Beyond Remission: Powerpoint by Kiera Van Gelder


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  • People haven’t been able to cure cancer, but they envision it as a goal…
  • Living at a Tibetan Buddhist Center--of all the religious traditions, Buddhism tends to be the least damaging and believes that we all are Buddhas--we just need to develop compassion and clarity and we will shed all the negative layers that have prevented us from recognizing our inherent goodness.  But even within this household, I am afraid that if I don't follow the practices exactly--which I DON'T, as I am dedicated to my own path--I am afraid of being cast out. Will I be rejected if I don't conform?  I haven't been yet, and the people I live with and the Tibetan Lama understand I have my own way, but still I worry.  Same thing if I date someone, or take a job.  I lose my reference point in the hope of being connected, and the fear of being rejected.  It's an ongoing
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  • Beyond Remission: Powerpoint by Kiera Van Gelder

    1. 1. Mapping BPD Recovery: Beyond Remission Kiera Van Gelder, MFA Middle Path © Kiera Van Gelder 2008
    2. 2. © Kiera Van Gelder 2008
    3. 3. The Need for BPD Recovery Model © Kiera Van Gelder 2008
    4. 4. What Does Recovery from BPD Look Like? <ul><li> Where are the people who have gotten better? </li></ul><ul><li> What processes did they go through to get better? Can it be generalized? </li></ul><ul><li> What are their lives like now? What has been resolved and what continues to be problematic? </li></ul><ul><li>Which treatments offer patients and families a full view of the recovery process? </li></ul><ul><li>Which treatments offer hope and lived examples of recovery? </li></ul>© Kiera Van Gelder 2008
    5. 5. REMISSION from BPD 2 years = 40% Remission 6 years = 68% Remission 10 years = 85% Remission ( Zanarini, 2005, 2006) Remission is defined as “no longer meeting 5 of 9 criteria” However, “Remission” does not necessarily signify a better quality of life © Kiera Van Gelder 2008
    6. 6. The “Subsyndromal Phenomenology” of BPD What resolves most quickly : “ Symptoms reflecting core areas of impulsivity (e.g. self-mutilation and suicide efforts) and active attempts to manage interpersonal difficulties (e.g. problems with demandingness/entitlement and serious treatment regressions) seemed to resolve most quickly.” Least resolved : “ In contrast, affective symptoms reflecting areas of chronic dysphoria (e.g. anger and loneliness/emptiness) and interpersonal symptoms reflecting abandonment and dependency issues (e.g. Intolerance of aloneness and counter-dependency problems) seemed to be the most stable.” (Zanarini, Am J. Psychiatry, 2007 June 164(6):929-35 ) © Kiera Van Gelder 2008
    7. 7. Remission does not address: <ul><li> Quality of life as subjectively defined </li></ul><ul><li> Self-esteem and self-concept </li></ul><ul><li> Experiences of belonging and community integration </li></ul><ul><li> Sexual satisfaction </li></ul><ul><li> Sense of purpose and meaning in life </li></ul><ul><li> Fulfillment of chosen vocational and social roles </li></ul><ul><li> Perception of world </li></ul>© Kiera Van Gelder 2008
    8. 8. <ul><li>Remission = </li></ul><ul><li>The decrease of </li></ul><ul><li>DSM Criteria from 5/9 to 4/9 </li></ul><ul><li>Research specific, along limited domains </li></ul><ul><li>Focused predictors, treatment adherence, symptom reduction </li></ul><ul><li>Recovery = </li></ul><ul><li>The incremental process of transforming disability into livability </li></ul><ul><li>Person specific, multiplicity of domains </li></ul><ul><li>Focused on Quality of Life </li></ul>© Kiera Van Gelder 2008
