Tag: CBT

a busy past few days

by Midnight Demon, posted in blogging, chronic physical pain, CRPS, depression, disability, FTM, gender dysphoria, mood disorders, psychology, PTSD, suicidality, writing

A busy past few days

I have a busy week with a lot of appointments. I had two today, back to back. Tomorrow I see my pcp to discuss my cardiac markers and a BP med. I am hoping she listens to me and puts me back on labetalol rather than another med. But if she isn’t open to it, then I will go on what she suggests.

I saw my TG doc today. She had a fellow interview me first. Things went well. The fellow tried to get me a 5mL vial of T but the pharmacy just filled a 1mL vial. I have enough T to last me the next few injections. She also referred me to plastic surgery so I could get a top surgery consult started. I am glad because my pcp never responded to my request from last week. The fellow also answered my concern about whether T had caused the dislocation in my shoulder. It didn’t. I am glad. She did say that because I had removal of my ovaries, I have to be concerned about my bone health. But I am still young enough that I don’t have to go for a bone scan. The only bone scan I want to do is on my shin to see if the CRPS has spread to it. I have been having severe pain for no reason and it is worrying me.

After my TG appointment, I had the chronic pain group, which had already started. I was about fifteen minutes late but they accepted me anyways. We had a good chat about families not getting our disabilities and I told them how rough it was living with my sister who triggers my PTSD often. I also came out to them as transgender and they didn’t seem to care, which I was glad about. We also talked about how our families don’t believe our pain and disability. It was a good group. I did talk about how my therapy session went and got support around it. There maybe future discussions about CBT.

I had therapy yesterday and we talked about my ED visit went. I told her I was freaking out over my lab results, thinking I was having a heart attack. Tomorrow when I see my pcp I am going to discuss what the lab values mean as having this marker in the blood indicates some kind of cardiac injury. I also asked my therapist if we could role play a bit about me asking for the blood pressure medication that I want so that I don’t get turned down. I didn’t want to come off as obstinate but I really think this med will be better as I have been on it before and had little to no side effects from it. We talked for more than a few minutes about it and I wrote down how to approach my pcp on this issue. I just hope I remember.

We then talked about how I feel we are divided and not on the same page about things. That is when she said to me “take the reins”. I was like what? She repeated what she said, adding that I was in charge. I was flustered. I couldn’t believe what she had said so I got my journal that has the notes to the bCBT book and shared with her what a structured session looks like. It had listed “agenda” and then went on to list other things. I asked the author of the book what is meant by this and he gave me a more descriptive outline of what the session looks like. I think there should have been an “:” to indicate this. So I went to my blog for the crisis response plan (Suicide Crisis Response Plan – midnightdemons7). This needs to be reviewed. In it, it said that if I get specific I should contact my therapist or psychiatrist. I should ask them if this is right or if I should just go to the psych ED. My therapist might not be available but I will bring it up with her when I meet with her next as that is when we will start with the new sessions I guess. She agreed to allow a new skill to be introduced and to practice it while in session. I think this is going to work out now as this seems more collaborative than what it was in the past where I spent the time just talking or not talking during session. I asked her if she was more DBT oriented or CBT. She said she was CBT so that will help a lot during the next few weeks. I am glad this is happening because I really felt like we were going on different directions. It just seemed like we would talk about stuff and then she would ask what is helpful but never follow up on what was helpful during the week or if I had practiced or done what was helpful. Mostly that meant me reading this manual for discussion. I felt like I was alone in reading it but it not going anywhere. I also felt like it was pointless to read if I couldn’t share what I was reading.

I have a busy week. Tomorrow I see my pcp and that is going to take a lot of energy. I wanted to get my hair trimmed but my barber had a death in the family. I contacted him today and he said his sister died. Her breast cancer had come back and it wasn’t a good prognosis. I am surprised she last this long. It was more than a year since she was diagnosed with this. I set up an appointment with him for Sat. Fri I plan on making his favorite dish, chili cornbread. I just have to get the ingredients. I will Thurs after my session with my psychiatrist. I will also ask him if I can contact him in an emergency as we have never discuss this before. There wasn’t really a need to as I really haven’t been in crisis since he became my psychopharmacologist.

