Archives for July 2013

Energy Drinks

Henry David Abraham, M.D.

Henry David Abraham, M.D.

By Henry David Abraham, M.D. The story goes that coffee was discovered when a shepherd noticed his sheep dancing after they ate beans growing on a hillside. Humans have been using that bean ever since for alertness, inspiration, and energy. Caffeine is the world’s most popular drug. The US is the world’s greatest importer of coffee- nine pounds a year for each one of us. At birth caffeine is present in 75% of infants, and thanks to sodas and cocoa, in preschoolers, too. So when caffeinated “energy” drinks appeared in gas stations and supermarkets, consumers yawned, until now. Today brands like Monster Energy and Red Bull are household names and a $20 billion a year business. One third to one half of teens and young adults will try them. As the use of these drug vehicles has increased, so have reports of problems. Most people are familiar with the common problems of caffeine- jitters, insomnia, and anxiety. Energy drinks kick that list up a notch, to include seizures, strokes, and at least 13 possible deaths. There are now 20,000 emergency department visits a year related to energy drinks. Kids with preexisting medical conditions, especially those of the heart or brain, are particularly vulnerable. Recently, the makers of Monster Energy moved to sidestep the FDA requirement that they report any problems with their products by calling them “beverages.” This moves Monster to a different aisle in the supermarket and lets them sweep bad news under the rug. “But wait a minute, Dr. Abraham. Aren’t you just being a caffeine cop? How much caffeine is in an energy drink in the first place?” Answer: about one to three cups of coffee. How bad can that be? This year 18 experts on child nutrition said how bad in a letter to the FDA. They pointed out that a caffeine drink is different from a cup of tea or coffee in a number of important ways. Caffeine in coffee or tea is in a natural, botanical form, while the caffeine in energy drinks is added by the manufacturer. Another difference is that chemically concocted caffeine drinks contain a wild mix of Frankenchemicals: compounds not often mentioned in polite company that have little or no connection to normal human nutrition. Occasionally these chemicals do things to you. Guarana, one energy additive, for example, has one of the highest concentrations of caffeine in any plant, triple the caffeine in coffee. A third important difference is a matter of the use of energy drinks by children. There is no minimum legal age to buy them. If a child consumes a drug at a dose intended for an adult, this is an invitation to an overdose. The smaller the child, the greater the trouble. This among other thoughts led a committee of the American Academy of Pediatrics to say, “…caffeine and other stimulant substances contained in energy drinks have no place in the diet of children and adolescents.” That brings me to the cultural differences between coffee, tea and energy drinks. Hot tea or coffee is sipped slowly. People meet for coffee. They serve coffee and tea at the book club. They drink tea together at the Chinese restaurant. The makers of energy drinks live on another planet. An ad for Monster Energy on Amazon says it all. The 16 oz. can of Monster “packs a vicious punch but has a smooth flavor you can really pound down.” Not exactly “meeting a friend for coffee.” This Brave New World of “beverages” may explain a recent study where Australian teens suffered cardiac and neurological toxicity after drinking three to eight bottles of energy drinks at a clip. From a public health point of view, the greatest harm from an energy drink is when it is mixed with alcohol. Being drunk is bad enough, but being wide-awake drunk is stepping on the accelerator with your eyes closed. Under no circumstance should an energy drink be thought of as a cure for alcohol intoxication. It’s not. Now before the proprietors of Starbucks and Peet’s take out a contract on me, let the record show that I am not a caffeine cop. Coffee is my favorite drug- er, drink. Of all the drugs I worry about, coffee is not even a warning blip on my radar. Its benefits vastly outweigh the risks. Its psychological and health effects are varied and proven. It reduces the risks of Alzheimer’s disease, certain cancers, heart disease, and type II diabetes. Should teens drink coffee? It depends. As kids enter the teen years their clocks for sleeping and waking, like daylight savings time, spring ahead an hour or two. That means when adults are getting sleepy, kids are getting ready to rock. That also means that the next morning, as the world awakens, teenagers are zombies. This also means for many teens early morning classes are cruel but usual punishment. Short of starting the school day later, a cup of tea or coffee may work wonders for the early morning zombie. It does for many of us. But it’s not for everyone. Steven Spielberg never drank a cup of coffee in his life. Voltaire drank 30 cups a day. They both turned out all right.

No-Nonsense-Final-Cover-640x1024Dr. Henry David Abraham is a psychiatrist in Lexington, MA. He is a co-founder of the International Physicians for the Prevention of Nuclear War which was awa rded the Nobel Peace Prize in 1985. Material for this article was adapted from his most recent book, The No Nonsense Guide to Drugs and Alcohol, an e-book for teens and young adults. It is now available online at Amazon.com and BN.com.

Parenting Matters is a collaboration between the Lexington Human Services Department and The Colonial Times Magazine.

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Facilitating Healthy Adaptations to Grief and Loss

Kevin M. Kozin, MTS, LICSW

Kevin M. Kozin, MTS, LICSW

By Kevin M. Kozin, MTS, LICSW

When experiencing a loss, it can seem that everyone has some sage (and often misguided) advice they are ready to give you. For example, you may hear remarkably unhelpful things like: Get over it, Move on already, Time heals all wounds. While possibly well intentioned, these words imply that a loss is something that a person “gets over.” For many losses, we do not “get over” the loss. Instead, we need to find a way adapt to the loss. We cannot “get over” things like the loss of a child or a partner, but we can find new ways of relating to that experience and adapting to the new situation.

Speaking about a loss can be difficult. Sometimes, “I’m sorry for your loss” is the best statement you can provide. When you are asked difficult questions about a serious loss, it’s OK to say, “I don’t know.” You may be joining with them in the “not knowing” of what is going on for them, and it can help to feel connected. It is often more helpful to use words like “died” or “death” instead of “passed on.” Especially with younger people, it helps them to understand what really happened.

Dr. J. William Worden describes four “Tasks of Mourning” that one must go through to facilitate a healthy adaptation, and Elisabeth Kübler-Ross describes the “Five Stages of Grief” which help to conceptualize some of the key emotions that people experience.

Dr. Worden is clear that these are active tasks, not things that happen to us, but things that we must do, to facilitate a healthy adaptation to loss. I’ve adapted Dr. Worden’s tasks to include all losses, by using “lost attachment.”

