Beyond Remission: Powerpoint by Kiera Van Gelder

Mapping BPD Recovery: Beyond Remission Kiera Van Gelder, MFA Middle Path © Kiera Van Gelder 2008

The Need for BPD Recovery Model © Kiera Van Gelder 2008

What Does Recovery from BPD Look Like?
 Where are the people who have gotten better?
 What processes did they go through to get better? Can it be generalized?
 What are their lives like now? What has been resolved and what continues to be problematic?
Which treatments offer patients and families a full view of the recovery process?
Which treatments offer hope and lived examples of recovery?

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

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

Remission does not address:
 Quality of life as subjectively defined
 Self-esteem and self-concept
 Experiences of belonging and community integration
 Sexual satisfaction
 Sense of purpose and meaning in life
 Fulfillment of chosen vocational and social roles
 Perception of world

Remission =
The decrease of
DSM Criteria from 5/9 to 4/9
Research specific, along limited domains
Focused predictors, treatment adherence, symptom reduction
Recovery =
The incremental process of transforming disability into livability
Person specific, multiplicity of domains
Focused on Quality of Life

Recovery Vision
We believe it is possible to live with, manage and transform the symptoms of Borderline Personality Disorder.
We have the ability to fully participate in life and to fulfill our greatest potential despite the obstacles and pain this disorder inevitably brings.
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.
We see that our recovery is not linear—that gains often necessitate losses. Crises and backsliding are opportunities for growth, not signs of failure.

The Goal of a Transformed System: Recovery
“ Services and treatments must be consumer and family centered”
“ 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”
The President’s New Freedom Commission on Mental Health © Kiera Van Gelder 2008

DBT : Dialectical Behavior Therapy (Marsha Linehan, WA) www.behavioraltech.org CBT: Cognitive Therapy (Aaron Beck, PA) www.academyofct.org SFT: Schema-Focsued Therapy (Jeffrey Young, NY) www.schematherapy.com Mentalization (Andrew Bateman and Peter Fonagey, UK) www.menninger.edu TFP: Transference-focused Psychotherapy (Otto Kernberg, NY) www.borderlinedisorders.com STEPPS: Systems Training for Emotional Predictability and Problem Solving (Nancy Blum et al, IO) www.uihealthcare.com/topics/medicaldepartments/psychiatry/stepps/index.html Treatment for Borderline Personality Disorder © Kiera Van Gelder 2008

“ DBT” Stages of Recovery from Borderline Personality Disorder*
Stage 4: “Incompleteness”
 Capacity for Joy and Freedom:
Love as inter-dependence, internalized mastery, “having
perspective”, self-management, sense of self is evolving.

Stage 1: Severe Behavioral Dyscontrol
Behavioral Control:
Reducing self-harm, addictions, dissociation, rage,
suicide attempts, chronic despair.
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

Judith Herman’s Stages of Recovery
1. Safety
2. Remembrance and Mourning
3. Reconnection

Treatment Triage
1. Behavioral (DBT)
2. Emotional and Cognitive (CBT/Schema)
3. Interpersonal (Psychodynamic, supports)
4. Meaning/Belonging/Identity
 Treatment Needs to be Specific to the Person and to their Recovery Journey 

Mapping BPD Recovery as a Journey
Survival
2. Emergence
3. Integration

Surviving the Dysregulation Zone Ludwig Meidner, The Burning City, 1913 © Kiera Van Gelder 2008

Survival in the Dysregulation Zone
Life is experienced as Living in a War Zone (for person with BPD and SOs)
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.
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).
Stage 1: Linehan and Herman
TREATMENT

Emergence
Birth of Recovery
Establishment of safe alliances and places via treatment and supports
Beginning of hope
Small bits of mastery via treatment
Developing Self-Awareness and other Awareness
Becoming present to physical body/emotions
Understanding impact of self on others and vice versa
Learning about own mind
Developing perspective– not in emotion mind all time
Trauma and Grief work
Identifying past neglect and abuses
Understanding “traumatic responses “ to non-traumatic causes (TRIGGERING)
Learning proper attribution
Identifying core schemas
Stage 2: Linehan and Herman, psychodynamic work, “exposure therapy” ---- but then what ???

Confronting Core Schemas:
I am endangered
I am like a small child
I am uncared for
Zanarini (1998)
The world is dangerous and malevolent
I am powerless and vulnerable
I am inherently unacceptable
Beck & Freeman (1990)
Mentalization, Cognitive Therapy, Transference-Focused Psychotherapy, Schema-focused Therapy and Internal Family Systems Therapy © Kiera Van Gelder 2008

“ Challenges That Happen in the Wake of Gains” -- Dr. Loren Crabtree
Destabilization and crises happen due to new challenges and risks being taken

Emergence Cycle © Kiera Van Gelder 2008 Challenge/ Risk Trigger / Destabilize Safety Renewed support/ structure

Aspects of the Emergence Process
Surveying the Devastated Village: Grieving & Repairing
What has been done to us and what we have done to others
Lost time, Not fulfilling expectations, Broken relationships & Lost opportunities
Dwelling in the intermediate realm between illness and wellness
People don’t understand that recovery is not the same as being “cured”
will we have validation and support from the “non-clinical world”?
Extreme responses to a “trivial” matters: How do we deal with this and get support for it?
Progress involves the loss of community and supports
NEED psychiatric rehabilitation practices to maintain supportive pathways towards full integration

Pathways of Emergence Require Nurturance and Structure
Areas of Challenge:
Identity and Sense of Self
Relationships and Belonging
Intimacy and Sexuality
Work and School

Relationship and Belonging
How do I manage the loss of support when I get healthier?
How do I explain to people what I deal with? How and when do I disclose my history and diagnosis?
How do I enter new communities/relationships and manage the triggers?

Intimacy & Sexuality
Closeness / physicality can be triggering
Needing someone brings up fear of abandonment
Threat of being absorbed into another person
Learning healthy boundaries can involve having them crossed / or crossing them

Work and School / Purpose
If past history is full of failure, why should things be different now?
How do I make vocational/ life direction decisions?
What needs have I identified as crucial to regaining meaningful work/activity?
Gaining financial independence can mean having the rug pulled out if I become symptomatic again.
Others will have expectations which I might not be able to fulfill

Identity and Sense of Self
Who am I, when I’m no longer entirely a patient or a problem?
Good things and successes can be threatening; how to accept and incorporate them into my sense of self?
How do I figure out who I am when I keep changing and other people can have the power to define me?

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

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

Living with BPD Means Encountering a New Set of Dialectics
Using skills and knowledge to gain exposure and collaborate with others to maintain stability
Developing relationships and pursuing goals which will make us symptomatic © Kiera Van Gelder 2008

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

Integration
Maintenance of physical and emotional well being.
Structuring environment in ongoing negotiations of own needs and others
Examining values and aligning ourselves with them
Defining goals, working towards them
Tolerating relapse and regression
Experiencing life as a journey and self as a work in progress
Belonging to communities outside of treatment
Engaging in meaningful activities
Enjoyment of recreation and play

Supports for Integration
Psychiatric Rehabilitation Practices:
Supported Employment, Supported Education,
Graduate Programs:
Peer Support, Mentoring, Co-training
Family/Friend/Partner Involvement
NAMI, Family Connections/Connections Place
Wellness Models:
Wellness Recovery Action Planning

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Beyond Remission: Powerpoint by Kiera Van Gelder

by Kiera Van Gelder on Jul 24, 2010

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Beyond Remission: Powerpoint by Kiera Van Gelder — Presentation Transcript