Dialectical Behavioral Therapy

To supplement my post about borderline personality disorder (BPD), I’ll comment on a highly effective therapy developed especially for BPD. I, myself, have been through DBT and can attest to its wonderful results. DBT is a modified form of cognitive behavioral therapy (CBT). CBT focuses on addressing cognitive distortions (thoughts that assume negative reasons for a potentially neutral situation) and practicing changing the way you think about the situation. DBT focuses on accepting the way you think, but changing the way you react to the thoughts.

DBT was created by Marsha Linehan for patients with BPD, but is now used for many other disordered patients who suffer from suicidal ideation and self-harm. DBT teaches skills that a person can use to react healthily to difficult emotions.

A dialectic, in the DBT sense, can be represented as a see-saw of extremes, with a healthy center-point. For instance, two state-of-mind extremes include Emotion Mind and Rational Mind. Emotion Mind is when a person’s thoughts and actions are governed entirely by emotions. This could be good – such as when someone is in love – but it is often bad. Too much emotion can lead to inappropriate decisions, behaviors, and unhealthy thoughts.

On the other side of the see-saw, a person might be in Rational Mind. Although this sounds good (and can be good when you are performing highly rational tasks like solving puzzles), it is generally not good to think exclusively in rational mind because you miss emotional components of the situation. For instance, a person who is entirely in rational mind is unable to experience empathy or react appropriately to emotional situations (this is often a complaint made about people with Asperger’s syndrome).

You are somewhere between rational and emotional mind at all times. The middle of the see-saw is called Wise Mind. Here, you can express the right amount of emotion and rational thought to make a clear-headed decision. DBT recognizes that people are often at the extremes of this see-saw, and asks that you use “skills” to move yourself back into Wise Mind before making decisions (such as breaking up with your significant other or self-harming).

Almost every situation has a dialectic see-saw. And according to DBT, it is often best to keep yourself in the middle of the two extremes. The middle would be a compromise. Of course, sometimes compromise is the wrong decision to make (such as when you need to cut ties with an abusive relationship), but compromise is generally best.

Skills that DBT suggest are separated into categories of mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.

Mindfulness includes: grounding yourself in a situation, for instance, recognizing where you are, what you are doing, and what is going on around you; being nonjudgmental, for instance, one of my employees assumes that when the nurses say “she is awful to work with” that they are talking about her. This is a judgmental thought. To be non-judgmental, she would have to say “well, maybe they’re not talking about me. Why am I assuming they are?”

Interpersonal effectiveness entails balancing your own needs with the needs of others, building relationships, and being in Wise Mind when approaching difficult situations.

Emotion regulation includes being mindful of what emotions you’re feeling; being aware of what you want to do – for instance isolating – and doing the opposite; doing things that make you feel good – like leisure activities – or work that makes you feel accomplished – like writing a blog post; coping ahead, for instance, if I know that I will be upset tomorrow because it’s the anniversary of my mother’s death, I can plan some distracting activities to keep myself from brooding.

Distress tolerance includes distracting yourself when you feel upset; self-soothing by taking a bath or rubbing a smooth stone; and accepting reality.

Yes, all this mindfulness stuff might sound cheesy to a lot of you, but being aware of your emotions and how you’re reacting to them is an amazing way of changing the way you behave – and changing the way you behave can eventually remove your dysfunctional thoughts, as well.

This is a series of posts summarizing what I’m learning in my Abnormal Psychology course. Much of the information provided comes from reading my James N. Butcher’s textbook Abnormal Psychology. To read the other posts, follow these links:

The Definition of Abnormal
A History of Abnormal Psychology
Abnormal Psychology in Contemporary Society
Contemporary Viewpoints on Treating Mental Illness – Biology
Contemporary Viewpoints on Treating Mental Illness – Psychology
Frontline: New Asylums
Brave New Films: This is Crazy
Clinical Mental Health Diagnosis: Biological Assessment
Clinical Mental Health Diagnosis: Psychological Assessment
Does the DSM Encourage Overmedication?
Post Traumatic Stress Syndrome – The Basics
Panic Disorder
Obsessive Compulsive Disorder
Hoarding and Body Dysmorphic Disorders
Depression – an Overview
Personality Disorders – Clusters and Dimensions
Personality Disorders – Cluster A
Personality Disorders – Cluster B
Personality Disorders – Cluster C
Biological Effects of Stress on Your Body
Somatic Symptom and Related Disorders
Dissociative Disorders
Borderline Personality Disorder
Dialectical Behavioral Therapy
Paraphilic Disorders
Gender Dysphoria – Homosexuality and Transgender
Anxiety Disorders
Bipolar Disorder – The Basics
Suicide – An Overview

Clinical Mental Health Diagnosis – Psychological Assessment

In my post about the biological assessment of mental health diagnosis, I mentioned that there are three ways a clinician can focus a mental health assessment: biological, psychodynamic, and behavioral. In this post I will discuss the psychodynamic and behavioral assessments of patients.