1. To accept the reality of the loss

2. To process the pain of grief

3. To adjust to a world without the lost attachment

4. To find an enduring connection with the lost attachment while embarking on a new life.

These tasks look nice and tidy with a simple four point plan of action. However, they can be remarkably difficult. Dr. Kübler-Ross describes the “Five Stages of Grief” as:

• Denial

• Anger

• Bargaining

• Depression

• Acceptance

In grieving, it is useful to experience all of these stages of grief as we process a loss. Unlike Dr. Worden’s tasks, you may notice that these aren’t numbered, but in bullet points. Worden’s tasks are more linear. You accomplish one task and then move on to the next. Dr. Kübler-Ross’s stages of grief are more fluid emotional states, and we may experience any one of them, and then move to a different stage at any time. There isn’t any one stage that is most useful or even necessary. A useful guiding principle is that in moving through the stages, the main concern is getting “stuck” anywhere but acceptance (that’s the eventual goal). So, one can experience denial, then depression, then acceptance, and move back to denial. It’s useful to notice when we are in these stages, but not to judge ourselves for being in any one of them.

There isn’t a timeframe for when things should change or healing should occur. In fact, some people never work thorough their losses. That’s why it is important to address the tasks in a deliberate and meaningful way. Healing isn’t about the amount of time that it has been since the loss.

Various age groups tend to process grief and loss differently. Infants and toddlers may sense a change in routine and caregivers, and can experience separation anxiety and regression. Having consistent caregivers is very useful at this age. Children of three to six years often struggle with the concept of the body not-functioning and finality of a death or loss. They can be prone to magical thinking and also regression. Consistent limit setting, patience, and simple (concrete) explanations are most effective. For example, a burial can be frightening if not better understood, since they may not understand the finality of death and become concerned that their loved one can’t breathe underground.

Between ages six to nine years, they begin to understand finality of death and may want details as to how someone died. They often have difficulty concentrating and worry about themselves and others, such as a caregiver or parent dying. It would be helpful to provide a space for talking about how the death/loss affects them personally. For ages ten to thirteen years, they may be able to understand that death is inevitable and happens to everyone. At this age, they may identify more with adults of their own gender and experience an array of feelings. They are often thinking about how death/loss affects relationships. For this age, it is helpful to encourage expression of feelings and foster open communication about death/loss.

Teens will often have the ability to confront and prepare for an impending loss. For teens and adults, they may not just be grieving for a current loss, but what might have been. They will often desire time with their peers. Some concerns is that the teen will be “parentified” and attempt to take on the role of the parent a parent during a major loss. Another possibility is that they may turn to risky behaviors. During this time, it is important to have open communication with the teen about their experience and to allow them the space to process their feelings, while offering support for when they are ready.

For all ages, be on the lookout for complicated bereavement, such as a grief response that is extended, amplified, delayed, distorted, absent, conflicted, chronic, or unresolved. This is when the grief response is interfering with psychological functioning, which can co-occur with adjustment disorders, depression, anxiety, substance abuse, PTSD, and suicidality. Some common indicators are sudden loss, conflicted relationships, pre-existing mental health issues, limited successful coping skills, financial or employment distress, or multiple stressors.

Never Worry Alone. In grief, one should not be alone in the process. Connectivity is a healing and protective factor. If you have concerns for another person, family, or yourself, you may benefit from working with a grief counselor. Below is a list of resources that may be useful in getting help or learning more about grief and loss. The way through grief and loss is together, not alone.

RESOURCES

The Children’s Room in Arlington – www.childrensroom.org

Offering a full array of bereavement services for families who have experienced early loss. Their website is full of helpful bereavement information.

Compassionate Friends – www.compassionatefriends.org

A national organization that helps families who experience the death of a child.

NASW Social Work Therapy Referral Service

www.therapymatcher.org or (800) 242-9794.

This is a free and confidential service from the National Association of Social Workers that connects people to psychotherapists on a range of issues – not just grief and loss.

 

Kevin M. Kozin, MTS, LICSW is a local psychotherapist and grief counselor in Lexington, MA and works with adolescents, adult, families, and couples. Mr. Kozin is highly active in the community in his work on the Board and Executive Committee of the National Association of Social Workers, Massachusetts (NASW-MA) and serving as the Co-Chair the Mental Health and Substance Abuse Committee of NASW-MA. He holds master’s degrees in Social Work and Theology from Boston University and completed post-graduate training at the Massachusetts Institute for Psychoanalysis. Information on Mr. Kozin’s practice can be found at www.kozincounseling.com or by contacting him at (781) 325-1858.

 

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Parenting Matters~Sweet Dreams

 

Lisa Foo, PhD

Lisa Foo, PhD

By Lisa Foo, Ph.D

The top of many Mother’s Day wish lists is a good night’s sleep for the whole family. What a challenge with our many responsibilities, endless things to think about, and being kept up by other family members!

The average daily sleep requirement is about 14.5 hours for infants, 13 for toddlers, 12 for preschoolers, 10.5 for school-aged children, 9 for adolescents, and 8 for adults. Many of us need higher amounts to compensate for accumulated “debt.” Research has linked insufficient sleep with not only fatigue, but also weight gain, heart disease, and diabetes. Decreased sleep can cause emotional and behavioral problems, including (ironically) child hyperactivity. Driving while drowsy is a major cause of car accidents and related injuries. Sleep serves an important role in learning, so late night cramming can interfere with remembering the information that was studied.

So what causes difficulties with falling asleep, waking during the night, or getting up too early in the morning? Everyone wakes briefly throughout the night when transitioning between deeper and lighter sleep, but most of us return to sleep easily and don’t even recall having been awake. Sometimes, however, our brains “click on” too much or have a hard time “clicking off” as we process stressful thoughts, making it hard to fall asleep or return to sleep.

Many sleep difficulties improve through developing healthy sleep habits. Staying up late and sleeping in on weekends can cause chronic jet lag in which our bodies can’t tell when to feel sleepy. Maintaining a fairly consistent sleep schedule throughout the week can fix that. Relaxing evening activities and predictable bedtime routines signal the body that it is time to sleep. It’s helpful to turn off electronic screens (TV, computers, cell phones, etc.) 30 to 60 minutes before bedtime, as they may keep our minds active and the lights that they emit signal the brain that it’s still daylight and time to be awake.

