DBT Peer Connections

Building Hope, Community and Skillful Means


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FREE DBT Skills Training Online! Participate in IRB Approved Research!

Do you want to take part in a free 6-week DBT skills training course? There is still one week left to get your name on the research participant interest list. All you need to do is fill out the form below. if you fit the study criteria, you will receive a formal invitation to join via email between 09/01/2015 and 09/15/2015. Thank you for support and interest. Please share this post!

Rachel Gill, Primary Researcher

 

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Dialectical Dilemmas of Extreme Emotional States in People with BPD

A defining feature of borderline personality disorder (BPD) is extreme, intense, and long-lasting emotions and an inability to recognize, label, and process such emotions. Therefore, people with BPD tend to move back and forth between extreme emotional states that leave them and those around them exhausted, overwhelmed, and uncertain of how to resolve unending crises.

Dialectical Dilemmas of Extreme Emotional States

The following describes 3 common sets of emotional extremes people with BPD vacillate between. The term dialectical dilemma refers to the ongoing goal for the affected and willing person with BPD is to synthesize a balance between each extreme state as they occur.

  • Vulnerability versus Self-invalidation
  • Unrelenting Crises versus Inhibiting Emotions
  • Active passivity versus apparent competence

Definitions

  • Active Passivity – Feeling helpless, wanting and/or asking others to solve one’s problems
  • Apparent Competence – Excessive independence, not seeking help from others or admitting to needing it
  • Inhibiting Emotions – Blocking/invalidating expression and/or denying acknowledgment of unwanted emotions
  • Self-Invalidation – Judging, punishing, questioning and/or denying acknowledging one’s emotional experience
  • Unrelenting Crisis – hyper-alertness to unwanted emotions that, in turn, increases their intensity/duration
  • Vulnerability – Expressing/communicating emotional experience/urges to self or others

Definition Examples

  • Active Passivity – “I can’t get through this on my own.”
  • Apparent Competence – “Don’t worry about me. I’m fine and have everything under control.”
  • Inhibiting Emotions – “If I just ignore my emotions, they will go away.”
  • Self-Invalidation – “I should not feel this way. I am too sensitive and emotional about every little thing.”
  • Unrelenting Crisis – “When I can’t stop feeling sad, I just drink until I black out.”
  • Vulnerability – “I will kill myself if he leaves me because I can’t live without him.”

BPD Dialectical Dilemmas by Rachel Gill

May is Borderline Personality Disorder Awareness Month

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My Name is Rachel Gill. I have Borderline Personality Disorder and I want the world to know  I am not ashamed. You want to know about BPD? Kindly ask and  I will tell you all that I can

My Name is Rachel Gill. I have Borderline Personality Disorder (BPD)and I want the world to know I am not ashamed. You want to know about BPD? Kindly ask and I will tell you all that I can about my experience. May is BPD Awareness month!


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PMS: A Threat or Culture That Devalues Emotional Experience?

It seems to me the problem with PMS is not that it is something we need fear but that so many refuse to acknowledge and accept its terms of being a qualitative expression of unpleasant emotions. This not only negates a person’s real and subjectively defined experience, but also essentially reinforces the continued tradition of labeling emotions not by quality of experience but by the degree of social approval/disapproval they receive. What is it that makes American culture so emotion-phobic, and stigmatizing toward emotional expressions only admiring them when manufactured for entertainment purposes as in movies and other media?

If we were an emotionally accepting society, we would not likely be arguing about PMS because there would be no social framework necessarily interested in belittling emotional experience, an experience as essential to our existence as any of our other biologically defined sensory perceptions: sight, sound, taste, touch, smell. When we attend to describing emotions as personal traits inextricable from the person, emotions become a flaw or defect in personality instead of simply another human behavior. Consider the following passage by Marsha Linehan who discusses how failure to acknowledge emotional experiences leads to further dysfunction in the person which causes the environment to become less supportive, which causes more distress in the person and so on.

Negative emotional expressions may be attributed to traits such as over reactivity, oversensitivity, paranoia, a distorted view of events, or failure to adopt a positive attitude. Behaviors that have unintended negative or painful consequences for others may be attributed to hostile or manipulative motives. Failure, or any deviation from socially defined success, is labeled as resulting from lack of motivation, lack of discipline, not trying hard enough, or the like … In any case, the individual’s private experiences and emotional expressions are not viewed as valid responses to events. (Linehan, 1993)

All judgment based assumptions do is fuel the fire of self-invalidation, misery, alienation and lack of acceptance of oneself and the world at large. Perhaps, American males are even worse off than women in the case of emotional expression as we live in a society that forbids males of expressing almost every emotion save for anger. Society has little tolerance for males expressing sadness, love, or fear without it being tied to a lack of masculinity. It is not that boys do not cry; it is that they face punishment and ridicule for expressing their human emotions, which are not qualities of gender at all.

I am an emotionally sensitive person. I cry; scream, yell occasionally, and I hated myself for many years because I had been convinced that my emotionality was a matter of choice, lack of will power. Strictly, from a perspective of someone who has borderline personality disorder (BPD), I can tell you that having BPD coupled with PMS is hell, but is it something to fear? Emotionality: it is like a hurricane within me that destroys my relational ties by the ironic force of my polar nature. It manifests itself through a chaotic blend of intense desperation for love, the fear of losing it, and not having the self-esteem needed to love myself. I am often frustrated with how my fellow humans take their ability to regulate emotions for granted American society I have to go to therapy for a year to learn interpersonal skills that come naturally to others. This frustration is reasonable. However, is it reasonable to frame emotional responses in terms of danger? It seems unreasonable to me. What do you think? Either way, it is clear society is improving its acceptance of human nature’s emotional reality and still has a ways to go to come to a more wise state of mind that balances emotion and logic equally.

