type I, a single-incident trauma, occurs unexpectedly and out of the blue. Type II refers to repetitive trauma or ongoing abuse, neglect, and other interpersonal maltreatment, whether intentional or unintentional (Terr, 1991).

In considering the multitude of dynamics and symptoms that vary on a case by case basis when treating complex trauma, a starting point would be comprehending how the traumatic experiences drastically mold not only the individual's lives, but their sense of self. Potential sequelae include, but are not limited to: extreme mood lability, social isolation, substance use and other addictions, impulsivity, high-risk behaviors, anger, self-injury, suicidality, social problems, dysfunctional relationships, dissociation, medical conditions, chronic low self-esteem, feelings of helplessness, hopelessness, conduct disorders, psychotic experiences, and psychosis. These symptoms may be categorized into alterations in: regulation of self, consciousness, self-perception, perception of the perpetrator, relationship to others, somatization, and systems of meaning.

Therapists treating complex trauma must be able to recognize and effectively treat a multitude of symptoms, particularly maladaptive approaches to emotions and reactions, emotional dysregulation, and loss of self-integrity. In spite of how overwhelming the complexities of trauma may seem, practitioners working with this population will likely discover an incredible resoluteness of spirit, sense of empathy, and innate strength in these most remarkable individuals who have found the inner fortitude to experience the unimaginable or intolerable.

References

Terr, L. (1991). Childhood traumas: An outline and overview. American Journal of Psychiatry, 148, 10-20.

Friday, July 28, 2017

Working and Living 12 Step Recovery

working living 12 step recoveryIt is a gift and a challenge when a person who is in their own 12 step recovery also gets to work in the field of addiction with other recovering addicts. From my perspective, it can be challenging to separate my own recovery from the work I do on the job. As a clinician, my focus is on the clients I work with and making sure they learn how to stay sober and use the 12 steps of Alcoholics Anonymous to support their recovery. Since I have my own experience as a recovering alcoholic, and I have a very good understanding of how the 12 steps can help a person stay sober, it is easy for me to pass this information along in a way that the clients can easily understand.

When a client talks about how “12 step programs don’t work” or that they feel as if they have tried the program and found it wanting, I can easily point out several success stories and self disclose my own long term recovery to help them see a living example of success based on the 12 step principles that we at Canyon Crossing are encouraging our clients to embrace. This is the gift I can give to my clients since I’m working a program of my own.

The challenge comes, when as a clinician, I can’t separate my own program from the program that I am asking a client to integrate. When I think, “I did it this way so they should too”, I need to take a step back and remember that every person has their own journey with the 12 steps and my clients will have their own journey that may not look exactly like mine. When this occurs I can use the Al-Anon 12 step program to practice detachment. Al-Anon teaches a person how to love the person and separate their disease from the person they are. It also teaches how to lower your expectations and meet a person where they are instead of wanting them to be where I think they should be.

I am a better clinician because I have integrated my own 12 step program into my life and live by the principles of the AA and Al-anon program. I am also very satisfied in my work because I’m doing something that I believe in and doing meaningful work is very important to me. I also practice my program outside of work in order to stay as healthy as I can be which enhances my ability to work with the women who need positive supportive role models of recovery.

I’m new at Canyon Crossing and have been working in and around the field of addiction treatment since 1986. I am a trained EMDR therapist and am presently enrolled in a master’s degree program to become a Licensed Marriage and Family Therapist. I find that a 12 step foundation enhances all of my education and allows me to be the very best clinician I can be, but working in the field of addictions does not take the place of the service work I need to do in my own program. It is a gift to work with this population and I enjoy sharing my own experience, strength and hope while maintaining my professionalism.