Regular exercise (not too close to bedtime) can improve sleep, as well as overall physical and emotional health. Utilizing deep breathing, muscle relaxation, and visual imagery can make it easier to fall asleep at bedtime and return to sleep after waking during the night. Noise, brightness, and temperature levels of the bedroom, as well as the comfort level of the bed and bedding, should be conducive to sleep. It’s helpful to avoid the bedroom during the day so that when you get into bed at night your mind associates that space with sleep and becomes drowsy, just as we often become hungry when entering a kitchen. When having prolonged awakenings during the night, try getting out of bed, going to another room with the lights dimmed, and doing something relaxing until you feel sleepy enough to return to bed.

Caffeine stays in the body for hours before being fully eliminated, so caffeinated coffee, tea, soda, and energy drinks can be eliminated or reduced and consumed only in the morning. “Decaf” coffees usually still contain some caffeine, and if taken in large quantities or throughout the day, can still interfere with sleep. While alcohol can cause sleepiness, it can also disrupt nighttime sleep. Abusing other chemical substances can also cause sleep problems. Regular use of over-the-counter sleep aids is not recommended without consulting with a medical provider, as long term use can cause grogginess or memory problems, and they may also become less effective over time. Sleep medications should NOT be mixed with alcohol, as the result can be fatal.

It sometimes can be tricky to use these recommendations with a child who doesn’t see the importance of sleep. Children may also need parents to ease bedtime fears or set limits regarding bedtime or middle-of-the-night behavior. It may also be necessary to address any larger anxiety or behavior problems. If your teenager is not getting enough rest, you might choose to have electronic devices turned into you before bedtime so as to reduce the temptation to talk or text during the night. Infant and toddler sleep is especially challenging due to the complexities of naps, nighttime nutritional needs, and little ones’ limited comprehension abilities.

Difficulties sleeping or chronic daytime sleepiness can be symptoms of underlying medical conditions. Individuals with sleep apnea have difficulty breathing while sleeping, and so without even knowing it experience frequent brief awakenings to breathe. Being overweight increases the risk of apnea, though individuals at a healthy weight can also have this condition. Discomfort, pain, or heartburn can cause sleep difficulties and may be assisted by strategies such as relaxation, not eating or drinking close to bedtime, avoiding trigger foods, or receiving appropriate medication.

If you or a loved one experiences sleep difficulties that are interfering with emotional or physical functioning, please consider seeking help from a mental health or medical provider. We can help create a plan to make it easier to fall and stay asleep, and also screen for and treat underlying disorders. For example, psychotherapy might be useful to address depression or anxiety, or behavioral therapy could help train a young child to follow bedtime limits. Individuals with sleep apnea can often be helped by a device that helps them breath better at night, or with assistance losing excess weight that is contributing to the problem. Sometimes prescription medications for other conditions can interfere with sleep and so can be switched, reduced, or eliminated in consultation with your provider. If a member of your family experiences other problematic sleep-related behaviors (screaming or walking while still sleeping, bedwetting or frequent urges to toilet during the night, attacks of excessive sleepiness during the day, etc.), please make sure to have them professionally evaluated.

I’ll end with a confession – I have children, and some of this article was written in the late evenings after they went to bed. And my infant sometimes woke me up a few hours later. Life happens. However, instead of just telling myself “I’ll sleep after I finish everything on my list,” I try to prioritize tasks so that I finish the most important ones before stopping for bedtime. Our children follow the examples that we set. Parenting takes a lot of energy and patience, both of which are easier to provide when we are well rested. I wish us all the best on our quest for households full of sweet dreams.

Lisa Foo, PhD, is a psychologist in private practice in Lexington. Dr. Foo is a Harvard graduate and Fulbright scholar who specializes in assisting individuals and families affected by health-related concerns. She previously worked as a senior psychologist and supervisor at a Level 1 trauma center. 33 Bedford Street, Suite 11; 612-237-8471; drlisafoo@gmail.com; www.drlisafoo.com .

 

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All Things Sustainable

Mark Sandeen, Chair Sustainable Lexington Committee

Mark Sandeen, Chair
Sustainable Lexington Committee

All Things SustainableQ: I’m planning to install solar power at home and I was wondering if I could use the solar power system to run my home during a power outage.

A: One of the wonderful things about solar power is how well it works with the utility grid. When your solar energy system produces more power than your home currently needs, you can pump that power out to the grid and your utility will give you a credit for the value of that electricity. When your home demands more energy than the solar energy system is generating, you can draw power from the grid to make up the difference.

Unfortunately when the utility power is out, your solar energy system still needs another energy source to act as a backup – a place to send electricity when the system is producing more power than you need and a place to pull extra power from when a cloud passes overhead. Your utility doesn’t want you to do that during a power outage. because it endangers line workers trying to restore power. So all solar installations must disconnect from the grid during a power outage.

One common backup strategy is to add batteries to your solar installation. Unfortunately the price of batteries hasn’t fallen as fast as the price of solar panels. That means a battery backup can easily add 30 – 40% to your overall cost of installation.

Another idea is to combine solar with a backup generator. This makes a lot of sense for buildings – like our schools and municipal buildings – that already have a backup generator installed. Properly designed backup generators disconnect from the grid during a power outage – operating like an island – and supplying all their own power. A well-designed solar energy system can easily integrate with your backup generator, letting the solar panels carry the load when the sun is strong and the backup generator picking up the slack during evening hours. The NY Times has an excellent article about a school that survived Hurricane Sandy by doing just that. http://bit.ly/solarbackup

Q: We’ve all been told that one of the first things we should do to lower our emissions is to replace our incandescent light bulbs. LED lights sound great, but have the costs come down enough to make them a viable alternative?

A: Yes, the price of LED bulbs has been dropping rapidly. LED light bulbs are the longest-lasting and most efficient mass-produced light sources to date. And now, they’re also among the most affordable, with some costing less than $10 per bulb.

They are a much better product than compact fluorescents. They turn on instantly. They are dimmable. They last 25 times longer than an incandescent bulb and 3 times longer than a CFL. They are more durable and contain no mercury. And best of all, they look great, providing warm natural light.

And LED bulbs save a lot of energy — from manufacture to disposal, an LED bulb uses 5 times less energy than an incandescent bulb and about 30% less energy than a CFL.

Plus LEDs can do things no incandescent or compact fluorescent bulb has ever done before. Some LED lights can be controlled over the internet or with your smartphone, allowing you to turn lights on and off remotely. You can set up presets like Home, Away, Night with schedules controlling light bulb groups and dimming levels, all with one touch. No more crawling behind the couch to plug in that timer before you leave on vacation.

