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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by Ilene on September 15, 2004, at 12:27:28
I'm starting to see a psychiatric resident at a large university medical center for meds. They also offer therapy--either CBT or DBT. Psychotherapy never helped me in the past, but I felt like my last meeting with the pdoc was a little too brief. I was seeing my old pdoc for an hour every week. We talked about meds and other stuff, but I never felt like it was formal psychotherapy.
Anyway, the question is CBT, DBT, or nothing? I'm interested in DBT because I think it's designed to overcome the limitations of CBT, but I don't know if I'm a suitable candidate because I don't have borderline personality disorder. I'm intractably depressed.
Downside: the university is about an hour's drive from here. Upside: my insurance would probably cover it.
Opinions?
Posted by alexandra_k on September 15, 2004, at 17:45:15
In reply to CBT or DBT?, posted by Ilene on September 15, 2004, at 12:27:28
I find it interesting that DBT is an option for you without a dx of BPD. It was designed (primarily) to reduce SI, inpatient admissions and that kind of (typically) BPD (expensive) stuff. It is also typically offered as a package deal (for the first year, or the first 6 months at least) where one goes to group skills training (yeech) in conjunction with seeing a DBT therapist.
That being said, in my experience DBT is about a million times better than CBT. Less judgemental etc. But then these are problems / limitations that people with a dx of BPD typically have with CBT and so others may find that CBT works for them just fine.
Can you have a go, and then change your mind??
Posted by Ilene on September 15, 2004, at 18:38:42
In reply to Re: CBT or DBT?, posted by alexandra_k on September 15, 2004, at 17:45:15
> I find it interesting that DBT is an option for you without a dx of BPD. It was designed (primarily) to reduce SI, inpatient admissions and that kind of (typically) BPD (expensive) stuff. It is also typically offered as a package deal (for the first year, or the first 6 months at least) where one goes to group skills training (yeech) in conjunction with seeing a DBT therapist.
>Right. That's one of my misgivings--that I'm not the usual client. I don't SI, etc. I *do* have quite a bit of suicidal ideation, but not being an impulsive sort, I've never attempted. I always figured I'll do it once and get it over with.
I also have emotion dysregulation--have a hard time overcoming strong negative emotions, even in the face of evidence to the contrary--but that is a lot better now that I'm on a med that takes care of my anxiety. I also grew up a mother who contradicted my needs--Linehan has a term for that, but I forget what it is. If I said I was hungry, my mother would often say, "You can't be hungry, you just ate."
> That being said, in my experience DBT is about a million times better than CBT. Less judgemental etc. But then these are problems / limitations that people with a dx of BPD typically have with CBT and so others may find that CBT works for them just fine.
>The main issue I have with CBT is that it works on a rational level, and my emotions are irrational. I can see how it would work well for a person with only mild or moderate depression.
> Can you have a go, and then change your mind??
I don't know if I can change my mind. It makes sense that I could.
Posted by alexandra_k on September 15, 2004, at 19:33:41
In reply to Re: CBT or DBT?, posted by Ilene on September 15, 2004, at 18:38:42
>I've never attempted. I always figured I'll do it once and get it over with.
Yeah, I figured that too, but the body is harder to kill off than one might have supposed.
> I also grew up a mother who contradicted my needs--Linehan has a term for that, but I forget what it is. If I said I was hungry, my mother would often say, "You can't be hungry, you just ate."
Invalidating. For people with an invalidating childhood CBT can be experienced as invalidating with its focus on 'if you change the way you think it will change the way you feel'. It may seem as though the message is that you are creating your own distress - and should just snap out of it. But with an invalidating childhood some people (the emotionally intense / sensitive ones) never learn how to regulate intense negative emotional states. Linehan considers it is like telling a person with no legs to get up and walk without providing crutches for her to walk on. The skills training is supposed to teach you HOW to regulate the distress in a doing way instead of focusing on rational refutation of faulty cognitions.
> The main issue I have with CBT is that it works on a rational level, and my emotions are irrational. I can see how it would work well for a person with only mild or moderate depression.Yup. CBT focuses on a thoughts -> feelings -> behaviours model. The notion is that if you change your thoughts, this will result in a change in emotional state. There is some truth to that with respect to thoughts refiring emotions etc. But sometimes because of our physiology (both genetic and the way it matured via environmental influence) we get a state of intense physiological arousal - which tends to be experienced / interpreted as distressing. In that kind of case the negative emotion comes first and the 'faulty cognitions' are employed retrospectively as we attempt to rationally justify our distress to clinicians who insist on such a rational justification (before berating you for having faulty cognitions).
When I did CBT I would get annoyed and would feel very misunderstood. I KNOW my emotions are irrational. I KNOW that if you insist that I attempt to rationally justify them then I will either misrepresent the world in an attempt to legitimate them or I will say something illogical. Then when I do this your eyes light up and you berate me for being irrational and causing my own distress. Thats where DBT can get around some of these problems with CBT that some people experience.
> I don't know if I can change my mind. It makes sense that I could.
Ok. My thought on that was that if DBT is being run as preached by Linehan then you would need to sign a contract to stay in therapy, work on the treatment hierarchy, go to group etc for x amount of time. Sure you can pike wheneva you like, but then if you change your mind back again you may be stood down from doing it again for a year.