    9. 9. Recovery Vision <ul><li>We believe it is possible to live with, manage and transform the symptoms of Borderline Personality Disorder. </li></ul><ul><li>We have the ability to fully participate in life and to fulfill our greatest potential despite the obstacles and pain this disorder inevitably brings. </li></ul><ul><li>We recognize that BPD Recovery is a process that can take many years. It requires a full range of supports and the enduring belief by others that we can and do get better. </li></ul><ul><li>We see that our recovery is not linear—that gains often necessitate losses. Crises and backsliding are opportunities for growth, not signs of failure. </li></ul>© Kiera Van Gelder 2008
    10. 10. The Goal of a Transformed System: Recovery <ul><li>“ Services and treatments must be consumer and family centered” </li></ul><ul><li>“ Care must focus on increasing consumers’ ability to successfully cope with life’s challenges, on facilitating recovery, and on building resilience, not just on managing symptoms” </li></ul>The President’s New Freedom Commission on Mental Health © Kiera Van Gelder 2008
    11. 11. DBT : Dialectical Behavior Therapy (Marsha Linehan, WA) CBT: Cognitive Therapy (Aaron Beck, PA) SFT: Schema-Focsued Therapy (Jeffrey Young, NY) Mentalization (Andrew Bateman and Peter Fonagey, UK) TFP: Transference-focused Psychotherapy (Otto Kernberg, NY) STEPPS: Systems Training for Emotional Predictability and Problem Solving (Nancy Blum et al, IO) Treatment for Borderline Personality Disorder © Kiera Van Gelder 2008
    12. 12. “ DBT” Stages of Recovery from Borderline Personality Disorder* <ul><li>Stage 4: “Incompleteness” </li></ul><ul><li> Capacity for Joy and Freedom: </li></ul><ul><ul><ul><li>Love as inter-dependence, internalized mastery, “having </li></ul></ul></ul><ul><ul><ul><li>perspective”, self-management, sense of self is evolving. </li></ul></ul></ul><ul><li> </li></ul><ul><li>Stage 1: Severe Behavioral Dyscontrol </li></ul><ul><li>Behavioral Control: </li></ul><ul><li>Reducing self-harm, addictions, dissociation, rage, </li></ul><ul><li>suicide attempts, chronic despair. </li></ul> Stage 2: “Overcoming Quiet Desperation”  Emotional Experiencing: Dealing with PTSD and trauma, fear of emotions, understanding triggers Behavioral Emotional & Cognitive Interpersonal Sense of Self * Adopted from M.M Linehan, 2004 Stage 3: “Problems in Everyday Living”  Ordinary Happiness and Unhappiness: Rebuilding a life, generalizing skills to relationships and work, involved with life. © Kiera Van Gelder 2008
    13. 13. Judith Herman’s Stages of Recovery <ul><li>1. Safety </li></ul><ul><li>2. Remembrance and Mourning </li></ul><ul><li>3. Reconnection </li></ul>© Kiera Van Gelder 2008
    14. 14. Treatment Triage <ul><li>1. Behavioral (DBT) </li></ul><ul><li>2. Emotional and Cognitive (CBT/Schema) </li></ul><ul><li>3. Interpersonal (Psychodynamic, supports) </li></ul><ul><li>4. Meaning/Belonging/Identity </li></ul><ul><li> Treatment Needs to be Specific to the Person and to their Recovery Journey  </li></ul>© Kiera Van Gelder 2008
    15. 15. Mapping BPD Recovery as a Journey <ul><li>Survival </li></ul><ul><li>2. Emergence </li></ul><ul><li>3. Integration </li></ul>© Kiera Van Gelder 2008
    16. 16. Surviving the Dysregulation Zone Ludwig Meidner, The Burning City, 1913 © Kiera Van Gelder 2008
    17. 17. Survival in the Dysregulation Zone <ul><li>Life is experienced as Living in a War Zone (for person with BPD and SOs) </li></ul><ul><li>Feeling constantly under attack, unsafe and unprotected, vulnerable and helpless, alone and under fire. “Lymbic Storm” is fully activated: Hyper-vigilance, fight-or-flight, dissociation, internal and external world experienced as traumatizing and intolerable. </li></ul><ul><li>Treatment focus is on establishing safety /reliable self-care and gaining control over destructive behaviors (reducing self-harm and suicide attempts; addressing addictions, dissociation, rage, and overwhelming despair). </li></ul><ul><li>Stage 1: Linehan and Herman </li></ul><ul><ul><li>TREATMENT </li></ul></ul>© Kiera Van Gelder 2008