By Sunday, I am just going to rest as I will need it. I don’t know when I will be able to read. I got hit with a flare up and couldn’t finish this blog yesterday. The flare was so bad that the bones in my foot and leg were aching very deeply and intensely. The pain in my leg is higher than it was and I fear that the CRPS is spreading. I want to contact my neuro and see if I can get a bone scan to see if it is CRPS or something else. I don’t think an X-ray will show anything as It only hurts when my ankle or foot is flared up and when I am resting on my bed. It doesn’t hurt when I put weight on it or walk on it. It is a very unusual type of pain when it comes on. I am feeling better because I got some sleep. I woke up around 0030 and had something to eat as I was hungry. I had honey nut cheerios. I emptied my bladder because it had been more than five hours since I last emptied it. I probably will have to go again as I drank the milk in the cereal and had some water afterwards. It’s 0130 now and I am not so tired. I might read the book for a bit until I am tired and can get back to sleep. My pain has finally settled down.

My Thoughts on Zero Suicide as a Person with Lived Experience

by Midnight Demon, posted in Bipolar Disorder, depression, mood disorders, suicide, suicide attempt

My thoughts about Zero Suicide as a person with Lived Experience

There has been a lot of talk on Twitter about Zero Suicide and it’s mission to reduce the suicide rate to zero, because 1 is just too many. At first, I was appalled that clinicians think that is possible. I for one think that it is outrageous because there is always going to be someone who dies by suicide. Maybe not in their organization but outside their organization. But then I learned that it’s not an individual’s practice but an organization or health system that strives to achieve this goal. They have trainings and meeting with those in the suicidology world.

Something kept bugging me about this. I kept quiet because I didn’t want to anger those that are for it, though I think there are a few blogs that I wrote about it before I understood the mission. While talking to a friend that is a suicide loss survivor, the bells went off. She said that it goes against Shneidman’s questions, where do you hurt and how can I help?

I am a big supporter of Dr. David Jobes work with his framework called CAMS (Collaborating, Assessment, and Management of Suicidality). I don’t know if Dr. Jobes trains these Zero Suicide clinicians. And even if they are trained, I am not sure it will be used. Most clinicians have the attitude that their skills on suicide risk are good enough when it could be faulty. Worse, they go through the training yet don’t use what they are taught. That drives me up the wall. Why bother going to a training (unless it’s a mandatory thing) if you aren’t going to take away from it?

I really think CAMS is a tried and true framework to prevent suicide based on my experience of using it in my former therapy. I also used the Suicide Status Form. Unfortunately, my therapist did not want training in CAMS and we drifted apart, thus ending our relationship. We did, while we worked together, use the initial and tracking forms but unfortunately, we never got to the outcome form. She wasn’t committed enough to see it through and that kind of pissed me off. Every time I had a suicidal episode, she just wanted to know one question on the form, The one thing that would help me no longer feel suicidal. It is an open ended statement where the client fills in their thoughts on the matter. Unfortunately, I could never come up with a satisfactory answer as I really didn’t know the reason for my suicidality. I just wanted to die and that was that. I wrote a blog about CAMS if you would like more information about how it is formed and the use of the Suicide Status Form.

I went on the website for Zero Suicide but could not seem to find the specific training that they went through. From what I gathered on Twitter from their live tweets, some of it is CAMS and some of it is using risk factors for suicide. Unfortunately, risk factors alone are not predictive of a suicide attempt. CBT has been useful in reducing suicide attempts but not all clinicians are trained in this modality. The book by Craig Bryan on CBT for preventing suicide attempts is a good book to learn more about it. I also wrote a review on the book that you can see here.
The other thing that gets me is that no where among Zero Suicide is there talk of a person’s psychological pain. There are measures, if you look for it. Dr. Holden at Queen University in Canada has created a scale to measure what Dr. Shneidman calls psychache. See my review on the research article for more information. I think it is a good psychometric to gauge a person’s level of suicidality and pain, which ultimately leads to thoughts of suicide. This must be included in any talk of preventing or intervention of suicide and also postvention, should a suicide attempt occur.