Since I cannot change the world; I can only change myself, to counteract my conditioned urge to hate and punish my emotions, one of the new skills I am recently practicing rooted in Zen Buddhism is Loving Kindness. I learned it at a 2 day mindfulness training with Marsha Linehan last year. I am using it to help create an opposing force, a dialectic, to my chronically accessible negative self-talk. I do this by acting opposite of my urge, sending myself love and kindness and radically accepting myself and the world, all as it is. Here is a mantra.

“I am an emotional person and I accept me and the world and all within it as is. I send love and kindness to myself, to my emotions and my emotional sensitivity and to all creation without judgment, but an open heart and mind.”

 References

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder (p. 50). New York: Guilford Press.


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Suicide: Seeking Support in a Culture of Stigma

Mental Illness Awareness Week-Pinki Tuscaderro.Art-WEB

Suicide: it is the act of killings oneself. With suicide being the leading cause of violent death in the United States and, “data-based projections suggest that the number of self-inflicted deaths will increase by as much as 50 percent from 2002 to 2030,” (Nock et al., 2008) society can no longer afford to remain silent about suicide. Yet, even with such alarming predictions indicated by these statistics, it seems suicide is a topic that seems only to reluctantly capture the public’s attention and only when a police wellness check[1] goes awry or the suicide happens concurrently with a homicide. Then discussions on prevention and intervention may briefly find their way into news segments or public service announcements, but action rarely occurs before the topic loses interest and abandoned, suicide does not come up again until the next incident occurs and so the cycle continues.

Although in America suicide bears a mark of shame, its role in other cultures has complex roots that must be studied in their own right before there can be cross-cultural comparisons. To this end, the focus here is upon aspects of suicide as they relate to American culture, and contemplation of the act itself focuses on suicide because of impulsivity. Therefore, death with dignity and issues of doctor-assisted suicide are not a focus of this discussion. Examination of concepts, beliefs, and traditions that define how society regards suicide, cultural effects of stigma, and a compendium of the various methods employed by society to address suicidal behavior shall be set forth, and implications for improving upon these methods discussed in conclusion.

In American culture where stigma complicates the question of seeking support for suicide, a person who may be contemplating taking his or her life not only faces the difficulty of resisting fatal urges to die, but he or she must likewise weigh the consequences of asking for help. The caveat is that the potential that there will be aversive instances of judgment, criticism, and shaming at some point down the line of care is such that provides a powerful argument to suicidal persons for not seeking assistance in the event of a suicidal crisis. This tendency to avoid help-seeking is highlighted in a recent study of college students whom were asked about whether they would seek help if they had suicidal thoughts and/or actions the overall message was one of, “ambivalence about treatment need or effectiveness, stigma,” (Arria et al., 2011). The lack of compassion and validation that would encourage persons to seek assistance for suicidal thoughts within the system of care must shift if this is to change. Society must come to understand that by shaming or condemning those who attempt suicide it drives the person toward rather than away from the behavior.

To give an example of how firmly ingrained stigma is within the American culture. Let us look at a podcast recently viewed on ITunes University where an emergency room medical doctor gives medical students a lecture on suicide. Since emergency responders are likely to be on the front end of caring for suicidal persons, it is disconcerting to say the least the degree of irreverence, humor, and apparent lack of concern expressed over the course of the half-hour lecture. Suicidal persons are described as selfish, made light of, and while there was discussion related to determining whether or not to believe whether a person claiming to be suicidal is serious or not, there was virtually no information offered to students on how to appropriately interact with such persons.

Furthermore, the lecturer shares with the class his first incident on the job as a new doctor; where he witnessed a suicidal person engage in suicidal behavior. He describes how when presented with a person holding a sharp implement up to his neck threatening orderlies not to come closer the attending physician shrugged nonchalantly and told the suicidal person to “go ahead, we’ll just sew you back up again,” (Reiser 2011) to which the suicidal person responded by proceeding to stab himself in the neck, to which medical staff responded to by physical restraint and the doctor set about stitching the person back up again. This example shows how ambivalence toward person’s suffering antagonizes patients and can actually serve to ensure escalation of suicidal actions. Therefore, it is critical for emergency responders to receive appropriate training to understand the mechanism of interpersonal relations as it relates to suicidal behavior. Dealing with persons already in an aroused state toward self-violence, requires intervention that is mindful in choosing words, tone of voice, body posture. Any perceived criticism on part of the patient, may lead to interpretations that upset the suicidal individual further. Generally, interveners need to communicate without judgment, condescension, sarcasm, or marked ambivalence. Marsha Linehan, one of contemporary clinical psychology’s foremost experts in the area of treating suicidal behavior explains.

Reinforcement of patients’ behavior is one of the most powerful means of shaping and strengthening skilled behavior in borderline[1] and suicidal patients. Frequently, these patients have lived in environments that overuse punishment. They often expect negative punishing feedback from the world in general and their therapists in particular, and apply self-punishing strategies almost exclusively in trying to shape their own behavior (Linehan 1993).

What appears to be the disconnect from the perspective of first responders is that they are trained to respond to physical ailments where interaction with patients on an interpersonal level is generally restricted to efforts of gathering facts related to the source of injury. Suicidal action is unique in that the quality of interacting with suicidal persons plays a role in how severe the injury turns out to be in the end. By giving medical professionals some simple training that would give them an idea of how suicidal persons may perceive and respond to different communication strategies, the chance for escalating suicidal action once in medical care reduces.