 

Send your sustainability questions to questions@sustainablelexington.org. We look forward to hearing from you.

 

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A Personal Connection~Learning About Life Through Little League

Coaches

Little League Coaches

By Hank Manz

Even with some of the fields still brown and even with the nights still cold, it is now a very important time of year. Spring? Well, sure, but more important than that. I am speaking of something that surpasses everything else because it is time to start playing baseball.

I don’t mean just watching baseball. Sure, that can be important, too, but not as important as actually playing the game.

There are other sports that people might like, but there is nothing quite like a warm summer night, a well-oiled glove, a hat that fits perfectly, and a bunch of players who can’t hit my knuckleball. OK—that last is getting harder to come by, but even with three out of four, there is nothing with which to compare it.

I was a very small kid with no arm, but one summer in Police Athletic League baseball I ran into a coach who had a couple of the fingers on his throwing hand in a recent war. All he could throw was a knuckleball which was perfect for a player who would never be able to throw faster than 65 mph, even in college.

That knuckleball, along with an ability to scratch out singles with men on base, and a Vern Law signature model glove earned me a spot on several teams over the years. More than 50 years later I still have the glove. Oh, there have been love affairs with flashier models now and again, but I have always returned to that Law Trap-Eze glove. I once buried an almost new glove at a field in Cambridge after committing five errors including one that lost the game for my team.

The non-wood bats gave me a boost about the time my hitting was starting to really sag, but my first home run would not come until I was just past my 40th birthday when the perfect pitch and the best swing ever came together in my first round-tripper. It broke a window in a passing T-bus, but the driver just shrugged it off as did the police officer whose cruiser windshield I cracked when I fouled one off later in the game.

So it was inevitable that one day I would take my then only eligible child to Little League registration. After signing up we waited for the coach to call to tell us what team she was going to be on, but instead a smooth-talking league organizer came by to tell me that an awful lot of kids were going to be disappointed if I couldn’t sign up as a manager, the baseball equivalent of a head coach. It seems they were short of volunteers and really needed someone with my experience, etc., etc. Later, when I became a league organizer, I would use that line more times than I care to count.

I stuck with Little League, eventually joined the board of directors, and ended up as a league organizer. But I also stuck with coaching.

That somehow led to running for Town Meeting although I still do not fully understand exactly how that came about. And that led to running for Selectman.

I finally gave up Little League, but then concentrated on youth hockey and Boy Scouts. About four years into the transition I realized that what I had learned as a Little League organizer fit right into both hockey and Scouts. Hmmmmm.

One day, a light dawned. What I had learned in Little League also fit into town government and a lot of other endeavors. Everything I had learned about life appears to have been learned in Little League. Wow!

One of the first things I learned was that you can make all the rules you want, but if they fail to pass by a huge majority, nobody will follow them.

Use all your players. The day will come when you will be thankful that you spent all your time on that kid who just couldn’t seem to catch the ball because he will make a brilliant catch late in a tournament game which will more than make up for all the ones he dropped.

While we are on that subject, you will spend 75% of your time coaching 25% of your players. If you are a good coach, it will be the lowest 25% and not the highest 25%. The highest 25% are probably better players than you were anyway.

Of course you shouldn’t cheat, but don’t even cut corners. You may be following the letter of the law, but someday the fact that you didn’t pay attention to the spirit of the rules will come back to haunt you.

Try not to relive your past glories through your team. Most of the kids are just looking to have some fun while they figure out that they don’t really want to play ball for their life work. To be honest, your past glories probably weren’t perfect, either. No need for your players to know that.

Keep in mind that there will be failures. With a lifetime batting average of .210 that means I failed close to 4 out of every 5 times at bat. You are surprised I know my lifetime batting average? It doesn’t hurt to keep track so long as you don’t beat anybody else over the head with it.

Winning it all can be exciting, but pizza after you have spent the season in the cellar, but then knocked off the #1 seed in the tournament tastes really good … even when you get knocked out by the #12 seed two nights later. Live for the moment and don’t always concentrate on the big picture.

Try to see the humor in what is going on. My Little League team once won a game when the opposing coach yelled at his pitcher “Just throw strikes.” The pitcher looked over at me and smiled, then started to laugh so hard that he couldn’t get anything even close to the plate. That pitcher is now 28 years old and we both still chuckle about that game. I mean what did his coach think he was trying to do?

Don’t take advantage. It is, after all, only a game. With three players on base, the opposing catcher was hit so hard by a pitch that he fell down in front of the plate screaming. Technically, the team at bat could have sent all the runners home and won the game, but both coaches immediately called time and instructed the spectators to stop yelling. As one coach put it “Winning by stepping over a screaming child is not my style.”

There is so much more, but I will leave you with this thought. We all know healthy snacks are good for you, but while players may like them, nobody really adores them so now and then break out the licorice ropes and Hershey bars. The players will sing your praises and who knows—the resulting sugar high may win you a game.

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Managing Resources & Making a Profit

By E. Ashley Rooney with Photos by D. Peter Lund

 

The new culvert paid for by the Lexington Composting Facility.  The spoils or the material dredged from the former culvert is now being transformed at the facility. Courtesy of D. Peter Lund

The new culvert paid for by the Lexington Composting Facility. The spoils or the material dredged from the former culvert is now being transformed at the facility. Courtesy of D. Peter Lund

Once upon a time, the Town of Lexington had a dump on Lincoln Street. Today, it has a recycling facility, which transforms waste into valuable products that are sold throughout the region. As a result, the Lexington Composting Facility not only makes a profit, it diverts materials from the waste stream. Robert Beaudoin, Superintendent of Environmental Services, projects that for this fiscal year the facility may exceed $500,000 in total revenues.

Businesses, contractors, and other towns come to purchase compost and other products at the 60 Hartwell Road facility. Our yard waste now resides as beautiful loam in Lincoln, Cambridge, in the reconstructed Commonwealth Avenue in Boston, and even Foxboro Stadium! Lexington residents and contractors dump leaves, grass and soil at the facility, which then transforms the material into high-demand products. The contractors pay; we can use it for free.

Although nonresidents pay to purchase the compost, topsoil, and super loam in bulk and pay to dump yard waste, Lexington residents can take for free the wood chips deposited from the tree service companies or the compost that is screened at 2.5 inches (in other words there are small lumps and bumps in it). During the holiday season, you will see residents looking through the brush pile for holly branches and pine boughs. A local Lexington sculptor finds wood to carve there. The Lexington Field and Garden Club uses loam from the facility to pot plants for its annual sale.