Janet E. Bontrager
Primary Therapist/EMDR

Saturday, July 15, 2017

Somatic Experiencing Interventions for Healing Sexual Trauma

somatic interventions sexual traumaThe first part to healing trauma within the body comes with identifying where the emotion is being experienced within the body. Recognition is the start to healing. The client needs to feel safe within the therapeutic relationship and learn how to transfer that feeling of safety into their everyday life by using self-soothing techniques. Dr. Peter Levine, Ph.D is the originator and developer of Somatic Experiencing and the director of Somatic Experiencing Trauma Institute, says that it is important to give tools for emotional regulation and self-soothing for those who have experienced trauma, so that they do not become dependent upon the therapist for soothing and an inner sense of safety. The first step is becoming attuned to our feelings and the place we are feeling that emotion within our body.

The first exercise is putting your right arm under your left arm pit and the left hand on the right shoulder, then taking a moment to feel what is going on inside of your body. Shut your eyes and allow yourself to feel and fully experience the moment. The benefit of this practice is to help the person become aware of the idea that the body is the container of all the sensations and feelings of each person. A good time to put this exercise into practice is when a flashback is happening or when someone has been triggered by a smell, word, sound, taste, or touch. When one realizes that the body is the container, and they can feel safely soothed and contained within, then the emotions will not be as stimulating or overwhelming as they have been before.

Squeezing your muscles or tapping all over the body can be helpful in a person’s sense of boundary because in trauma - especially sexual trauma - there is a hole in someone’s boundary not having a sense of where they begin and end. This hole comes from the powerlessness and loss of control and protection of their entire being. The aim for the therapist is to initially touch the client with their presence. According to Seigel (2015) “presence is a way of keeping trust alive and keeping connections strong and communication wide open (p. 250).” Presence is cultivated by allowing whatever arises to come and gives flexibility to move with the client in the path that they need to go without judgement or predetermined manipulation in a specific direction. Presence is simply being fully in the moment with the client, feeling with them, observing while being aware of their nonverbal reactions and responding accordingly. With a client of sexual abuse the person has lost their autonomy, the ability to govern themselves or maintain internal emotional homeostasis, thus a partnership of the counselor client relationship is crucial for the client to gain back their own autonomy. The root meaning of therapist is “fellow traveler on a journey” this is the essence of the healing that takes place within the relationship of the counselor and client. It is a process that must be taken together, but gradually the tools are building up the client to govern their own inner emotional state.

Thursday, July 6, 2017

Co-Occurring Substance Use and Mental Health

co occurring substance use mental healthAn extremely high prevalence of comorbidity exists between substance use disorders and mental illnesses. What “comorbid” or “co-occurring” means is that the symptoms of two or more disorders occur simultaneously (or congruently) in the same person. The interaction between the illnesses can drastically exacerbate the symptoms a person experiences, as well as make the conditions challenging and more complex to treat. Co-occurring disorders can be quite difficult to diagnose due to the compound nature of the symptoms, as for each disorder there is a biological, psychological, and social component of the symptoms that often overlap. It is fairly common that individuals will receive treatment for one disorder while the other is left untreated. When left undiagnosed or untreated, co-occurring disorders can lead to more severe symptoms than solely mental illness or substance use, such as: medical illnesses, homelessness, incarceration, suicide, and death.

With substance use and mental health, the question that plagues providers is often similar to the chicken and the egg question- which came first? One aspect of this conundrum is certain people with mental health disorders are far more likely to experience substance use disorders than those without mental health disorders, and vice versa.

It is quite challenging to determine causality of substance use and mental health disorders for several reasons that include, but are not limited to, the following considerations:

1) Mental illnesses can prompt a person to self-medicate symptoms with substance use. Consider a depressed person who drinks alcohol to alleviate symptoms of depression. Alcohol is a known depressant, so while drinking may temporarily cause the person to feel better, the symptoms of depression remain untreated and will likely worsen, requiring greater amounts of alcohol or more frequent episodes of drinking to provide the person with some relief, this pattern being one of the criteria for the onset of alcoholic drinking.

