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May 31, 2019

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ReVisioning Borderline Personality Disorder: Seeing The Person Within

Written by Theresa Hasting, LMHC

I remember my first job out of graduate school, working in a psychiatric inpatient facility, and listening intently as nurses and doctors spoke about the patients with whom we were working.  A patient in particular sticks in my mind, a young adult female who had been in and out of our facility ten times in the past two months, who loudly exclaimed her self-harm for all to see and hear.  The stigma of Borderline Personality Disorder (BPD) that I witnessed some twenty years ago is still with me. Since that time, I have revised how I think of people who present with these symptoms and with this diagnosis, realizing how these behaviors do not define them, but rather how they are an expression of fear, of pain, of vulnerability, and of anxiety.

An article, that many of you may have seen, recently floated across Facebook: “We need to treat borderline personality disorder for what it really it is – a response to trauma.”  I was intrigued and as I read through the comments posted prior to the reading the actual article, I realized just how much the stigma of BPD hasn’t actually changed in the past twenty years.  I still hear parents gasp with shock and fear at the mention of BPD traits.

Let’s forget the Facebook article, that while true and accurate, isn’t actually a credible source and instead examine scholarly research.  A study by Bandelow, et al, (2005) indicated that those diagnosed with BPD had a statistically higher rate of early childhood trauma than the control sample.  These traumas ranged from abuse and neglect, parental separation, childhood illnesses, medical trauma, unhealthy family systems, etc. Premature birth was also noted as statistically higher for those diagnosed with this disorder.  This is one of many research articles making this link.

In practice with adolescents and their parents, those presenting with borderline traits consistently have a history of trauma and as they describe the symptoms we are so familiar with (poor ego strength, instability in functioning and achieving goals, impairment in relationships, frequent mood changes, separation insecurity, anxiety, impulsivity and/or risk-taking, and hostility), they talk about really wanting connection, to feel safe in relation to others, fearing rejection and abandonment, and having big emotional responses to small situations that they don’t understand any more than the next person.  Sometimes, I hear stories of a big Trauma and other times I hear stories of little traumas that accumulated over time. It may be that there were dozens, maybe hundreds of little emotional betrayals and hurts that added up and derailed a child’s ability to trust someone with their care. They described the need to be impenetrable and safe while simultaneously tormented by the human desire to feel closeness, created the push/pull dynamic that friends, families, and therapists are so acutely aware of.

The Facebook article is right…it is time we recognized BPD as a response to trauma.  Rather than focus on the very difficult symptoms to manage, recognize the strength being presented to you in their ability to survive.  Recognize that inside the layers of muck, there is a precious human being desperate for safe connection. With this new formulation of BPD at hand, we also have to look at how we treat BPD.  Ultimately, we have to approach treatment from a trauma-informed lens, one that aims at healing, providing reparative experiences, and teaching healthy attachment. To do this, we must focus on emotional regulation, emotion tolerance, debating negative self talk, building ego strength and finding ways to celebrate success; all in the context of healthy relationships being role-modeled and the clinician providing a safe, non-judgemental space to hold what is present and return it back to the person in a form they can digest in order to heal the relational trauma of the past.  Only then, will a person be able to move to a place of accountability, examining unhealthy relational patterns, and work on their ensuing identity crisis as the “get better.”

Ultimately, what a client who presents with these symptoms needs from their treatment team is compassion and the unwavering ability to see through the unpleasant layers of protection they have covered themselves in.  Or, in the words of the late Dr. Karyn Purvis, who specialized in relational and developmental trauma: “It is powerful for [people] to know that they are loved and adored even in the midst of their worst behaviors.”

November 15, 2017

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Letting It Out, Letting It Go

By: Theresa Hasting, LMHC, Clinical Supervisor

As students come and go in waves, I have seen an upsurge in students experiencing complicated grief issues.  Mostly recently, I’ve worked with four students within a six month period who have experienced the loss of a parent; through long-term sickness, suicide, and unexpected accidental death.  What these students have in common is they had not previously experienced their grief and instead turned to unhealthy coping skills to express their emotional responses. Each of these students had experienced this loss several years prior to their enrollment at Pacific Quest.

Theresa Hasting, LMHC
Clinical Supervisor

As we work with each student in their journey, we have many tools for the expression and healing of grief.  One of the most successful interventions for this is using nature.  Through the life and death cycle of plants in the garden, students can safely relate their own experience.  As students explore this cycle in the safety of the garden, they are also working to care for the land and given tasks of nurturing untended garden beds.  Through this nurturance they are able to find a motivation for self-nurturance, which allows the defensive walls to tumble down, exposing the vulnerabilities they have covered with maladaptive coping skills and letting out their anguish.