My final thoughts of Zero Suicide is that it is a novel idea but as Dr. Shneidman says, “How many suicides do you want, and I say I don’t want any, but I want there to be the freedom to do it. I study suicide but I am not pro-suicide. I’m for suicide prevention.” I share his sentiments. I do not like the talk of “suicide is not an option”. To me, that is hindering free will. I do hope the rate of suicides goes down, but the way that health care and mental health are going, I think there will be more before it lowers, especially among the chronic pain patient population.

CBT for Preventing Suicide Attempts: A Review

by Midnight Demon, posted in Bipolar Disorder, blogging, depression, mood disorders, suicide, suicide attempt

CBT for Preventing Suicide Attempts: A Review

I have been reading CBT for Preventing Suicide Attempts edited by Craig Bryan, PhD and these are my thoughts about the book by chapter. I also describe what each chapter is about.

Chapter 1: Deals with the problem of suicide and how it’s on the rise. It also describes the difficulty of knowing what works and what doesn’t. The authors goes on to what the book is about and how CBT has been shown to be useful in some clients with suicide ideation.

Chapter 2: Describes the dreaded nomenclature of suicide attempts, ideas, suicidality, etc. The authors describe how the term SDV (self-directed violence) is a more accurate term and also other terms to decide pathways on treatment protocols. They term the entire suicidality as SDVCS-Self-Directed Violence Classification System. It is used by three large federal organizations- the CDC (Center for Disease Control and Prevention), the VA (Veterans Administration), and the DOD (Department of Defense).

This chapter gives good examples of how different researchers, clinicians, and other professionals can use this classification system. I didn’t review the system pathways and yes/no guidelines because terms don’t mean that much to a suicide attempt survivor writing about my lived experience. I’m either suicidal or I’m not. I don’t need to classify and put myself into a category. But if you are a clinician/researcher or other academic interested in suicide prevention, the nomenclature is pretty good and better than what Silverman et. al. proposed in 2007 a and b (see this blog post on my thoughts about their terms).

Chapter 3 deals with what works and what doesn’t in suicide risk. It talks about studies pertaining to talking therapies and psychopharmalogical treatment of suicidal behaviors. I found this to be more of a review of what I know as of right now in terms of evidence based practices (EBP) and what is not. Some studies were really small and others were large. Most centered around Borderline Personality Disorder (BPD) as that is a high risk group. What I found upsetting is that those with bipolar disorder or those that were psychotic were excluded from most of the studies. As I suffer from psychosis and bipolar disorder, my participation would not be included and I find that disappointing, especially since bipolar disorder and other psychotic disorders such as schizophrenia have a higher incidence of suicide than major depression alone.

Chapter 4 was an eye opening chapter that I really liked. It talked about all of the suicidologists that I have been following for the past eleven years. It discusses different theories and models of suicide and risk assessment. It also discusses protective factors of suicide such as reasons for living/dying. I found this chapter to be really good and a lead off to how all of the things talked about lead to the next chapter, which is a case example.

Chapter 5: In this chapter, a case is described step by step of a suicidal older gentleman and the cognitive steps, consent, etc. are used by a play by play dialogue. Things like safety planning, coping cards, and hope kit are discussed in detail and how to implement them in therapy using cognitive therapy.

Chapter 6 talks about a brief cognitive behavior treatment (BCBT) for inpatient units called PACT (Post Admission Cognitive Therapy). It discusses the criteria for engaging patient, pros/cons of treatment and how not everyone may be suitable for this type of treatment, e.g., those with active psychosis/mania.
It would be good if this could be implemented but as the treatment is 5-6 days and on average most admissions are 3 days, I don’t see how this is to be helpful. Discussion of staff resistance and burnout are also discussed.

Chapter 7: This was very interesting as I’ve never really read about military psychotherapy before. The chapter gives specifics on how to approach a veteran or active military personnel in crisis or dealing with suicidal thoughts. It talks in detail about Brief Cognitive Behavioral Therapy (BCBT) and the steps per session. Not all persons will respond within the 12 sessions. It is individualized for each person. The chapter also talks about hot to discuss lethal means safety and means restriction (see chapt 9 for more information; e.g., gun safety in particular). When the sessions are down to the last two and command of previous exercises are demonstrated to be efficient, end of therapy is initiated. Booster sessions are discussed in case of future crises should happen. I found this therapy to be specific not only for military but can be used for any type of suicidal behavior. It’s a collaboration between therapist and client.