I’m not sure what a psychological assessment feels like to the clinician, but I have been through several assessments as a patient. Some of them have been very grueling and embarrassing – my 2 hour long assessment for dialectical behavioral therapy comes to mind. Generally, the mental health worker will ask a series of questions to determine personality (am I maladaptive?), social context (am I from an abusive family? caring for an sick family member? a bullied teen?), and culture (I’m a WASC) .

Such an assessment can be either a structured or unstructured interview. In the structured interview, the patient is asked a set of pre-determined questions, even if some of the questions seem inapplicable. In the unstructured interview, the clinician decides which questions to ask. The unstructured interview is much less grueling than the structured one, but it is more likely to produce bias due to the direction of questions that the clinician chooses.

Generally while the clinician is giving the interview, she also assesses the general appearance and behavior of the individual. Is he well-dressed, have good hygiene, look the clinician in the eye? Does he seem to be lying? Observation can also be done through role-playing and self-monitoring. Self-monitoring is a fantastic way to get information that the clinician might miss in a one-hour interview, but it tends to be biased towards what the patient is willing and able to record.

There are also a lot of tests to determine personal characteristics. A famous one of these is the Rorschach Inkblot Test. It’s a series of 10 inkblot pictures to which the patient tells the clinician what she sees and thinks while looking at the picture. The Rorschach test takes a lot of time both to administer and to evaluate, though it can be very enlightening to a clinician who is well-trained in the system.

Another well-known personality-trait test is the Thematic Apperception Test (TAT). The TAT uses a series of simple pictures of people in various contexts. The patient tells a story about what the character is doing and why. Like the Rorschach test, the TAT takes a long time to administer and interpret. The TAT has become a bit obsolete since the pictures were designed in 1935, making them harder for the modern patient to relate to.

The Rorschach and TAT are considered subjective assessments, because they are subject to the clinician’s interpretation. There are also objective tests like the Minnesota Multiphasic Personality Inventory (MMPI), which was introduced in 1943, and revised to the MMPI-2 in 1989. The MMPI-2 is a computerized test consisting of 550 true-false questions on topics ranging from physical condition and psychological states to moral and social attitudes. From these 550 questions, several “clinical scales” are determined. Such scales quantify hypochondria, depression, hysteria, pscyhopathic deviance, masculinity-femininity, paranoia, psychasthenia, schizophrenia, hypomania, and social introversion. It also quantifies the likelihood of lying (inconsistent answers), addiction proneness, marital distress, hostility, and posttraumatic stress.

Such computerized objective tests are helpful because they (for the most part) lack clinician bias, and they are inexpensive. However, they depend upon the patient’s ability to honestly and accurately describe themselves, which many patients are unable or unwilling to do. These tests also tend to be impersonal, and might alienate the patient.

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 4: Clinical Assessment and Diagnosis. Abnormal Psychology, sixteenth edition (pp. 101-127). Pearson Education Inc.

Clinical Mental Health Diagnosis – Biological Assessment

One of the most difficult tasks for mental health workers is to clinically assess and diagnose mental illnesses – especially when comorbidity (having more than one mental illness) is so common. It usually begins with a psychological assessment through tests, observation, and interviews so the clinician can catalog the symptoms. Then the DSM-5 is consulted to give the diagnosis.

A clinician may focus the assessment in three ways – biological, psychodynamic, and behaviorally.

Biological approach

For the sake of appropriate treatment, it is very important to make sure that the symptoms are not due to a physical rather than a mental illness. In my experience, many doctors shrug off certain types of symptoms as those of a mentally ill patient. For instance, when I fainted at work a while back I was told it was “anxiety.” (And because it was diagnosed as a mental problem, my insurance didn’t pay – but that’s a problem to discuss on another day.) Granted, my fainting spell could have been anxiety-induced, but it could have been many things.