Once in this place of vulnerability, we further utilize our setting to process and memorialize their experience.  Students have created memorial beds, worked in the compost, and used ceremony/Rites of Passage as ways to concretely mark their process.  In additional to the work on the land, I have seen tremendous work happen around grief in our Sandplay trays, where students are able create their inner experiences using symbols and the sand, where words have previously failed them. Having personally witnessed these students, it is amazing to me, each time, the healing power students are able to access through their work in nature and in relation to others as they let it out and let it go.

December 8, 2016

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Thanksgiving Blessings: Gratitude and Grace

As I sat in my dining room with my seven guests for our annual Thanksgiving meal, I recounted what I was grateful for in my life. Thanksgiving is actually my favorite holiday, not because of what it represents in terms of American history, but because it is a day that I am able to celebrate my friends and family without the messy pressure of gift giving that comes with the Christmas holiday. As I sat down with my family and we exchanged our thoughts of thankfulness, I realized that I am most thankful for grace. The grace that gives me forgiveness when I have screwed up, that has taught me to be a better person, the grace I was given as I learned table etiquette and proper socialization (though I rarely employ those strategies these days), the grace to stumble as a daughter, wife, and mother, and finally the grace to be a human. I realize the amount of grace I have been given as I have navigated the years of my life and think about the students with whom I work and the amount of grace that they need.

Thanksgiving Blessings: Gratitude and Grace - Pacific Quest: Wilderness Therapy for Teens & Young Adults

Theresa Hasting, LMHC

I am grateful for the students and families I get to work with and feel honored to have the privilege to help these young people start the process of reworking their lives. It doesn’t always take on the first try, but the courage and bravery that I see when I am working with teens and their parents often amazes me. To allow themselves to be vulnerable about their deepest pains, even if they do in the messiest of ways, earns the right to given the same amount of grace I have been given in my life.

At Pacific Quest, we work hard to provide them with the grace they need to explore their inner experience, their family dynamics, and how they can learn to give themselves graces. Through my own years, I have realized that grace must ultimately come from within. To do this, we have to offer our students a firm but loving hand, working to join with them through creative, fun and meaningful interactions. The work in our gardens offers such a wonderful medium for this relationship to grow in. We are able to destroy and create whatever needs to be for the student to find meaning. At our fingertips is the ultimate metaphor for destruction and creation, death and renewal, loss and rejuvenation; the island itself, formed by the very fertile Pele.

The idea of grace is at the very core of what we do at Pacific Quest. We must give grace to our students having their process and acknowledging that change does not occur because we simply will it or give insight to it. Change happens because someone gave us the grace of their time and energy so that we could then transform our own inner grace into accepting cognitive change.

By: Theresa Hasting, LMHC
Primary Therapist

June 6, 2016

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Combining Trauma-Focused Treatments with Horticultural Therapy

Theresa Hasting PQ

Theresa Hasting, LMHC

By: Theresa Hasting, LMHC
Therapist

Working in the garden alongside students and seeing the benefits it yields students (and, of course, myself) has left me asking “How do we integrate additional evidence based treatments with our practice of Horticultural Therapy?”  The garden offers so many options for regulating the nervous system and calming the mind and body.  Having specialized in working with students with trauma histories, it seemed only natural to fit the pieces together.

 

Modalities

Trauma Focused Cognitive Behavioral Therapy (TF-CBT) is an evidence based, manualized, psychosocial treatment model designed to treat posttraumatic stress and related emotional and behavioral problems in children and adolescents. It incorporates trauma-sensitive interventions with cognitive behavioral, family, and humanistic principles and techniques. Students learn new skills to help process thoughts and feelings related to traumatic life events; manage and resolve distressing thoughts, feelings, and behaviors related traumatic life events; and enhance safety, growth, parenting skills, and family communication. The first stages of TF-CBT involve learning relaxation skills and emotional regulation skills.

Trust Based Relational Intervention (TBRI), also an evidence based model, is designed for working with students who have suffered from relational trauma. It focuses on the tenets of Empower, Connect, and Correct. Through empowerment, students learn effective means for regulation and gain a sense of felt safety. Connection, or relationship, focuses on re-establishing trust in others and in one’s self. The tenet of correct looks to give students alternative and appropriate methods for cognitive and behavioral expression of needs.