Robert Beaudoin, Superintendent of Environmental Services, points out that Lexington is not only managing its resources, it is taking waste products in, transforming, and selling them. Lexington Public Works Director, William (Bill) Hadley, was recently named to the National Top Ten Public Works Leaders of the Year list. He said, “Over the past five years, Robert and Kerry Weaver, crew chief at the facility, have dramatically improved the overall management of materials at the site and have enhanced the services. Because of these enhancements, revenues have increased allowing us to replace a failed culvert, purchase a Cat Loader, and hire a new employee.  This was all done with no money from the tax levy.”

The town has developed a major profit-making facility, and those involved in operating it are still seeking new uses.

INCREASING USE OF ORGANICS

Crew captain Kerry Weaver is turning over the leaves and grass left by Lexington residents with a front-end loader. Courtesy of D. Peter Lund.

Crew captain Kerry Weaver is turning over the leaves and grass left by Lexington residents with a front-end loader. Courtesy of D. Peter Lund.

Within the Commonwealth, more than one million tons of food waste and other organic material are disposed of every year by food processors, large institutions, and residences. Approximately 100,000 tons of organics are recycled or composted each year, but the state has set a goal of diverting an additional 350,000 tons per year by 2020. This material, which comprises about 25 percent of the state’s solid waste, consumes valuable space in our landfills and creates greenhouse gases. A cutting-edge green technology is anaerobic digestion (AD), which can convert organic materials into clean renewable energy and valuable fertilizer.

Currently, there are six AD facilities now in use in Massachusetts and a few AD units used by commercial food processors. The Hartwell facility is considering the possibility of an anaerobic digester. The selectmen will hold public hearings on the subject later this summer.

USING THE SITE CREATIVELY

Massachusetts’ households generate a great deal of toxic waste every year in the form of common cleaners, paint products, automotive materials, mercury-containing devices such as fluorescent lights and thermostats, and numerous other items. Much of this waste could end up in landfills or contaminate surface water. To address this problem, the facility holds eight household hazardous waste collections – many more than other towns. More than 40,000 cars have passed through since 1998.

The waste is processed and screened extensively. This pile of compost tailings filled with rocks, tree branches, plastic bags and old tennis balls is what remains.  Courtesy of D. Peter Lund.

The waste is processed and screened extensively. This pile of compost tailings filled with rocks, tree branches, plastic bags and old tennis balls is what remains. Courtesy of D. Peter Lund.

Bill proudly showed off the Homeland Security cache contained in the facility as part of Northeast Homeland Security Planning Region (NERAC), overall strategy to effectively provide emergency resources for the entire Northeast Region. The cache contains equipment that municipalities cannot usually afford to buy on their own, such as multiple large lighting towers, variable electronic message boards, or large numbers of cots, sandbags, or barricades. Because Lexington stores the equipment, it can use it for free when needed. The town of Lexington has used some of this equipment during hurricanes and other emergencies.

The facility also contains the shooting range for the police and an area to contain any impounded cars.

WORKING WITHIN THE TOWN

The facility also partners with other DPW departments, saving money for the town. For instance, it grinds up stones and makes material that can be used by the highway department. It is currently storing a large hill of soil from the Estabrook project. It redid the culvert on its access road leading to the wetlands with its own money rather than increasing our tax burden. When streets or sidewalks are repaired or redone, all the spoils are reprocessed and reused.

Kerry Weaver and his staff work hard to maintain the cleanliness of the 28-acre site. Kerry, who has been with the facility for 17 years, is the one who tracks down the contractor who tosses his cigarette pack out the window or the resident who dumps his garbage in the grass pile.

CT_Story_End

 

 

 

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Calming the Chaos

 

Drs. Blaise Aguirre and Gillian Galen

Drs. Blaise Aguirre and Gillian Galen. Photo by Jim Shaw.

New Book by Lexington Authors Applies Mindfulness Practices to Living with Borderline Personality Disorder

| By Laurie Atwater

 

Mindfulness for Borderline Personality Disorder: Relieve Your Suffering Using the Core Skill of Dialectical Behavior Therapy Blaise Aguirre MD (Author), Gillian Galen PsyD (Author) Available at Amazon.com, barnesandnoble.com and newharbinger.com.

Mindfulness for Borderline Personality Disorder: Relieve Your Suffering Using the Core Skill of Dialectical Behavior Therapy.
The new book by Aguirre and Galen is available at Amazon.com, Barnesandnoble.com and newharbinger.com.

 

 

 

“I need to want to die less.”

This line appears in the introductory chapter of Lexington resident Dr. Blaise Aguirre’s new book Mindfulness for Borderline Personality Disorder: Relieve Your Suffering Using the Core Skill of Dialectical Behavior Therapy (New Harbinger Press) coauthored with his colleague and fellow Lexington resident Dr. Gillian Galen. Both Aguirre and Galen have spent their careers working with BPD patients at 3East, unit at McLean Hospital in Belmont devoted entirely to the treatment of females with borderline personality disorder (BPD).  Dr. Aguirre is the Medical Director at 3East and Galen is the Director of Training.

Sylvia, the woman quoted above is reaching out for help.

Working with patients in this kind of mental pain is the challenge at 3East. Currently women are more frequently diagnosed with BPD (75-90% of those diagnosed with BPD are women according to the Borderline Personality Research Center at New York Presbyterian Hospital). Research is being done to validate this working assumption and the situation may change in years to come, but for now, female teens are the faces of BPD.

Because many of the symptoms of borderline personality disorder can closely resemble what we perceive as ordinary adolescent behavior, BPD often goes undiagnosed until a traumatic event occurs. According to the Borderline Personality Research Center, “10%, or one in ten, people with BPD commit suicide. Thirty-three percent of youth who commit suicide have features, or traits, of BPD. This number is 400 times higher than the general population, and young women with BPD have a suicide rate of 800 times higher than the general population.”

Parents faced with moody, withdrawn, sad or angry adolescents often assume that their child is just suffering the normal ravages of teen years—and most are. However, individuals with BPD are so emotionally charged that their feelings erupt quickly and more intensely than an average teen and they take much longer to calm down. This emotional instability is the calling card of the disorder.