Now, in order to more clearly identify what stigma is and how it functions let us consider how society generally regards those whose source of ailment is visibly apparent compared to those whose ailments are not visible as is the case with most mental disorders. While people battling cancer may find labels that describe them as brave, strong, fearless, determined, etc., people who have suicidal crises are often seen as being clingy, needy, and attention-seeking, which likewise precipitates withdrawal of support from loved ones as well as the system of care. Add to that the fact that most mental disorders have yet to be defined in anatomical terms, which would provide a descriptive map of how signals in the brain lead to suicidal behavior, it becomes apparent the means to convince and thus satisfy skeptical, discriminating minds are meager at best.

The fact that suicides are continuing to be on the rise the world over suggests that suicide is not characteristic of the individual but is an urgent issue affecting public health and needing immediate action. As such, questions of suicide require examination from as many angles as possible, looking at factors from more scientific over anecdotal and case study perspectives is imperative. There must likewise be agreement that the, “suicidal patient is not receiving adequate care unless he or she is provided with a psychotherapeutic relationship that offers support, accessibility, investigation of the patient’s current life impasse, and close monitoring of the patient’s mood shifts” (Maris, Berman, Maltzberger, & Yufit, eds. 1992). The problem is getting from where suicide intervention is today, a haphazard process of medication, emergency room visits and brief hospitalization with referral to psychotherapy that would address suicidal behavior in a more comprehensive manner being restricted to a few sessions to check in with the patient after which the case is essentially dropped.

Even if patients were referred to psychotherapy, the quality of such therapy is not necessarily apparent without simply submitting to trial and error since current suicide research remains mostly focused on assessing and predicting suicide, analyzing statistics, and testing experimental drugs, and while looking for academic literature that would offer research data supporting the diverse methods employed in preventing or treating suicidal behavior, it seems assessment and prediction studies outnumber treatment research as much as 10 to 1. The good news is that there is exciting work underway in the field of neuroscience thanks to the profound advancements in brain imaging technology, over the last twenty years. While the data gathered will certainly lead to a greater understanding of the biological processes that occur in tandem with suicidal action, it will still take some time to come to any sort of reasonable conclusions as to what all the data collected means.

Since science has yet some time to offer information about the brain that could capture public attention enough to initiate change in minds by scientific measure, advocates must do what they can to fight stigma at the local level even if it means changing one mind at a time through conversations in casual settings, social networking, organizing community events, etc., There are three areas from the perspective of reform that require consideration. First, there needs to be a priority on a) treating the dysfunctional behavior from within the social environment by way of advocacy, awareness, and educational campaigns led by people who have lost loved ones to suicide or attempted suicide and that can provide a model of compassion that is more accessible, generally, than statistical data b) increase research funding and provide more scholarship opportunities that would give students incentive to pursue degrees in the mental health field c) define a clear chain of command where those building evidenced-based research are direct advisors to legislation, reform projects, external quality assurance reviews, etc. d) Finally, there needs to be a clear process outlined for bringing treatments out of the lab to train professionals so that they may be put into practice in the real world.

One particular myth that is prevalent and needs dispelling is the idea that suicide attempts are manipulative acts expressly intended to get others to respond accordingly. The problem here is that suicidal people are typically acting in response to intense emotions that they do not have the skills to label accurately, experience, and modulate effectively Despite popular belief, “most individuals do not want to die; they just want the pain to go away” (Leenaars, 2004). To the person who may engage in suicidal behavior, the possibility of death represents an immediate solution to a temporary state of emotional suffering the person does not believe he or she can otherwise effectively alleviate. It seems that the combined factors of emotional reactivity, tendency to think he or she is bad and deserving of punishment/death, and lack of skillful means to counteract intense emotions overwhelms the person so they become desperate and want immediate relief, which is what death appears to be. However, while Death is certainly immediate, whether it leads to relief remains unknown.

Furthermore, there is little debate that “prevention should address all levels that influence suicide: individual, relationship, community, and society” (Barnes, Golden, and Peterson). The problem with statements like these is that instead of producing comprehensive strategies that outline steps which may lead to intelligible solutions, the result of government delegated committees, task forces, and organizational allies claiming to be working hard to address suicide are usually long-winded documents that restate the problem of suicide, the goals toward reducing it and why it is so important that society acts immediately to address the problem. When looking closely at these reports, references to authors responsible for composing the documents are simply omitted in favor of simply listing the name of the department or agency. References to literature are usually restricted to other government reports rather than academic research if there be any references at all, and formats for papers generally reflect what is available from Microsoft templates rather than following any formal pattern of technical writing.

When we look at comprehensive treatments addressing suicide outside the realm of brief intervention, it seems that, “Dialectical Behavior Therapy is the only treatment with published manuals to date…” As to disseminating evidence-based treatments, “for suicidal individuals [DBT] is also the only treatment for which training is currently available” (Comtois & Linehan, 2006). So in addition to increasing funding toward research aimed at treating suicidal behavior there must likewise be a definitive organizational structure that requires and defines a chain of authority where researchers have the final word, are compulsory in advising legislative bodies, and where laws call for organizations to have external reviews or internal processes that monitor quality assurance.