    18. 18. Emergence <ul><li>Birth of Recovery </li></ul><ul><ul><li>Establishment of safe alliances and places via treatment and supports </li></ul></ul><ul><ul><li>Beginning of hope </li></ul></ul><ul><ul><li>Small bits of mastery via treatment </li></ul></ul><ul><li>Developing Self-Awareness and other Awareness </li></ul><ul><ul><li>Becoming present to physical body/emotions </li></ul></ul><ul><ul><li>Understanding impact of self on others and vice versa </li></ul></ul><ul><ul><li>Learning about own mind </li></ul></ul><ul><ul><li>Developing perspective– not in emotion mind all time </li></ul></ul><ul><li>Trauma and Grief work </li></ul><ul><ul><li>Identifying past neglect and abuses </li></ul></ul><ul><ul><li>Understanding “traumatic responses “ to non-traumatic causes (TRIGGERING) </li></ul></ul><ul><ul><li>Learning proper attribution </li></ul></ul><ul><ul><li>Identifying core schemas </li></ul></ul><ul><ul><li>Stage 2: Linehan and Herman, psychodynamic work, “exposure therapy” ---- but then what ??? </li></ul></ul>© Kiera Van Gelder 2008
    19. 19. Confronting Core Schemas: <ul><li>I am endangered </li></ul><ul><li>I am like a small child </li></ul><ul><li>I am uncared for </li></ul><ul><li>Zanarini (1998) </li></ul><ul><li>The world is dangerous and malevolent </li></ul><ul><li>I am powerless and vulnerable </li></ul><ul><li>I am inherently unacceptable </li></ul><ul><li>Beck & Freeman (1990) </li></ul>Mentalization, Cognitive Therapy, Transference-Focused Psychotherapy, Schema-focused Therapy and Internal Family Systems Therapy © Kiera Van Gelder 2008
    20. 20. “ Challenges That Happen in the Wake of Gains” -- Dr. Loren Crabtree <ul><li>Destabilization and crises happen due to new challenges and risks being taken </li></ul>© Kiera Van Gelder 2008
    21. 21. Emergence Cycle © Kiera Van Gelder 2008 Challenge/ Risk Trigger / Destabilize Safety Renewed support/ structure
    22. 22. Aspects of the Emergence Process <ul><li>Surveying the Devastated Village: Grieving & Repairing </li></ul><ul><ul><li>What has been done to us and what we have done to others </li></ul></ul><ul><ul><li>Lost time, Not fulfilling expectations, Broken relationships & Lost opportunities </li></ul></ul><ul><li>Dwelling in the intermediate realm between illness and wellness </li></ul><ul><ul><li>People don’t understand that recovery is not the same as being “cured” </li></ul></ul><ul><ul><li>will we have validation and support from the “non-clinical world”? </li></ul></ul><ul><ul><li>Extreme responses to a “trivial” matters: How do we deal with this and get support for it? </li></ul></ul><ul><li>Progress involves the loss of community and supports </li></ul><ul><ul><li>NEED psychiatric rehabilitation practices to maintain supportive pathways towards full integration </li></ul></ul>© Kiera Van Gelder 2008
    23. 23. Pathways of Emergence Require Nurturance and Structure <ul><li>Areas of Challenge: </li></ul><ul><li>Identity and Sense of Self </li></ul><ul><li>Relationships and Belonging </li></ul><ul><li>Intimacy and Sexuality </li></ul><ul><li>Work and School </li></ul>© Kiera Van Gelder 2008
    24. 24. Relationship and Belonging <ul><ul><ul><li>How do I manage the loss of support when I get healthier? </li></ul></ul></ul><ul><ul><ul><li>How do I explain to people what I deal with? How and when do I disclose my history and diagnosis? </li></ul></ul></ul><ul><ul><ul><li>How do I enter new communities/relationships and manage the triggers? </li></ul></ul></ul>© Kiera Van Gelder 2008
    25. 25. Intimacy & Sexuality <ul><ul><ul><li>Closeness / physicality can be triggering </li></ul></ul></ul><ul><ul><ul><li>Needing someone brings up fear of abandonment </li></ul></ul></ul><ul><ul><ul><li>Threat of being absorbed into another person </li></ul></ul></ul><ul><ul><ul><li>Learning healthy boundaries can involve having them crossed / or crossing them </li></ul></ul></ul>© Kiera Van Gelder 2008