They also experience self-loathing, feelings of worthlessness and hopelessness about the future combined with an intense fear of abandonment. They are very often suicidal and many BPD sufferers make several suicide attempts. About one in ten are successful, and this is why it is critical to identify this disorder early and get effective treatment.

Many teens are great at disguising their suffering and looking quite “normal” on the surface for long periods of time. In fact BPD patients can be very high functioning, but they almost inevitably erupt in episodes that are so out of control they are really scary—especially to parents. BPD kids’ lives are in a perpetual state of drama and chaos.

Galen says that patients come to McLean when they are in a pretty fragile state. “They are sick a lot, chronically tired, sleeping is poor and they are often overmedicated. These kids are living on a constant roller coaster of emotions. A typical adolescent might come home from school angry and frustrated and there could be door slamming and screaming, but they will go to their room and regulate themselves and come down to dinner. They can have momentary mood dysregulation but still have a normal life—go to school, do their homework.”

“But BPD kids are so mood dependent that they can’t finish things. They drop out of activities. They don’t make it through sports season. They can’t ever find something that they like.”

BPD is obviously very disruptive to the family unit. “People start walking on eggshells around these kids because they are so unpredictable,” Galen says. “What happens is the child threatens an extreme act like suicide as a way of getting what she wants and if the child has that history (of attempting suicide), the parents become frightened and refuse to set limits. Out of fear for their child they end up reinforcing the bad behavior.” This dangerous dance can have dire consequences.

Behaviors like cutting (self-injury that involves puncturing or cutting the skin to release tension) burning, excessive drinking, irresponsible sex and reckless driving may provide behavioral clues for concerned parents who are ill equipped to handle these kids who have huge emotional swings and can be chronically acting-out.

 According to DSM-IV criteria (DSM-IV is considered the diagnostic “bible” for psychiatric disorders), signs and symptoms include:

  • Make frantic efforts to avoid real or imagined abandonment.
  • Have a pattern of difficult relationships caused by alternating between extremes of intense admiration and hatred of others.
  • Have an unstable self-image or be unsure of his or her own identity.
  • Act impulsively in ways that are self-damaging, such as extravagant spending, frequent and unprotected sex with many partners, substance abuse, binge eating, or reckless driving.
  • Have recurring suicidal thoughts, make repeated suicide attempts, or cause self-injury through mutilation, such as cutting or burning himself or herself.
  • Have frequent emotional overreactions or intense mood swings, including feeling depressed, irritable, or anxious. These mood swings usually only last a few hours at a time. In rare cases, they may last a day or two.
  • Have long-term feelings of emptiness.
  • Have inappropriate, fierce anger or problems controlling anger. The person may often display temper tantrums or get into physical fights.
  • Have temporary episodes of feeling suspicious of others without reason (paranoia) or losing a sense of reality.

 

A great YouTube video about BPD , Back From the Edge offers guidance on treating Borderline Personality Disorder. The video was created by the Borderline Personality Disorder Resource Center at New York-Presbyterian.

http://www.youtube.com/watch?v=967Ckat7f98&feature=youtube

 EARLY INTERVENTION IS KEY

In his 13 years as the Medical Director at 3East, Aguirre has remained passionately hopeful about the prognosis for those diagnosed with BPD, though he admits they can be frustrating to diagnose and treat. Patients often have symptoms that overlap with other illnesses and many teens may have received several different diagnoses that never quite fit before making it to 3East. Dr. Aguirre stresses that it is extremely important to get the right diagnosis because BPD sufferers do not respond to the same drugs or treatment modalities as more commonly diagnosed conditions like conduct disorders, depression or bi-polar disorder. It’s also important to catch this disorder early. Although there is some controversy about the diagnosis of BPD before age 18, temperamental tendencies can be identified early, and Dr. Aguirre feels that early intervention is critical. Research shows that dialectical behavior therapy (DBT) reduces the incidence of suicide attempts and keeps teens in therapy for longer periods of time. Untreated, BPD symptoms can persist into adulthood, but with treatment the outlook for a successful life is greatly improved. “Kids stick with it,” Aguirre says, “because they want out of their misery—they are in so much pain.”

THE BRAIN AND THE ENVIRONMENT

Marsha Linehan of the University of Washington is one of the leading experts in BPD. Dr. Linehan has developed a biosocial theory of  BPD  over many years of dealing with highly suicidal, treatment-resistant patients. On the biological side of the equation she theorizes that BPD patients have a lower neurological threshold for emotional stimulation.

New research published in the journal Biological Psychiatry in this past January shows that the emotional priming for BPD may well be biological as Linehan theorizes. A recent review of imaging studies by neuropsychologist Dr. Anthony Ruocco at the University of Toronto (Ruocco is a clinical neuropsychologist who specializes in the use of neuropsychological and brain imaging techniques to understand the brain. His primary area of interest is in identifying biological liability markers of borderline personality disorder) recently observed heightened activity in brain circuits involved in the experience of negative emotions, and reduced activity of brain circuits that are normally recruited to regulate emotion.

Aguirre and Galen have an entire section of their book devoted to brain imaging, genetics and brain chemicals. They present the science showing that BPD sufferers have an overactive amygdala (fight or flight central) and an underactive prefrontal cortex (the seat of reason and control). The interaction between the two regions of the brain is out of balance in BPD sufferers as brain scan studies like the one cited above have shown.

On the social side of BPD, Dr. Linehan has identified that BPD patients suffer the effects of an invalidating environment. This is an environment that is experienced as hostile by and to the BPD patient—where their emotions are seen as unacceptable and are often dismissed or punished. This can be very difficult for loved ones to comprehend. Dr. Aguirre explains that many “invalidating” remarks and behaviors are often used  innocently by loved ones to “console” or to “help” someone who is in psychological distress. Things as common as telling someone ‘cheer up, it’s not that bad’,  ‘you’ll be fine’ or  ‘just get over it,’ can invalidate a BPD sufferer’s feelings. When the BPD sufferer experiences a negative and stressful situation like a breakup with a boyfriend or a fight with a friend and is met by invalidating comments, a cycle of self loathing, anger and acting-out may begin. These episodes often end in self-harming behaviors that are, to the BPD sufferer, a form of self-calming.

Based on her clinical experience, Dr. Linehan pioneered a practice known as DBT (dialectical behavior therapy), the therapy that is now considered the gold standard treatment for BPD. This  program used with great success with teens at McLean.