What is more, assigning mental health agencies the responsibility for monitoring the quality of their own services creates a conflict of interest that allows agencies to follow their own choice of rules and weakens the rights of clients who are dissatisfied with the services received. It is unreasonable to assume that asking a business whose interest is to serve its own needs above all is going to ensure that it places the best interests of patients first is like asking a known thief to guard an unsecured diamond and then never bothering to check on the diamond again. One way to determine if self-monitoring is effective in quality assurance is to look over county community mental health records who have been monitoring themselves for a number of years and see how many instances there are of an internally monitored mental health agency reporting itself to the appropriate governing board for violating its patient’s rights or reporting itself to the state for allowing employees to act in positions without appropriate professional license. Unfortunately, it seems, consistent records are not necessarily convenient to locate where there is a request for public information.

Is it too much to ask for a few qualified mental health inspectors to come around once a year and hold agencies that do not provide in-ho0use services accountable to their legal obligations? It seems the biggest challenge to create a similar process for mental health agencies is employing experts not necessarily influenced by money. An answer to this problem would be to have governing authorities team up with academic institutions in evaluating mental health agencies rather than employing government contracted providers that act under the advisement of those they are professed to objectively evaluate and there are financial motives, which may serve prejudice assessors.

By incorporating colleges into the process there is not only the benefit of educational opportunity for students interested in formulating research in real-world settings but with college/government collaboration, financial compensation could benefit the college as a whole rather than paying the individuals who happen to be responsible for reviewing agencies. Furthermore, since the individuals engaged in carrying out work would be continuously rotating as students graduate nepotism and concentration of power would be less a concern than it is where there is a long history of cooperation between a governing body providing suicide crisis services and a contractor who reviews them annually. This process or some other similar strategy are imperative as the current honor system is not sufficient to ensure that patient rights are upheld where Medicaid is the funding source or that agencies are necessarily operating legally and according to its proclaimed standards.

It is clear that current suicide intervention strategies employ a variety of methods, many of them have become standard practice, but few rigorously tested by scientific standards. What is more, professionals most often given the responsibility of intervening in suicidal behavior are not necessarily appropriately qualified or a logical choice where the goal is to create a context of support. For example, police receive little to no training in responding to suicidal crises or psychological crises in general, yet they routinely deal with such situations in the line of duty. It does not make sense to think that police would be effective in encouraging a suicidal person to reconsider life, especially, when the police are trained to be defensive and ready to shoot, and if necessary, kill at any moment. Little if any research exists that would prove one way or the other whether police intervention in suicidal crises is an effective strategy. However, there are many instances where unarmed persons claiming to be suicidal end up dead at the hands of police. From a common sense point of view it seems that bringing a person who has a loaded gun and a license to kill, is increasing the risk of violence to all parties involved. The less opportunity there is to access objects that could inflict harm, the less opportunity there is for the suicidal person to act upon his or her impulses. Therefore, it is never wise to bring a gun within the vicinity of one expressing suicidal urges and in a state of hyper arousal.

To offer an example of how subtle and critical interpersonal interaction is in responding to suicidal crises let us imagine the goal is to convince a person that she should live by using arguments of persuasion alone. How the intervener approaches the person is critical in determining whether the interaction turns out to be effective or harmful. An effective way to interact might be to ask the suicidal person what brings her joy, love, and connectedness to this world, what would she miss if she died, this approach facilitates an interaction that functions by impressing upon the suicidal person that the intervener cares. Whereas asking a suicidal person if she has children and who would take care of them or how she thinks they will feel if she kills herself facilitates a sense that intervener is judging and any compliance elicited by this way of guilt is likely to be brief and backfire once the suicidal person realizes the argument provides her more evidence that she deserves punishment or to die.

In addition to the lack of training and evidence based research guiding service delivery methods and oversight of organizations providing services to suicidal persons, few are appropriately aware of the weighty legal consequences that lay ahead for the suicidal person who speeds away in the back of an ambulance and is brought to an emergency room where he is labeled as being a threat to self or others. Although such a person may be somewhat disoriented, he may firmly refuse suggestions that he be committed to psychiatric care. His wife being frightened and wanting to ensure her loved one’s safety acts with little if any question when informed that she has options that would force him into psychiatric care. The term for the procedure where a person is labeled as potentially harmful to his/herself and said person agrees to enter psychiatric care and forfeit his/her power of attorney to a designated person is called civil commitment. Involuntary commitment refers to a person identified as being a danger to his/herself and/or others and whom refuses  recommendation to psychiatric care and so is held against one’s will at the pleasure of the state. There are several problems with this means of suicidal prevention/intervention. First civil commitment is a strategy that refers strictly to matters of law and does not employ clinical expertise to address the delivery system, which would be ideal. In fact, such experts largely are employees working for state and county departments and may have little more than an arbitrary certificate that attests to the fact that they attended a two-day to one week training created by other employees who may be but typically, are not legally qualified and/or licensed mental health professionals.

The most alarming and disregarded fact of civil commitment is that it is a procedure, which essentially deprives individuals of life and liberty as defined by the United States Constitution. With a simple claim that a person might be a danger to his or herself individuals are sent to a hospital that is more like a prison since individuals are under 24 hour watch and their movement is restricted to a ward with minimal if any time outdoors. What is more, civil commitment procedures are not standards assessed, measured, and decided by qualified clinicians, but by judges, lawyers, and officers of law whose training conditions them toward purposeful skepticism, unemotional objectivity, solutions that value protocol over process, and rely on isolated events to define absolute judgments of character.[3]  These factors of style in communication challenges the wisdom in putting legal professionals in charge of suicide treatment/intervention programs.