Melding the above treatments within Horticultural Therapy model of PQ has been a seamless process. Before a student can work through the 11 session manualized TF-CBT model, they must first have access to the parts of their brain in charge of reason. To do this, regulation and connection must exist. Through nature and the garden, students are able to customize their regulatory techniques- whether it be mulching banana trees, working the compost pile, weeding, or using the garden to create an individualized 5 sensory meditation practice. The gardening experience also allows for experimentation in life and death, promotes teamwork, and a nonjudgmental environment for students learn; thereby starting the process of connection to nature and to others. As students start to feel more connected to nature, others, and themselves and are functioning in a regulated fashion, they can then start to engage in rest of the TF-CBT process; examining their cognitive processing and exploring their trauma narrative.

A Client’s Perspective

But don’t listen to me, hear a student in her own words about her experience at PQ where she engaged in trauma focused treatment:

“The garden here is a lot different from the small garden I had at home.  At home, I never learned much about gardening of the processes  that made the flowers bloom and the lettuce grow.  There was no relationship between nature and me. Here at PQ, I learned about something called Aloha Aina, it refers to the deep connection between humans and the land.  It is sacred to the native Hawaiians and it is sacred to me as well.

“The garden means a lot to me. It is where I can be myself. I can weed, plant, mulch, and no matter what, I feel good and do good, which is my essential goal and personal legend in life.

“Usually when plants are transplanted they a little in shock when they are pulled out of the soil and taken away from what they are use to; however, with a little help, love and care they can blossom and grown. This is in direct alignment with what I am going through at this time.  I am being transplanted.  In order to cope, I will utilize EFT, coloring, cane grass meditation,  rock thingy, ocean breathing, and lavender- sniffing just as plants utilize chicken poop, water, sunlight and the soil that they have.

“I am quite like the banana trees. Each time I harvest a rack, I must cut down the tree in order for a new banana tree to grow in its place. I have been cutting down my inner banana trees.   During Nalu, I cut down the banana tree of thinking that I didn’t deserve love and support.   During Kuleana and Ohana, I have been cutting down shame and depression and anxiety.  When I leave PQ, I will continue cutting down bad habits so good habits can form. I love the garden and I love myself!”

Connecting the Dots

As a therapist, I’m passionate about creating meaningful relationships in a healing environment for our students to step into the power of redefining their story.  Pacific Quest provides a unique experience for the combination of these therapeutic modalities.  Relationally based TBRI emphasizes felt safety in a therapeutic relationship, allowing the body and  brain to be regulated enough to utilize TF-CBT, all the while giving space for HT to access and reprocess trauma on the level it was experienced- in the body.

January 8, 2016

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Working Through Compassion Fatigue

theresa-hasting-450By Theresa Hasting, LMHC

You’ve given everything you had; sleepless nights making sure your son stayed in his room, missing work to ensure he went to school, constant vigilance to ensure his safety.  You’ve got him in a safe place where he is able to work on these issues.  Now what?  As we work with parents of adolescents who come to treatment, we hear so many stories of parents being at the end of their rope.  Treatment offers not only their child a chance to reset, but also a chance for parents to reset.  Before this can happen, parents express feeling exhausted, relieved, sad, guilty, and angry.

Compassion Fatigue is a term to define this state; when parents feel that they have little, if nothing left to give in offering help and support to those in need.  The work of healing from compassion burnout requires finding time for one’s self each day, creating space for healing in the family/spouse relationship, asking for and receiving support, and self compassion.  Setting realistic and reasonable goals is necessary for healing to happen in a way that honors the depth of pain parents are experiencing.

At Pacific Quest, therapists support the family through these emotions during weekly family therapy sessions.  As we work with our students on the Five Pillars of Health, we encourage parents to examine their process in keeping with these pillars through journaling exercises.  In addition, we offer parents a PQ cookbook that allows them to experience an anti-inflammatory, whole food diet – similar to what their child prepares and eats while at Pacific Quest.  In assisting parents process their emotional response, parents are provided with journal topics that focus on the family system, parenting styles, emotional awareness, and negative thought patterns. Additionally, the communication process between adolescents and their parents is slowed significantly through the letter writing process to allow the creation of emotional boundaries and help students and parents process their emotional response with others before responding.  Parents are asked to write a letter to their child and express the emotional, physical, social, and spiritual exhaustion they’ve experienced in trying to support their son or daughter.