DIALECTICAL BEHAVIOR THERAPY

DBT balances empathy and acceptance with an unwavering focus on changing problem behavior. Through this balance, DBT aims to help change the behavioral, emotional, and thinking patterns associated with problems in their lives, while promoting the development of, and reliance on, an inner wisdom—something Linehan calls the “wise mind.”

“What makes DBT so successful,” Aguirre explains, “is that it is extremely accepting that a person has the limitations that they have. It accepts them at face value without making any interpretations or judgments.” This accepting and validating  therapeutic relationship nourishes the patient’s ability to see that change is necessary to end their pain and suffering.

But it is not only the therapist that must practice non-judgmental acceptance. The patient must also be able to accept themselves and their situation. Linehan calls it Radical Acceptance which means being nonjudgmental of the self and accepting life as it is. Dr. Linehan found that without this fundamental acceptance it is almost impossible for patients to progress in therapy.  And many drop out because of this.

“This is a process that you have to accept over and over again,” Gillian Galen says. “But,” she adds, “pain plus non-acceptance equals more suffering. We have skills for dealing with difficult feelings, none for non-acceptance.”

The “dialectic” in DBT is this notion of holding the opposing ideas of acceptance and change in balance. This dialectical approach acknowledges the yin and yang of feelings, situations and relationships and get away from black and white thinking (good/bad, right/wrong). Through practice it helps patients synthesize opposing thoughts and feelings into their “wise mind”—a balanced place between acceptance and change.

When patients come to treatment, they often have a hard time with the concept of acceptance. They can’t accept themselves, the diagnosis, the love and caring of their friends and family or the reality of circumstances that they find difficult. They will argue their position and feel extremely misunderstood when others don’t agree with them.  But once the threshold has been crossed the change can begin, and it is typically very effective.

The formal aspects of DBT training involve individual meetings with therapists, classroom style training in the fundamental skills of DBT–mindfulness, interpersonal effectiveness, distress tolerance and emotional regulation—and group training sessions in which patients learn to incorporate the skills into life situations. In DBT therapy sessions life-threatening behaviors are always addressed first and then work continues on specific situations and feelings that have caused pain. It is typically a one year process with follow-up.

“The theory that we hold is that BPD is, in part, a skills deficit,” Galen explains. “These are people, who along the way in their development, didn’t learn these skills so we teach them the skills, how to use them, when to use them and then we give them coaching in the moment.” DBT takes time and dedication to unwind these individual and family patterns.

“The brain does not distinguish in any way, shape or form between adaptive or maladaptive behaviors—good, bad or indifferent,” says Aguirre. “What we know is reinforcement behavior—the more you repeat something the better you get at it. So, if you keep repeating the same maladaptive behaviors you get really good at it.”  The same holds for adaptive behaviors. DBT is a process of identifying problematic thinking and behavior and swapping it out for the newly acquired adaptive behaviors and then reinforcing and repeating the process through role play and therapy until it forms new muscle memory for the patient—a DBT toolkit at the ready when needed. “In large part we are teaching patients to pay attention to those things that just aren’t working for them,” Aguirre says, “As therapists we’re the sympathizers, the tool-givers and the cheerleaders.”

DBT also requires the commitment of the parents. “We ask the parents to participate in a skills group because we have to change these transactional patterns that have developed over time,” Galen says. Aguirre says, “In my psychiatric career, the vast majority of parents who have these kids are the kindest, most well-meaning parents who just don’t understand how difficult their kid’s struggle is, and they don’t always have any experience with these types of feelings.” DBT can work wonders in interrupting this painful cycle and creating new habits for both parents and their suffering children.

Learning to identify the physiology, thoughts and situations that trigger emotional reactivity is the biggest challenge for patients. They have the tools, but when to use them? This is where mindfulness comes in. Mindfulness is the core skill of DBT.

SARAH’S STORY

Sarah was a patient at the 3East Residential Program at McLean. She generously shared her story with us by phone from college where she is continuing her education. Sarah uses the skills of mindfulness and DBT every day. 

“I started getting depressed around my junior year in high school. I’ve always been a perfectionist and a really hard worker in school. I started feeling really overwhelmed with my work. I wasn’t sleeping enough and all I cared about was school. I just felt out of control in life and I didn’t know what was going to happen the next day. That continued into my senior year when I had my first suicide attempt and my first inpatient hospitalization.

During my junior year I started cutting but I never really did it for very long. I went to public schools my whole life, but in an area where everything is so competitive. Everyone was so smart and so good at sports and I just felt—even when I was getting good grades—someone else was better than me. That made it a lot worse. You just lose sight of reality. Everyone in my area is this certain way and it’s expected that you go to college and maybe even get a graduate degree.

After high school I realized that there’s a whole lot more to this world.
In the fall of 2009 I went off to Emory University and I lasted about six weeks there before I had a major breakdown. Before my first exam I had a panic attack. The school sent me home and said I wasn’t taking care of my health. I was really devastated when they told me I had to leave school—I thought it was ridiculous, but when I got home I realized it was definitely the right decision because I needed more help so I went into the day program at McLean.

After my next suicide attempt I went to 3East—the residential unit at McLean. I absolutely loved the program and I would definitely say that it saved my life. Living on the unit with everyone about my age going through the same things—it was like a family.Eighty-five percent of the time I am perfectly fine and then I have a huge breakdown and I get suicidal.

But it was hard at first to go to treatment. My whole life growing up, I never thought it was okay to ask for help. That was the first hurdle. Once you’re able to accept it it’s a lot easier to make progress.

My parents never dealt with anything like this before. I’m the only one in u family to have mental illness and my parents had no idea. They just thought I was being an angst-y teen. I refused to talk with them. They would ask me how school was and I would snap at them. I tried to distance myself from them. That’s when they knew something was up. My friends weren’t really coming around and I was spending all my time in my room. I know they definitely had to read into the signs—it wasn’t obvious to them. Now I realize that my parents have always been pretty worried about me.

I struggle with anxiety. Most of the time I don’t even know what I’m anxious about. But since I’ve learned DBT I’ve started to pay attention to it. I’ve learned to pay attention to all of the feelings and sensations and then I think, ‘is there a cause for this? Is there really anything to worry about? It’s been really helpful. There are four modules in DBT and I’ve probably been through them all many times. In those moments when I’m really distressed, using a skill can really help, but it’s hard. I have to find the skills that really work for me.
I really loved doing the yoga.