For this reason, civil commitment is by far the most questionable means of suicide intervention as it involves forcing a person to do something against his or her will, which is a violation of our most fundamental right to liberty. Despite a loved one’s best intensions to protect the suicidal person, the fact it is civil commitment is a legal process that effectively denies individuals their constitutional rights defined in amendment v, which state that no citizen shall, “be deprived of life, liberty, or property, without due process of law.” Amendment VI further defines due process.

… [t]he accused shall enjoy the right to a speedy and public trial, by an impartial jury of the State and district wherein the crime[4] shall have been committed, which district shall have been previously ascertained by law, and to be informed of the nature and cause of the accusation; to be confronted with the witnesses against him; to have compulsory process for obtaining witnesses in his favor, and to have the Assistance of Counsel for his defence [sic].”  (Bill of Rights Transcript Text, 1789)

The effect upon the suicidal person accused of being potentially dangerous to his or herself and/or others is a system that essentially imprisons individuals without the civil liberties enjoyed by those accused of crimes so that people may spend years locked up in a psychiatric institution without any protective measures to counterbalance powers of authority. The XIV Amendment expressly forbids governance that would “deny to any person within its jurisdiction the equal protection of the laws.” (Bill of Rights Transcript Text, 1866) Unfortunately, in the case of mental health law, any legislative measure enacted to protect patient rights and/or safety, is essentially useless to patients since they have no power to uphold the laws that would protect them.

Meanwhile agencies continue to experiment with court-as-treatment models like that of Multnomah County’s Mental Health Court, which provides distinct powers of authority to the court where a person is convicted of a crime and also has one or more of the following diagnoses, Bi-polar disorder, Schizo-affective disorder, Schizophrenia, or Major depression, (which are each well-known to be disorders that carry a higher risk for suicide than the general population.) The courts use this power to force individuals to use particular drugs related to his or her mental health diagnoses, to increase legal authority to search, seize, and monitor individuals of interest to criminal investigations. Again, it is unreasonable to put legal professionals in charge of people’s mental health. It seems the shift toward letting jails be responsible for people with chronic mental disorders makes as much sense as creating a cancer court or H.I.V. court. The association between mental health and the justice system is a relationship formed not for practical purpose but is a consequence of stigma.

Although courts may describe mental health court in terms of opportunity to reduce probationary timelines, little research would provide evidence that such methods are effective or if they truly do reduce the time a person stays sick. In addition, “because the control of deviance involves basic values, and because most of those who are involved in the process as potential patients are relatively powerless, the formal protections of law are all the more important.” (Levine, 1981) So while it seems the emergency response system combined with the forces of legal authority may be effective in creating physical barriers that prevent/discourage suicide in the short term, these social contexts are inadequately qualified at best and harmful at worst to those it intends to serve.

The last two areas discussed relate to gatekeepers who look for indicators of suicide before persons make an attempt and suicide hotlines. In the case of gatekeeping, persons employed, typically hold positions with a degree of administrative authority, but rarely hold equal professional qualifications. The term gatekeeper itself refers to the fact that the strategy aims at the front end of health care service delivery system (Evans & Farberow, 1988). The primary environment where gatekeepers operate is schools and the hope is that by identifying individuals who may be at risk, responders may act preemptively so that intervention comes before crisis (in theory), thereby preventing suicide. Again, these professionals are not typically qualified to practice psychology. Instead, such persons tend to receive minimal training, again, usually consisting of 1 or 2 workdays with each program devising trainings according to the preference of its particular service delivery environment.

The final mode of suicide prevention/intervention discussed is suicide hotlines. In this service design, prevention measures are not in the context of a government function or legal process, but typically operate as non-profit organizations ran by volunteers who have themselves attempted suicide or lost someone to suicide. Therefore, as one might expect, communication strategies of this nature are more likely to be comprised of individuals working in the capacity of empathy, concern, and genuine care than those formerly discussed. This is the strength of suicide hotlines. However, research testing the effectiveness of suicide hotlines is largely non-existent. As such, the actual usefulness of hotlines in suicide prevention has yet to be determined.

It seems that the major issue in providing supportive services to suicidal persons is not whether there is a need for support; it is garnering the will necessary at the operational level to bring about a change in public attitudes so that the stigma currently preventing those in crises from seeking help can be eradicated and people in crises can feel comfortable instead of ashamed for asking for help. While legislative action has attempted to reform mental health service systems o ver the past couple of years, there has been little will within governing bodies to implement these laws. Further, while, “suicidologists have argued that therapy with the suicidal patient requires distinctive competencies, such as the ability to conduct an ongoing assessment of lethality, the capacity to intervene directively and forcefully, and the skill to mobilize the social support available in the client’s natural environment” (Neimeyer & Pfeiffer, 1994), However, as treatment accessibility/efficacy remains tentative at best, and it continues to be a slow and difficult process engaging the public in discussions about suicide that would spark national concern more than political debate, it seems that a primary obstacle to defining a process of appropriate care, is that stigma operates within social institutions where change is slow and resistant to incorporating new ideas.

It seems that in treating suicidal behavior the overall message from a practical stand-point appears to be that saving lives is going to require us to turn our concerns from continuing to create physical barriers (like putting up a fences around Portland, Oregon’s Vista Bridge, to stop people from jumping off of it or forcing individuals into locked psychiatric wards to protect the person as well as the public.) and, rather shift focus toward identifying factors that may effectively remove social barriers that reinforce suicide behaviors. Therefore, not only must we commit to challenge prejudice in others, we must challenge prejudice in ourselves so that people who are contemplating suicide can stop being afraid to seek help. We must likewise commit to researching and developing evidence-based treatments that incorporate training elements that are articulated in treatment manuals and designed for dissemination to professionals who work with suicidal persons.