While this process may seem daunting and it may be difficult to find time for self care and self compassion, here are a few tips to consider: take a five minute thought break, turn off the background noise (music/tv/podcast), schedule time for yourself/spouse/family, weekly review of goals and projects, close your door, journal, and meditate.

May 7, 2015

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Setting The Stage for Healthy Attachment

theresa-2PQ Therapist, Theresa Hasting, LPC-S, LCPAA

During the formative years of adolescence the development of the self is a primary focus. As teens learn to navigate social relationships and attempt to differentiate from their parents, attachment difficulties may become pronounced and interfere with healthy identity development. Young people who have experienced adoption, relational trauma, stressful relationships and loss are highly vulnerable to experience relational difficulties during this critical time of development. At Pacific Quest attachment theory is applied through our integrative clinical practice model to effectively help our students regulate their emotions, develop and claim a deep sense of self, and improve relational health.

Attachment theory is based upon the work of John Bowlby who provided the structure for how we understand parent-child relationships today. Mary Ainsworth conducted research to validate and further the theories around attachment and to provide the language of our current understanding of attachment. The important tenets that come out of attachment theory include: the importance of the early relationship between infant and caregiver, attachment style is determined and evident within a child’s first year of life, the attachment cycle is linked to stimulation of the sympathetic and parasympathetic nervous systems, and self-regulation develops from attachment. When an infant becomes distressed their sympathetic nervous system becomes activated, which sends the brain and body into a state of alertness and stress; the infant expresses their need. If the parent is responsive, consistently and appropriately, the parent soothes and meets the infant’s need. At this point, the parasympathetic system becomes activated, deactivating the sympathetic nervous system, allowing the brain and body to return to a state of calm and regulation creating a secure attachment style. If this cycle is broken and the child’s need is not regularly met; not only does the infant develop an insecure attachment style, the infant’s brain learns to stay in a state of high alert and dysregulation.

In attachment theory, there are three styles of insecure attachment: avoidant, anxious and disorganized. With avoidant attachment style, students may appear mature for their age, taking care of their own needs, but are emotionally underdeveloped and do not believe that they can trust/rely on others to help them meet their needs. Anxious attachment style is portrayed by neediness, attention-seeking behavior, feeling insecure if away from their caregiver. This student demonstrates difficulty in regulating and looks to others for help with regulation. The student with disorganized attachment style has no clear strategy for self soothing (regulating) or relating to others. This style is characterized by contradictory behaviors in relationships and often demonstrates controlling behaviors toward caregiver.IMG_3679

At Pacific Quest, we use brain-based strategies to treat students who demonstrate mild to severe attachment issues as characterized by one of the three insecure attachment styles. Fortunately, due to neural plasticity, we are are able to set the stage for addressing these issues and start the process of achieving “recovered secure attachment” with our students. Working with students to learn methods of emotional and physical regulation is the first step. We utilize nature, horticultural therapy, and mind-body techniques in an intentional way to help our students manage their regulatory system. Through a series of interactions with the garden and our team, students have repetitive and corrective experiences regulating their nervous system in the context of relationship. Each new experience creates neural pathways strengthened through repetition, resulting in the emergence of new behavioral patterns and perceptions of self, others and the environment.

The progressive camp system of Pacific Quest is based on developmental stages of growth and provides a safe container for the work. Our first stage, Nalu (Hawaiian word for reflection) is organized around a student’s basic wellness needs, adjustment to the program, and self-reflection. Contact between students is limited. The result is that students rely on our staff to meet their needs, much like infancy and the cycle of attachment. They are also afforded the time and space to begin internal healing. In the second phase, Kuleana (Hawaiian for personal responsibility) students have structured, low stimulus relational experiences similar to that of early childhood. Students work with staff to co-regulate and practice social skills in small groups as they explore what brought them to Pacific Quest and write their life story. In the third phase, Ohana (Hawaiian for family, community), students become responsible members of a community and learn to self-regulate using internal resources and improve communication with others, including their family. These phases of development allow students not only to have a corrective experience with regulation, but also with relationships.

Our highly trained staff and therapists build on the foundations of mind-body wellness, horticultural therapy and our camp system to individualize treatment for each student. Finally, the Rites of Passage component of Pacific Quest creates a formal opportunity for our young people to leave “old story” patterns of insecure attachment and enter their “new story” more deeply connected to themselves, others and their environment. These connections, along with their newfound capacity for self-regulation, set the stage for a secure sense of attachment as they venture onward from Pacific Quest.