I’ve started going to yoga classes on my own and it’s amazing how it can calm you down and put you in a different mindset. It stops you from thinking about the future.”

 

MINDFULNESS

Mindfulness practice has been shown to mitigate the underlying problem of BPD by activating and strengthening the prefrontal cortex and reducing the body’s stress mechanisms.

The concept of mindfulness has exploded throughout American culture.  A mainstay of Eastern religions, this practice has been inching its way into the Western mainstream for some time. In Lexington, our own Jon Kabat-Zinn has been on the forefront of exploring Mindfulness-Based Stress Reduction (MBSR) which he launched at the University of Massachusetts Medical School in 1979. Since that time, thousands of studies by Zinn and others have documented the physical and mental health benefits of mindfulness.  Mindfulness is being used to combat stress in the classroom, in business and in just about any setting where attention is being hijacked by modern life. With roots in the Buddhist tradition, mindfulness meditation involves paying attention to thoughts and feelings in the present moment and accepting and letting go of those feelings and emotions non-judgmentally. A mindfulness practice can give the participant more control over their thoughts and feelings and has been proven empirically to result in more activation in the pre-frontal cortex.

“If you look at mindfulness-based stress reduction it has shown lots and lots of efficacy in many medical conditions,” Aguirre says.  “Though the research on mindfulness specifically for BPD is scant, through clinical observation, we see the kids who use mindfulness recover much more quickly. It is imperative that we as clinicians pay attention to things that work.” Teaching patients to slow down their breathing and check in with their bodies can help them identify the biological stress signals that the body sends before they react emotionally. Once they realize that their pulse is racing, their palms are sweating, their breathing is shallow or any of the myriad physical symptoms they may suffer, they can reach for a DBT skill that might help them to cope.

PRACTICE WHAT YOU TEACH

About 7 years ago Dr. Aguirre was attending a conference in Washington D.C. and happened to be seated next to BPD expert Dr. Marsha Linehan.  Aguirre had been at McLean practicing using the DBT program for several years with adolescents and he was becoming more and more interested in the mindfulness component of the program.

“I heard that Dr.Linehan was doing training in Tucson and I asked her to get me in,” he says with a short laugh. What Aguirre learned upon arriving in Arizona was that the “training” had nothing to do with DBT. “It was a Catholic monastery and I had to be sitting there staring at a wall in silent mindfulness for sixteen hours a day,” he laughs.

Admittedly he panicked, called his wife and begged for her to make up an excuse to get him out of there. “She hung up on me,” he says ruefully.

“So there I was stuck in the monastery with Marsha Linehan and it changed my life,” Aguirre says. “I finally woke up to the way my mind works.”

Aguirre’s co-author Gillian Galen came to mindfulness through yoga. A dancer and an athlete, Galen relocated to West Hartford, Connecticut for her graduate work and found herself looking for some dance or sport that she could fit in with her studies. She ended up in a yoga studio and fell in love with the practice. “I got really hooked on yoga,” she explains “and I started to notice myself changing off the mat and I was fascinated by it.”  Galen noticed that she could come to yoga after hours of studying and clinical work and within fifteen minutes my mind would go from spinning to a sense of quiet and soon I became interested in the science behind it.”

Galen ended up writing her doctoral dissertation on the effects of yoga on mental health. “People began noticing how level I was. I was much less judgmental. I was paying attention and I was essentially ahead of my experience and all of this was happening as I was developing as a psychologist.”  Galen had worked for a time at McLean before doing her graduate work so she had some exposure to DBT. “Once I added yoga it all came together.”

The last time I saw Aguirre and Galen they had just returned from a mindfulness retreat. So they are both “all in” on mindfulness and what it can do to enhance anyone’s life.  But its application to DBT is essential for success.

MINDFULNESS FOR BPD: THE BOOK

Skill-building is the backbone of the DBT program or as Aguirre says: “Skills not pills.”

Being mindful, learning to sit with difficult emotions without resorting to old behaviors, learning to reframe internal thoughts and calm overactive emotions—this is DBT and the work that goes on at 3East.  The program has shown so much success that Aguirre and Galen wanted to share it with those who are unable to participate in a hospital-based program. Their new book lays out a path to end the suffering of BPD through DBT focused mindfulness training.

“We had a great time writing the book because we love mindfulness and we love thinking about it,” Galen says. “It’s changed both of our lives completely and we loved trying to figure out how to bring it to people in a very easy, non new-age-y, non-judgmental way.”

Writing this book was a labor of love, but it required lots of hard work. Galen and Aguirre staged marathon writing days on the weekends, joining up with their respective spouses for dinner and then starting it over again the next day. “We have crazy work schedules so we just had the weekends, and we did this for multiple weekends a month,” Galen explains. “Our families were very understanding!”

What they have produced is a highly readable book that incorporates case studies, accessible explanations of the science and symptoms of BPD, and a plethora of mindfulness exercises. The book immediately engages by speaking directly to the reader in a down-to-earth and compassionate voice.

The authors very clearly discuss BPD in all of its dimensions, the concept of mindfulness and its application to BPD, and the neuroscience underpinning both. The balance of the book is devoted to explaining a series of known BPD behaviors like emotional instability and anger, unstable relationships, fear of abandonment, impulsivity, self-injury (and many others), and teaching mindfulness exercises that can be helpful in interrupting old patterns.

“Whether you have borderline personality disorder or not, these skills help anyone,” Galen says. “We’ve had parents tell us that they use these skills at work now.”

Learning to calm a frenzied mind and quiet the emotions through mindfulness helps patients to do the necessary work of building their DBT toolbox and to ultimately learn to see themselves, and the world, in a way that’s less judgmental, gentler and more hopeful.

 

McLean’s DBT Programs

The program specializes in intensive dialectical behavior therapy (DBT). 3East now offers four levels of individualized care; enabling teenagers and young adults to fully benefit from ongoing, consistent treatment and support at varying levels of care:
-3East Residential Intensive. A program for teens and young women, ages 13 through 20.
-3East Residential Step-down. A program for “graduates” of the “3East Residential Intensive” treatment, ages 13 through 20.
-3East Day Program. A mixed-gender, non-residential day program, for individuals, ages 13 through 20, who live in the surrounding area or have completed the 3East Residential Intensive program and reside on the 3East Step-down unit.
3East Transitional Care. A program for women 18 through 25 who have already received intensive dialectical behavior therapy (DBT) treatment and would benefit from extended care before returning to live independently in the community.

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