Once the stigma and taboo associated with suicidal behavior and mental disorders in general is overcome, psychology may finally be in a position to not only usher in a new era of innovative and enlightened approaches to treating suicidal behavior but perhaps it may finally catch up to the wealth of technological advancements that have revolutionized modern life in most other fields of science. In terms of defining the biology of suicidal behavior, it appears that the brain is the final frontier, the last place within the human body that still casts an aura of mystery, fear, and suspicion of mental disorders that will not stop until neuroscientists present us with a physical model of depression and other disorders of the brain which still largely exists in the realm of theory.

It is true that brain-imaging technology is leading to a wealth of new data. However, process for analyzing such data meaningfully is yet to remain seen in the future. At last, while it may seem a daunting if not insurmountable mission to change the culture surrounding suicide, still, as long as there are people who continue to speak up and work toward changing attitudes surrounding the issue of suicide, it is certain that awareness will lead to acceptance and change will lead to hope and ultimately save lives.

Endnotes

[1] A wellness check is when a party requests the police to check on someone who may have mental and/or other health problems that cause significant impairment and where the concerned party has not been able to otherwise reach such person.

[2] Borderline refers to people who have borderline personality disorder, which are known particularly for engaging in self-injurious and/or suicidal behavior.

[3] For example, judges routinely favor police officers over civilians testimony in proceedings where there is conflicting statements and/or lack of further evidence, which implies without reason that the fact of one’s employment is enough to determine a person’s degree of honesty and reliability. Further reinforcing this myth is the good guy/bad guy dichotomy that defines the U.S. system of crime and punishment.

[4] In the context of civil commitment, individuals do not necessarily commit a crime. Instead, at there is a presumption of danger. 

References

Arria, A. M., Ph.D., Winick, E. R., B.A., Garnier-Dykstra, L. M., M.A., Vincent, K. B., M.A., Caldeira, K. M., M.S., Wilcox, H. C., Ph.D., & O’Grady, K. E., Ph.D. (2011). Help seeking and mental health service utilization among college students with a history of suicide ideation. Psychiatric Services62(12), 1510-1513. Retrieved October 6, 2013, from http://www.ps.psychiatryonline.org

Barnes, D. H., Golden, R. N., & Peterson, F. L. (2010). The truth about suicide. New York, NY: Facts on File.

Cohn, D., Taylor, P., Lopez, M. H., Gallagher, C. A., Parker, K., & Maass, K. T. (2013). Gun homicide rate down 49% since 1993 peak; public unaware. Pew Research Social & Demographic Trends Project. Retrieved November 6, 2013, from http://www.pewsocialtrends.org/2013/05/07/gun-homicide-rate-down-49-since-1993-peak-public-unaware/

Comtois, K. A., & Linehan, M. M. (2006). Psychosocial treatments of suicidal behaviors: A practice-friendly review. Journal of Clinical Psychology62(2), 161-170. doi: 10.1002/jclp.20220. Psychology and Behavioral Sciences Collection

Evans, G., & Farberow, N. L. (1988). The encyclopedia of suicide. New York, NY: Facts on File.

Leenaars, A. A. (2004). Psychotherapy with suicidal people: A person-centred approach. Chichester, West Sussex, Eng.: John Wiley & Sons.

Levine, M. (1981). The history and politics of community mental health. New York: Oxford University Press.

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder (p. 61, 63). New York: Guilford Press.

Maris, R. W., Berman, A. L., Maltzberger, J. T., & Yufit, R. I. (Eds.). (1992). Assessment and prediction of suicide. New York: Guilford Press.

Neimeyer, R. A., & Pfeiffer, A. M. (1994). Evaluation of suicide intervention effectiveness. Death Studies, 18(2), 131-166. doi: 10.1080/07481189408252648

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Reiser, Robert, MD. “Suicide Lecture.” Lecture. Emergency Medicine. University of Virginia, Charlottesville. 08 Nov. 2013. ITunes: A Lifetime of Learning on Tap. Apple, 08 Feb. 2011. Web. 24 Nov. 2013. https://itunes.apple.com/us/podcast/suicide-lecture/id401907904?i=91128597&mt=2

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Fighting Mental Health Stigma: The Power of Your Personal Story

RecoverThere are plenty of reasons why not to share your mental health story and one very important reason why to share  your mental health story; the only way to really fight the shame and stigma of having a mental disorder is for us who have mental disorders to stop acting as if we are ashamed of our mental health status, i.e., hiding and protecting our mental health diagnoses like a dark secret or a skeleton in a closet. The mental health movement would be wise to follow our LGBT friends example. It is time for us to come out of the closet about mental health. In the end, it is the only way we will truly conquer stigma.

I have come to find that sharing one’s story is not only powerful but the most powerful tool one has to fight stigma. Therefore, I shout it loud and proud that I have borderline personality disorder and I am not ashamed. The more I say it too, the better I feel about myself. My goal is to show that there are real people behind the diagnosis who are not only decent, likeable persons, contradicting stereotypes but who are working hard to overcome their mental health challenges and be productive members in their communities and society at large.