    26. 26. Work and School / Purpose <ul><ul><ul><li>If past history is full of failure, why should things be different now? </li></ul></ul></ul><ul><ul><ul><li>How do I make vocational/ life direction decisions? </li></ul></ul></ul><ul><ul><ul><li>What needs have I identified as crucial to regaining meaningful work/activity? </li></ul></ul></ul><ul><ul><ul><li>Gaining financial independence can mean having the rug pulled out if I become symptomatic again. </li></ul></ul></ul><ul><ul><ul><li>Others will have expectations which I might not be able to fulfill </li></ul></ul></ul>© Kiera Van Gelder 2008
    27. 27. Identity and Sense of Self <ul><ul><ul><li>Who am I, when I’m no longer entirely a patient or a problem? </li></ul></ul></ul><ul><ul><ul><li>Good things and successes can be threatening; how to accept and incorporate them into my sense of self? </li></ul></ul></ul><ul><ul><ul><li>How do I figure out who I am when I keep changing and other people can have the power to define me? </li></ul></ul></ul>© Kiera Van Gelder 2008
    28. 28. Living with BPD Means Encountering a New Set of Dialectics I have BPD but I am not the disorder A disorder that involves one’s sense of Self A sense of Self that is not defined by the disorder © Kiera Van Gelder 2008
    29. 29. Living with BPD Means Encountering a New Set of Dialectics Experiencing vulnerabilities that interfere with living Managing one’s life to compensate for those vulnerabilities Ie- I have problems but am not helpless to deal with them © Kiera Van Gelder 2008
    30. 30. Living with BPD Means Encountering a New Set of Dialectics <ul><li>Using skills and knowledge to gain exposure and collaborate with others to maintain stability </li></ul>Developing relationships and pursuing goals which will make us symptomatic © Kiera Van Gelder 2008
    31. 31. Positive and Negative BPD Characteristics are two sides of the same coin! Sensitivity to social and emotional cues, especially negative ones Empathy to the moods and thoughts of others, especially the suffering of others Spontaneity Fear of Abandonment Reactivity Lack of Boundaries Ability to merge (easily fall in love, see things in new ways) Neediness Willingness to please Intensely Emotional Passionate & Creative Vengeful Strong sense of right and wrong Strong personal attachments Unstable Sense of Self Flexibility © Kiera Van Gelder 2008
    32. 32. Integration <ul><li>Corresponds to Linehan’s Stage 3 & 4, Herman’s Stage 3 </li></ul>Living in the Village © Kiera Van Gelder 2008
    33. 33. Integration <ul><li>Maintenance of physical and emotional well being. </li></ul><ul><li>Structuring environment in ongoing negotiations of own needs and others </li></ul><ul><li>Examining values and aligning ourselves with them </li></ul><ul><li>Defining goals, working towards them </li></ul><ul><li>Tolerating relapse and regression </li></ul><ul><li>Experiencing life as a journey and self as a work in progress </li></ul><ul><li>Belonging to communities outside of treatment </li></ul><ul><li>Engaging in meaningful activities </li></ul><ul><li>Enjoyment of recreation and play </li></ul>© Kiera Van Gelder 2008
    34. 34. Supports for Integration <ul><li>Psychiatric Rehabilitation Practices: </li></ul><ul><ul><li>Supported Employment, Supported Education, </li></ul></ul><ul><li>Graduate Programs: </li></ul><ul><ul><li>Peer Support, Mentoring, Co-training </li></ul></ul><ul><li>Family/Friend/Partner Involvement </li></ul><ul><ul><li>NAMI, Family Connections/Connections Place </li></ul></ul><ul><li>Wellness Models: </li></ul><ul><ul><li>Wellness Recovery Action Planning </li></ul></ul>© Kiera Van Gelder 2008
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    56. 56. Kiera Van Gelder, MFA Middle Path © Kiera Van Gelder 2008