A more extreme example that I heard of from a doctor at a large university hospital was that a foreign patient (I can’t remember his origin) kept coming in complaining that there was a worm in his head. The doctors kept shunting him off to mental health. Eventually, the man came back and said “There’s a worm in my eye!” They looked, and sure enough there was a worm in his eye. (Possibly something like this?) Yeah. Sometimes the patient knows what he’s talking about.

Of course generally there aren’t really worms in people’s heads – but symptoms that seem mental could be due to head injuries, strokes, seizures, etc. There are a number of brain scans that can be performed to check for such problems.

One is computerized axial tomography (CAT) scan, which moves X-ray beam around the head to create a 2D image of the brain. CAT scans have become more rare because of the availability of magnetic resonance imaging (MRI). MRI quantifies magnetic fields affecting varying amounts of water content in tissue, thus giving a sharp image of different structures (or lesions / tumors) in the brain.

Another brain imaging technique is the positron emission tomography (PET) scan. PET scans measure the metabolic activity in the brain, thus allowing more clear-cut diagnoses to be made. PET can reveal problems that are not anatomically obvious. However, the images in PET images are low-fidelity and the scans are prohibitively expensive.

Functional MRI (fMRI) measures blood flow of specific areas of tissues, thus providing information about which areas of the brain are active. fMRI is the scan that helps researchers discover which parts of the brain are important for certain types of thoughts or activities. At the moment, it is more important in the research than in the clinical world, but there is some optimism that fMRI might eventually be used to map cognitive processes in mental disorders.

Sometimes, a lesion hasn’t developed enough to be recognizable by brain scans. In this case, neuropsychological tests can be performed to quantify a person’s cognitive, perceptual, and motor performance to determine what parts of the brain might be affected. The neuropsychological assessment usually involves a battery of tests such as the Halstead-Reitan assessment for adults. This assessment is composed of 5 tests.

1. Halstead Category Test: Measures learning, memory, judgement, and impulsivity. Patient hears a prompt and selects a number 1-4. A right choice gets a pleasent bell sound and a wrong choice gets a buzzer. Patient must determine the underlying pattern in prompt-number combinations.

2. Tactual Performance Test: Measures motor speed, response to the unfamiliar, and the ability to use tactile / kinesthetic cues. A blindfolded patient is asked to place blocks in the correct spaces on a board. Then she draws the board from memory, without ever seeing the board.

3. Rhythm Test: Measures attention and concentration. The patient listens to 30 pairs of rhythmic beats and must determine whether the pairs are the same or different.

4. Speech Sounds Perception Test: Determines whether patient can identify spoken words, and measures concentration, attention, and comprehension. Nonsense words are spoken, and the patient must choose the word from a list of four printed words.

5. Finger Oscillation Task: Measures the speed at which the patient can press a lever.

References:

Butcher, James N. Hooley, Jill M. Mineka, Susan. (2014) Chapter 4: Clinical Assessment and Diagnosis. Abnormal Psychology, sixteenth edition (pp. 101-127). Pearson Education Inc.

Frontline: New Asylums

New Asylums (2005) is a Frontline documentary that delves into the problem of housing the mentally ill in prison systems. Believe it or not, the world’s three largest asylums for mentally ill are the Cook County Jail in Chicago, the Twin Towers of the Los Angeles County Jail, and Riker’s Island in New York. This problem has been escalating ever since the mid 1900’s when deinstitutionalization of mentally ill and intellectually challenged became a popular movement to encourage “humane” treatment of mentally ill and to reduce state expenditures on medical care.

The original plan, as described by the Community Mental Health Act of 1963, was to fund community mental health centers in which the mentally ill could be treated while working and living at home. However, most of the proposed centers were never built, and few of those built were fully funded. As deinstitutionalization accelerated, hundreds of thousands of mentally ill patients were released without a place to go and without adequate access to mental health care. A lot of them ended up on the streets. And on the streets, their mental illnesses flared up, leading to law-breaking. Many of the laws broken were for basic living purposes – theft of food, break-ins to get a place to sleep, stealing blankets out of a car – and many were violent crimes fueled by a desperate situation combined with psychosis. And this is how jails and prisons became the new asylums.

The documentary New Asylums focuses on the Ohio state prison system, which has a relatively well-developed system for dealing with the mentally ill. In 2005, when the documentary was filmed, there were nearly 500,000 mentally ill people housed in America’s prison systems – 10 times more than the 50,000 housed in mental institutions.