However, if you are going to go public like me and use your suffering as a positive tool to advocate for ending stigma against mental disorders, it is best to stay mindful of the image you project as you are essentially setting a tone for your diagnosis or diagnoses in the public eye, so be aware of and intentionally work to counteract stereotypes. Write your story in terms of recovery, avoid going into detail about extreme behaviors/symptoms or sharing your story while dissociating, emotionally dysregulated, etc. Share while you are in your wise mind and always be aware and considerate of your audience. Even though stigma may cause you to become justifiably angry or frustrated, responding to these emotions is rarely effective at getting others to see your point of view.

Finally, if you are unsure whether your posting is appropriate for public consumption, remember this; if you would not feel comfortable with your parents, grandparents, or children (if applicable) reading your story, do not publish it online.


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Could DBT skills training prevent bullying?

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Bullying is a significant problem the world over that only continues to grow. With the threat of harassment, physical and sexual assault affecting youth at a critical stage of human development that eventually shapes the pattern of behaviors people will show as adults, it is imperative that researchers press for greater understanding of the causes and effects of bullying to construct means to reduce it. The preceding discussion offers an outline for preventing future victimization. 

Defining, Treating, and Preventing Bullying

With the increasing population, school systems that have high student to teacher ratios, and cultural traditions that generally place responsibility for preventing victimization upon parents or those victimized, if there is any addressing of prevention at all, it becomes apparent that the problem of bullying is one that society cannot afford to ignore any further. The problem is widespread, pervasive, and the methods employed by perpetrators of bullying are equally diverse. Bullying is apparently an important risk factor to developing a number behavioral problems and mental disorders as an adult, and, currently, preventative strategies for bullying are largely non-existent.

Purpose

The aim of this analysis is to define bullying with specificity toward behavior, persons involved, causes, effects and measures of prevention. In examining the current facts related to issues of bullying, a clearer description of the problem hopes to emerge and likewise inspire more dynamic, insightful solutions.

Hypothesis

Implementing a requisite skills training class for sixth graders that uses the four learning modules taught in dialectical behavior therapy skills training groups including core mindfulness skills, interpersonal effectiveness skills, emotion regulation skills, and distress tolerance skills (Linehan, 2014) may be a useful means to prevent bullying. Furthermore, skills training may concurrently address other problematic behaviors that tend to surface in adolescence and/or are a risk to increasing problematic behaviors that may lead to mental disorders and/or other problems in adulthood.

Methodology

Bullying shall be defined, for the purposes of this paper as, “aggressive behavior that is intentional, is repetitive in nature, and involves an imbalance of power between the aggressor and his or her target” (Haltigan & Vaillancourt, 2014). In the process of bullying it appears there are three types. There are those who perpetrate bullying, those victimized by bullying, and those who engaging in bullying both as a perpetrator and a victim depending on the circumstance. The theoretical framework for the proceeding treatment proposal emphasizes a developmental psychopathology and cognitive-behavioral perspective, respectively. In addition, there is special consideration given to the social and cultural contexts that influence bullying.

Discussion

Haltigan & Vaillancourt’s 2014 study finds that bullying is strongest between the ages of 13-17. This means that targets for the purposes of prevention and treatment may likewise be sensitive to the period and the nature of this developmental stage commonly termed adolescence. Additionally, as children get older they tend to bully the same targets. Specifically, in the early stages of group formation (i.e., at the beginning of middle school), bullies are more likely to direct negative and aggressive behavior toward a variety of targets. As they learn the reactions of their victims, the field of victims then becomes increasingly restricted.

This statement offers a compelling aspect of the facts related to developmental trajectories for bullying in the context of social learning. Since the evidence shows that victim responses are critical in the development, perpetuation and maintenance of bullying behaviors, it is logical to assume that intervening within the social and time framework of perpetration would necessarily augment the learning process. In this case, the suggestion is to teach adolescent youth a variety of skills gleaned from dialectical behavior therapy to fit within a mutually ideal time frame of adolescent academic and physical development. The aim is to enhance the developmental process in favor of effective interpersonal relations and emotional wellness. Those that would bully or be victims of bullying will learn more effective means to cope with the process of forming social bonds in the context of group membership, thereby preventing  bullying.

Contemporary Culture & Bullying Concepts

To date, there are no formal requirements at the school level to teach students how to interact with each other effectively as members of society. Most consider teaching children to behave socially the parents responsibility. As such, it is easy to see why problematic interpersonal patterns of behavior may occur over generations through social, as well as, biological paradigms and, furthermore, why it is so difficult to define and enforce codes of conduct at the individual and case level. What is more, parents often teach their children how to behave appropriately in social situations from a perspective of personal values, morality, and socioeconomic status. This makes teaching problem-solving much more difficult because generating behavioral solutions depends upon a solution’s relation to a system of values more than a solution’s relation to a desired outcome.

For example, a parent may teach a child to turn the other cheek in the event that a peer intentionally acts to inflict physical harm because the parent values non-violence. A value of non-violence may mutually align with the behavioral goal of preventing or stopping physical harm from occurring. However, a value-based perspective does not offer a framework for understanding the causes and effects that lead to a problem behavior or solution.

Therefore, the adolescent seeking to prevent current or future harm from happening has no means to frame his or her responses without adopting a totalitarian stance. This means that solutions are more likely grounded in judgments, lacking flexibility, and/or alternative explanations. As an example, a parent might suggest to a child to remain silent or not to press requests because social appropriateness may be more valued than the goal of the child getting what he or she wants. Therefore, a child may never learn to assert herself because effectively getting her needs and wants met is contingent upon a behavior’s apparent moral rightness or wrongness.