2) Drug and alcohol use can cause individuals to experience symptoms of mental illness. Consider a person who has been using methamphetamines for days without sleep, who begins to experience active hallucinations and symptoms of psychosis.

3) Both substance use disorders and mental illnesses can be caused by exposure to stress and/or trauma, genetic vulnerabilities or predispositions, and underlying brain deficits.

4) Mood disorders in particular increase a person’s vulnerability to substance use and addiction, as well as the inverse.

How are co-occurring disorders treated? These disorders are undoubtedly served best by an integrated treatment, where practitioners address both the mental health and substance use disorders simultaneously, as well as any primary care issues that may have developed as a result of the untreated disorders and the side effects thereof. According to SAMHSA, “Combining strategies from psychiatry and addiction treatment can lower relapse rate among rehab graduates, reduce the number of suicide attempts, and foster long-term abstinence.” In addition, comprehensive, integrated treatment not only reduces cost for the individual or family, but has far better outcomes than when treating the disorders separately.

When utilizing integrated mental health and substance use interventions, the same team of clinicians will work together in one setting, will all take responsibility for the client’s treatment, and will create a very comprehensive, coherent treatment package where symptoms from all disorders are treated. In this method, the treatment approach and philosophies remain consistent, as well as the set of recommendations. This also lessens the chance for individuals to medication-seek from providers who aren’t in contact with one another. For example, consider a person who suffers from symptoms of anxiety (as related to both Generalized Anxiety Disorder and alcohol use disorder). That person could easily go to a mental health provider, report the feelings of anxiety and not the alcohol use disorder, and be prescribed a benzodiazepine. This may lessen feelings of anxiety, but it would do nothing for the person’s sobriety, and would likely exacerbate the situation as now the person has a prescription for benzodiazepines and is drinking alcohol on top of them, a very dangerous combination that can be lethal. It is for this reason pharmacotherapy is much more effective when the treatment plan addresses mental health as well as substance use.

The following are additional reasons integrated treatment for co-occurring disorders is most effective:

1) Treatment of substance use and mental health issues simultaneously may help clients address unique triggers, such as depression, panic, or mood swings.

2) Group therapy in this setting provides a more specific and stronger support system for those who experience substance use and mental health disorders.

3) Integrated treatment also aims to overcome side effects of mental health disorder, such as barriers to socialization, impaired motivation, and reduced attention.

4) Challenges with medication are reduced, as there is a drastic reduction in prescribing medication that may be counterintuitive to symptoms of substance use, but not to mental health and vice versa.

In closing, co-occurring disorders are nothing less than very complex disorders that hence, require a complex form of treatment to be most effective. Substance use and mental health combined, when left untreated, are incredibly deadly. It truly requires a team of individuals collaborating recommendations and treating ALL symptoms to help those with these disorders to enjoy a life of recovery.


Heather Smyly

Friday, June 30, 2017

Interpersonal Relationships in Recovery

interpersonal relationships in recoveryDeveloping healthy interpersonal relationships, both platonic and intimate, is essential in maintaining long-term recovery from drug and alcohol addiction. When entering recovery many people have little to no close relationships due to the damage they have caused while in active addiction. Often the relationships they have maintained are unhealthy, not emotionally supportive, and occasionally even abusive. Learning how to detach from these relationships is imperative for the addict, because it is impossible to heal and recover while still involved in unhealthy environments. This can be a challenge for many people because although they are taking a step towards a healthier, happy life detaching from relationships can leave them feeling alone and vulnerable. Due to the nature of their past relationships many people don’t have any idea how to form healthy relationships or what a healthy relationship even looks like. Working with a sponsor and therapist can be very helpful in this area because they will model what healthy human interaction and positive emotional support look like. There are many things that are important to acknowledge when beginning to form new relationships in recovery.