Posted by fallsfall on September 15, 2004, at 20:00:34
In reply to CBT or DBT?, posted by Ilene on September 15, 2004, at 12:27:28
I think that DBT skills would be helpful for almost anybody.
I do have a BPD diagnosis (but I'm not "typical" - I'm not impulsive, for instance). I found that the people in my skills training class spent a lot of effort trying to show up and pay attention. I was at a point where I could do those things - I was ready to learn the skills. As a result, there was a lot of distraction away from the skills for me (for the last half or so there were only two of us, and we were both able to pay attention). You might find the same thing if you don't exhibit the typical BPD symptoms. I'm glad that I did the class. Like Alexandra says, I found CBT to be invalidating, but DBT seemed much more logical to me.
P.S. I cleaned out my freezer last week, and thought of you.
Posted by Ilene on September 15, 2004, at 20:06:25
In reply to Re: CBT or DBT?, posted by alexandra_k on September 15, 2004, at 19:33:41
> Invalidating. For people with an invalidating childhood CBT can be experienced as invalidating with its focus on 'if you change the way you think it will change the way you feel'. It may seem as though the message is that you are creating your own distress - and should just snap out of it. But with an invalidating childhood some people (the emotionally intense / sensitive ones) never learn how to regulate intense negative emotional states. Linehan considers it is like telling a person with no legs to get up and walk without providing crutches for her to walk on. The skills training is supposed to teach you HOW to regulate the distress in a doing way instead of focusing on rational refutation of faulty cognitions.
>Aha! Lightbulb clicks on!
> Yup. CBT focuses on a thoughts -> feelings -> behaviours model. The notion is that if you change your thoughts, this will result in a change in emotional state. There is some truth to that with respect to thoughts refiring emotions etc. But sometimes because of our physiology (both genetic and the way it matured via environmental influence) we get a state of intense physiological arousal - which tends to be experienced / interpreted as distressing. In that kind of case the negative emotion comes first and the 'faulty cognitions' are employed retrospectively as we attempt to rationally justify our distress to clinicians who insist on such a rational justification (before berating you for having faulty cognitions).
>I suppose there are people who react to the world differently than I do. There is a strong genetic component to my depression--at least half the members of my family on my mother's side have (or had) a psychiatric disorder, ranging from anxiety to personality disorder.
> When I did CBT I would get annoyed and would feel very misunderstood. I KNOW my emotions are irrational. I KNOW that if you insist that I attempt to rationally justify them then I will either misrepresent the world in an attempt to legitimate them or I will say something illogical. Then when I do this your eyes light up and you berate me for being irrational and causing my own distress. Thats where DBT can get around some of these problems with CBT that some people experience.
>It seems the height of rudeness to insist that a person's emotions be rational. Emotion is the opposite of rationality.
> > I don't know if I can change my mind. It makes sense that I could.
>
> Ok. My thought on that was that if DBT is being run as preached by Linehan then you would need to sign a contract to stay in therapy, work on the treatment hierarchy, go to group etc for x amount of time. Sure you can pike wheneva you like, but then if you change your mind back again you may be stood down from doing it again for a year.
>
>That could be. I don't know. The pdoc didn't promote psychotherapy too hard, outside of saying all their therapists were equally good (I bet they're all good-looking, too). So far she's let me push her around, but my basic suggestion (higher dose of meds) has made sense. At least I think so.
The other issue is whether the type of therapy really matters. From what I've read the therapist makes more of a difference.
Posted by Ilene on September 15, 2004, at 20:11:05
In reply to Re: CBT or DBT? » Ilene, posted by fallsfall on September 15, 2004, at 20:00:34
> I think that DBT skills would be helpful for almost anybody.
>
> I do have a BPD diagnosis (but I'm not "typical" - I'm not impulsive, for instance). I found that the people in my skills training class spent a lot of effort trying to show up and pay attention. I was at a point where I could do those things - I was ready to learn the skills. As a result, there was a lot of distraction away from the skills for me (for the last half or so there were only two of us, and we were both able to pay attention). You might find the same thing if you don't exhibit the typical BPD symptoms. I'm glad that I did the class. Like Alexandra says, I found CBT to be invalidating, but DBT seemed much more logical to me.
>Yeah, I've had similar thoughts--one, the skills would be useful for anyone, and two, the other people wouldn't necessarily be functioning on the same level.
> P.S. I cleaned out my freezer last week, and thought of you.
I'm glad you have a nice clean freezer. Mine is full of frozen burritos from Trader Joe's, and 3 lb. of coffee from Costco.
Posted by gardenergirl on September 15, 2004, at 21:33:54
In reply to Re: CBT or DBT?, posted by Ilene on September 15, 2004, at 20:11:05
Ilene,
DBT has been used in studies for other diagnoses. One that I know of is eating disorders. It makes sense to me that depression stemming from an invalidating environment might also respond to it. I would think, though, if it is a mixed group, then you might not have as much in common with people with other diagnoses and more impulsive behaviors. Hard to say.If it is being done formally, though, DBT is a good program.
Whatever you decide, good luck!
gg
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