Chapter 8: Emergency departments are the top places suicidal people end up, either with an attempt, ideation, or crisis. Sadly, if the right precautions are not set (e.g., inpatient care or some type of follow up care), individuals are more than likely to die by suicide.
This chapter talks about the challenges and brief interventions that can be initiated so that death by suicide does not occur after a visit. The authors describe specific suicide safety planning that is individualized for that person to help them cope with stress that makes suicide appealing. It also gives crisis numbers, either a trusted person they can talk to in time of need and/or the National Suicide Hotline (1-800-273-8255, text 741741 (US only)). Once a little role play is done and the individual can demonstrate they will use this plan, patients are discharged to follow up outpatient care.
Only trouble I have with this approach is that not all EDs are equipped with mental health professionals and don’t have the 30-45 minutes or so it would take to implement the safety plan, even though it is crucial this should happen.

Chapter 9: As more and more evidence is building that suicidal individuals are seeing a primary care provider prior to death by suicide, it’s become imperative that PCPs have the training to ask patients for means restriction. The author suggests several ways to initiate the conversation and lists steps to do this. If patients are resistant, the use of motivational interviewing techniques are employed. The end result is a means restriction receipt where PCP and patient have agreed to restrict their lethal means. If possible, a supportive person is asked to help secure the means.

Chapter 10: This chapter talks about the use of psychotropic medication and the use of CBT or BCBT in suicidal patients. To date, there has not been studies where therapy and medication has been shown to be effective in reducing suicide risk. It is suggested that despite the thoughts and black box warnings of the FDA, suicide ideation is still likely to occur of not treated or dealt with at the beginning of pharmacological treatment. The author also discusses the risk of substance use and dependence disorders that can increase the risk of a suicide attempt. PTSD has also been discussed as hyperarousal states can increase suicide risk.

Concluding thoughts: Overall, I found this book to be extremely helpful, concise, and important in the prevention of suicide attempts. With the right intervention at the right time, Brief CBT can help decrease the suicide risk and possibly the overall suicide rate.

Friday Morning blog

by Midnight Demon, posted in Bipolar Disorder, blogging, chronic physical pain, depression, mood disorders

Friday morning blog

I am watching my niece today because it’s Good Friday, a religious Catholic holiday. She has the day off from school, something that I never got when I was in school. Apparently, rules changes concerning religion so any time there is a religious holiday due to whatever domination, the kids have the day off from school.

Next week is April vacation week. I will be watching my niece on Tuesday as well. Today I will be ordering pizza. I don’t know what I will be doing Tuesday. Maybe I will take her to Starbucks with me, if she is willing to go. I was thinking of going today but my ankle is hurting kind of severely. I really don’t want to leave the house.

I woke up to a weird dream. I dreamed that I was in therapy with an older woman. It was our second session and I could barely hear her as she had laryngitis. My former therapist was in the room while we were talking. Then my teddy bear became a male toddler. He had just a diaper on him and was getting cranky because it was wet. I didn’t have another diaper but the therapist did. As I was changing him, he started crapping and it was diarrhea. I cleaned him up and he crapped green shit again. I got it all over myself. There was a shower in the office so I washed him and myself up. I didn’t have another diaper to change him. I felt like a bad father. I had no idea why my teddy bear became a live human. Anyways he walks to a chair and as I am telling him not to sit down, he sits and shit gets all over the chair. I pick him up and then I wake up, shaking my head. Weirdest dream ever.

I just ordered pizza and fries. Should be here in about a half hour or less. I can’t wait. I have been craving pizza all week long. I ordered a large so that my mother can have some, too. I usually order half because no one but me eats cold pizza. I don’t like it reheated. It tastes funny.

I am going to try finishing the CBT book that I started earlier this week after lunch. I should type up what I have written for the blog I am writing. I wrote it in a notebook on Monday. It’s an interesting book and I find it exciting to read because it stimulates my thought process. It’s a short book, only about 8 or 9 chapters and I am in chapter 5 right now. Reading it is not technical, least for me because I have a clinician brain. I am learning as I go as I am more psychodynamically oriented than Cognitive behaviorally. I can’t wait to write up this blog!