In DBT, the rationale behind interpersonal effectiveness skills progresses from a behavioral perspective. Getting what one wants breaks down into detailed steps of action that are consistent and applicable across interpersonal situations. Furthermore, by bringing these skills into the classroom, adolescents can apply what they learn in a controlled, safe environment.

DBT Skills Training: A Bullying Prevention Model

Dialectical behavior therapy (DBT) skills developed initially to treat suicidal behavior, particularly in individuals diagnosed with borderline personality disorder (BPD) (Linehan, 1993). However, mounting research is showing DBT skills training to be an effective transdiagnostic treatment (Neacsiu, et al, 2014). With an emphasis on dialectical thinking, a primary difference between DBT skills training models and other prevention models for problem behaviors is its emphasis on viewing problems from a non-judgmental stance and adopting a behavioral perspective over a trait-based perspective in describing patterns of problematic actions like bullying. Furthermore, “a dialectical or transactional model assumes that individual functioning and environmental conditions are mutually and continuously interactive, reciprocal, and interdependent. Within social learning theory, this is the principle of ‘reciprocal determinism’” (Linehan, 1993 p. 39). This means that the causes of dysfunctional behavior are not necessarily the fault of any one person or circumstance but rather a result of persons and their environment mutually affecting each other over time. From the perspective of reciprocal determinism, the progression toward a dysfunctional or functional pattern of behavior depends on the nature of the behavior, the environment, and the transacting response from all sides involved. To place this concept in the context of bullying, here is an example of progression from dysfunction to a pattern of bullying.

Let us say that an individual bullies, specifically, threatens bodily harm toward another peer. The threatened peer, wanting to deter the threat of violence responds by offering the perpetrator his or her lunch money in lieu of being the target of violence. While for all intents and purposes, the act of paying the perpetrator money solves the problem in the short-term; in the long-term, the likelihood of the perpetrator engaging in threats again increases and may further escalate into real bodily harm in the process of fulfilling conditioned expectations. Therefore, the more beneficial social consequences for problematic behaviors like bullying the more likely the behavior is to increase. On the other hand, the more undesired social consequences there are in place, the less likely problematic behaviors like bullying are to increase.

Initiating DBT skills training at a target age of 12-13 and teaching the four skill sets from within the non-judgmental framework of academic learning provides a context for applying and, therefore, integrating acquired knowledge for the purposes of preventing bullying. What this means is that first, youth may findbuild a common language for describing and understanding behavior, emotions, and interpersonal relationships. Second, because the learning facilitates in a group setting, adults have more control over directing the way adolescents interpret and respond to their own and others bullying behaviors so that they learn to interact more effectively in interpersonal situations. This strengthens behavioral reinforcement.

The DBT skill sets may apply preventively as follows. Mindfulness skills will teach adolescents how to build non-judgmental awareness to the present through a variety of strategies. Awareness, in the context of bullying, helps to identify the source of a problem as it happens one-mindfully and non-judgmentally through observing, describing, and participating. Interpersonal effectiveness skills shall teach youth how to go about getting what they want in an effective way that works toward building healthy mutually beneficial relationships. Emotion regulation skills shall teach youth how to identify, label, and emotion functions, as well as, how to accept, tolerate, and solve difficult emotions. This skill set may be particularly helpful in teaching victims of bullying how to cope with painful emotions caused by bullying and teaching those who bully how to manage urges caused by intense emotions like the urge to attack when angry. Therefore, emotion regulation skills may serve to teach the bullying person more effective means to respond to problematic and/or unwanted emotions.

Teaching adolescents interpersonal effectiveness skills provides youth means to assert themselves, to communicate needs, wants, and how to handle relational conflict. It is important to note, however, that because interpersonal behavior occurs within the broader context of cultural norms, the interpersonal effectiveness skills, according to DBT may need further consideration for those cultures whose norms may differ considerably from those of Western conception.

Conclusion

Bullying is a problem dominating school concerns the world over. It appears most prevalent between the ages of 13-17. While there is much focus on the causes and effects of bullying, comprehensive prevention strategies remain elusive. This study proposes incorporation of a DBT skills training to school curriculums to prevent bullying, mental disorders, and other problematic behaviors developed in adolescence. A process of in vivo group exposure to peer dynamics takes place in the course of skills training that creates a social learning environment that is more malleable than that of the one where parents instruct their children on how to respond to problems outside of the social environment that the problem occurs.

Emotion regulation and distress tolerance skills are further important factors in fostering resiliency in that they teach people how to accept, tolerate, and/or change problematic responses to emotions that, if left unaddressed in adolescence, may grow from a problematic response into dysfunctional patterns of behavior or even into mental disorders (Haltigan & Vaillancourt, 2014). Developing a year-long curriculum that teaches sixth graders core mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance skills provides a context to apply learning in a safe group environment. Therefore, a DBT skill training class for adolescents appears an effective means to prevention The strategy is reasonable in logic, scientific principles, and would seem a cost efficient, widely applicable solution to the continuously growing problem of bullying.

References

Haltigan, J. D., & Vaillancourt, T. (2014, November). Joint trajectories of bullying and peer victimization across elementary and middle school and associations with symptoms of psychopathology. Developmental Psychology, 50(11), 2426-2436. doi:10.1037/a0038030

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. 

Linehan, M. M. (2014). DBT skills training manual second edition. New York, NY: Guilford Press.

Neacsiu, A. D., Eberle, J. W., Kramer, R., Taylor Wiesmann, T., & Linehan, M. M. (2014). Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: A pilot randomized controlled trial. Behaviour Research and Therapy, 59, 40-51. doi:10.1016/j.brat.2014.05.005