The documentary begins with a disturbing scene of “group therapy” in which inmates are locked inside tiny cages, with just enough room to sit in a chair. In this warm, inviting environment, the inmates are encouraged to share their problems with their fellow inmates. I think it is fantastic that group therapy is provided for inmates, but how helpful is it really, in this environment? Can an inmate really share his fears and heartbreaking secrets with other inmates? Wouldn’t rumors get around quickly among the inmates and less sympathetic officers in prison? How much help can group therapy really do these inmates, especially since they are locked in a tiny cage; which probably doesn’t encourage openness?

A while back, I told my therapist that I thought Dialectic Behavioral Therapy (DBT), which I was currently undergoing, would be a world of help to many people in prison. She agreed. But now that I see this video, I realize the limitations of such therapy. Prison does not provide a safe environment to let those feelings out. But what to do? Do we just not provide the inmates with therapy because of these limitations? Clearly, the problem needs to be solved before the mentally ill people are imprisoned, but I don’t know how to solve that problem, other than reinstitutionalization.

The documentary only became more horrifying after that. There were scenes in which a naked, frightened, screaming man was resisting being handcuffed. Eventually, a group of 5 men who were dressed like a SWAT team and carrying a riot shield burst into the cell, pinned the man down, and carried him kicking and screaming away. One officer tells the camera “A lot of the mentally ill inmates in here, you gotta use more…I mean, you do have to use force on them.”

Having seen the footage, I understand why the officers feel that they need to use a lot of force. I mean, how else would they get the naked, psychotic, screaming man down to solitary? But don’t you think that the strict and unforgiving culture of prisons is part of the reason these inmates are acting out? Isn’t the fear of solitary, which would certainly exacerbate psychotic symptoms, part of why they’re acting out? Most of them would certainly be better behaved in a healthier, more caring environment. And then force wouldn’t have to be used.

I can see two solutions (both of which I think should be implemented): the number of mentally ill patients housed in mental institutions should be increased, thus decreasing the prison population. And people in prison should be treated with more kindness – providing a rehabilitative instead of punitive justice system.

The documentary continued by describing Oakwood Correctional Facility, which is a temporary housing unit for mentally ill inmates who need to be stabilized. The culture and environment seems so much more caring and open – it appears that inmates who were dangerously psychotic in the general prison are stable and well-behaved at Oakwood. There’s a heartbreaking scene in which one of the inmates is being told by a panel of mental health workers that he’s stabilized and ready to go back to the general prison population. The inmate practically begs to stay at Oakwood. The panel is at first kind, but they become more and more firm. They show a depressing lack of empathy. The tragedy is that they have to. They have to send the inmate back to the general population, because they don’t have enough beds to house all the thousands of mentally ill inmates in the Ohio state prison system.

At this point I got into a discussion with a classmate about why these inmates aren’t all housed in such therapeutic environments as Oakwood. But where would Ohio state get the money to pay for those units to be built? How would they decide who is mentally ill enough to end up in such a facility? And is it ethical to treat some 16% of their inmate population so humanely and ignore the inhumane treatment of all the other prisoners? Do the “healthy” prisoners not matter just because they don’t have a serious mental illness? Once we start creating this humane prison system, where do we stop?

During most of the documentary, I was applauding Ohio state for at least trying to create a therapeutic environment for its mentally ill inmates. But there were a couple of comments which made me rethink. Reginald Wilkinson, the Director of the Ohio Department of Corrections said that he once had a judge mention to him: “Well, I hate to do this, but you know the person will get treated if we send the person to prison.” So judges are more likely to give a prison sentence because they feel there’s better mental health care there? My question was confirmed later in the documentary when it pointed out: “We shouldn’t devote ourselves to continually raising the level of mental health care in prisons because the better you make an institution that shouldn’t be used for the purpose you’re improving, the more you’re ensuring its use.”

It’s a catch-22. If you don’t work to take care of the mentally ill in prisons, they’ll get worse and you’ll have to stash them away in solitary or other “general population” punishment areas. If you do develop a system to care for the mentally ill, then you end up with even more mentally ill people dumped into your system, where they don’t belong. So tragic. I wish enough people cared about this highly stigmatized group so that money could be raised to properly care for both the imprisoned and the unimprisoned mentally ill.

4 snowflakes for interest level, research, approachableness, and subject