It is incredibly important in recovery that people make sure to take the time to get to know each other. Taking relationships slow and steady helps to ensure that neither party causes harm to the other and that both people are aware of the things the other needs in a relationship. It's easy to mistake excitement and validation for love, especially in recovery where people are looking for instant gratification and distraction from intense negative feelings. For this reason people often jump into relationships quickly, whether it be a friendship or romantic relationships, and later realize they have nothing in common with this person or continue their pattern of volatile interpersonal relationships. In romantic relationships this often leads to relapse, as the person has been distracted from completing any deep personal introspection and adjustment of behavior. When relationships are taken slow and given time to develop naturally, the skills of healthy communication, confrontation, and emotional support can be learned with the help of treatment providers and 12 step programs. Community and healthy connection can be one of the biggest and most valuable assets in the difficult journey of recovery.

Another important factor in relationships in recovery is to make sure that both people are focusing on their individual program. Frequently when people begin relationships they stop going to as many 12 step meetings, limit communication with their sponsors, and slack in the personal areas of their programs such as 12 step and service work. This is because the new person in their lives becomes a distraction and they lose focus on their own work. This can be dangerous because when people are focusing on external factors and distractions instead of internal work and validation they put themselves at a risk for relapse. The other part of this is for people to be able to identify when a relationship is causing harm to them and use the tools they have learned in recovery to exit the relationship. These tools include setting boundaries, communicating feelings, identifying maladaptive behaviors in ones self and others, and identifying relapse risk factors (going to bars for social events, high levels of stress due to conflict).

Friday, June 23, 2017

Treating Substance Abuse with Co-occurring Disorders

substance abuse co-occuring disordersThe definition of recovery is "a return to a normal state of health, mind, or strength". It is becoming the norm for someone who suffers from substance abuse to also suffer from some sort of co-occurring disorder. It could be trauma, borderline personality disorder, a mood disorder, self-harm, amongst other things. Due to this increasing occurrence, it is has forced the treatment industry to evolve. 

Today, treatment often requires a multi-faceted approach. Let’s take a look at trauma as our first example. If a provider only treats the substance abuse, but does not treat the trauma an individual has suffered from, that person will not be able to make a full recovery, and it puts the patient at a higher risk for relapse. The reason being is that individuals with untreated trauma tend to unconsciously recreate the trauma in their lives. This means that if someone has untreated trauma, chances are they are going to put themselves in a situation that will not only cause pain of various types, but the individual will more than likely act out in certain behaviors that are not conducive to “a return to a normal state of health, mind, or strength.” They will be engaging in situations that put their newfound sobriety at risk.

The next example we can look at is some sort of co-occurring mood disorder alongside the addiction, such as bi-polar disorder. The same principle applies, if a provider treats the substance abuse, but not the mood disorder the individual will not be able to make “a return to a normal state of health, mind or strength.” People who suffer from addiction already suffer from extreme emotional swings due to the chemical imbalances in their brain. Couple that with bi-polar disorder and there is an extremely volatile situation that could quickly lead to relapse. In situations such as this it is paramount that they be under psychiatric care while being treated for their substance abuse. If the individual is not stable, how can they even benefit from substance abuse treatment? They won’t even be able to take in and apply what they are learning, nor will they be able to pursue the introspective practices necessary for substance abuse recovery. In the long term situation, an individual is at great risk for relapse if their mood is not regulated, because they run the risk of self-medicating with addictive substances.

If your loved one suffers from addiction with some sort of co-occurring disorder there are several things to look for when seeking treatment for them. Make sure the facility is adequately equipped to treat whatever co-occurring disorder is going on with your loved one. Ask specific questions pertaining to their treatment of the co-occurring disorder, and what the intensity of the treatment is. Furthermore, with someone who has a co-occurring disorder, it is absolutely vital they receive long term care. Substance abuse is a complex enough issue, couple it with a co-occurring disorder and treatment gets even more complex and intricate. Thirty days is simple not long enough to fully, effectively treat the issues at hand. A thirty day inpatient facility is a good start to get the ball rolling, but after care in a long term program is vital for recovery in situations with co-occurring disorders.