Let go. Hold on.

July 18, 2011 in Uncategorized | Tags: , , , , , | 1 comment

A few months ago, my relationship of seven years broke down. For a long time, I had struggled to be the person my partner deserved me to be. Seven years is a long time. We were engaged to be married. We had wedding and house-buying plans. We argued good naturedly over names for the children we would have. I was confident that I knew what was ahead.

Last autumn, she chose to move to the other side of the world for work. I knew there were tough times ahead, but I believed we’d make it. I was due to fly out to see her just three weeks after she left. The day I was due to fly, it snowed. How simple. And random. It snowed, and no planes flew that day. If I had gone one day earlier. If it had snowed one day later. These are the thoughts I catch, and put away. Over and over again, some days. And other days, they come faster than I can notice or catch them. The days when I am surrounded by people with partners and children.  

“We must be willing to let go of the life we have planned, so as to have the life that is waiting for us”

It’s not a DBT phrase. I don’t even remember where I saw it. But I think it captures the spirit of DBT perfectly. The magic word ‘willingness’. The concept of ‘letting go’. Radical acceptance. Flexibility.

The snow didn’t help. And it’s very possible that things would have gone badly even if we had seen each other at Christmas.  But the truth is: my partner suffered and my relationship ended because I am broken. And although I work so very hard in therapy, I am not sure whether I can mend myself. I know that until I am mended, I cannot be in a relationship. So here I am, with the permanent lump of loss in the back of my throat, fighting to accept that the children whose names we so hotly debated will never exist. That my engagement ring sits in a box in my bathroom. That I will never again go to sleep beside her.

Letting go.  But trying to hold on- to hope, that there might be a life which is waiting for me.

DBT or MBT?

May 14, 2011 in Uncategorized | Leave a comment

I stumbled across MBT (mentalization based therapy) in my search for DBT. Developed in the UK by Peter Fonagy and Anthony Bateman, it is based on the idea that people with BPD have disorganized attachment patterns and failed to develop the capacity to mentalize within an attachment relationship. Mentalization is the process by which we implicitly and explicitly interpret the actions of oneself and others as meaningful on the basis of intentional mental states. I read the books, looked at the published outcomes, and chose DBT. I felt that I already lived very much inside my own head, and only DBT would get me out of my head and living my life.

At the NEA_BPD conference last month, several demonstrations and comparisons of MBT and DBT were recorded and put online. I listened to the MBT and DBT sessions found here. Both sessions had the same ‘client’ who brought the same problem to therapy. What struck me most was how much more laughter there was in the DBT session…

Does DBT really work? Part I(!)

March 13, 2011 in Uncategorized | Tags: , , , , , , , , , , , , , , , , , | 3 comments

I got a comment this week which has pulled me back to my blog (thanks, Ivy!). In full, she asked:

“I’m curious about your experience of DBT and how you’ve written that you have ‘built a life worth living’ and yet seem to still be despressed and struggle with suicide, etc. I tried DBT – you could call me a “dbt dropout”. I found the classes patronizing and I found the skills were, well, not effective… For me, it was not an effective way to treat a client with BPD to tell them you won’t speak to them if they do not “do this”. That screams of abandonment, in my opinion, and that’s one of the main symptoms of BPD.
Obviously, your DBT experience is much different, yet your struggles with suicide and depression seem to be similar to mine, therefore I am intrigued.”

These are all interesting and important points, and I think it’s going to take two separate posts to do them justice. I’m going address the questions about the effectiveness of DBT first, and tackle the question of how clients experience the delivery of DBT (the feeling of being patronized and the abandonment that comes from the 24 hour rule) in another post. Phew!

So: does DBT really work? After all, I’m still not the happiest bunny on the planet. Yet the difference between my life before and now is immense. Prior to starting DBT, I was chronically suicidal. I mean every day. I was inching closer and closer towards completed suicide, with increasingly frequent hospital stays. I was leaving my twice weekly (undirected) therapy so distressed I’d hurt myself. I was drinking more and more and had some near misses with accidental death. I was in a job far below my capabilities, and frequently off sick. The only friends I saw were the ones who broke their way into my home, because I cancelled any plans I’d made- overcome by an inexplicable dread. It’s hard to describe the constant noise in my head. Now? My dangerous behaviours are gone. I have a fab job, see my friends, ’live’ well, even on the days when depression and suicide creep back. I guess their occasional guest apperances may sound disappointing. It doesn’t feel disappointing to me. I have been battling with them for 20 of my 28 years. I never expected this to be the final round. In the last few months, the event that’s had the biggest impact on me has been my partner’s decision to relocate, putting us in the longest-distance relationship you can have on this earth. It’s been hard. I’ve faltered. Has DBT failed me? The only thing DBT has ‘failed’ to do is to control other people’s (e.g. my partner’s) behaviour, and it never promised that…   

Some other random thoughts in no particular order:

*What most people talk about as ‘DBT’ is only Stage 1 of four stages. Stage 1 doesn’t promise to get you to a point where life feels worth living. All it claims to do is bring target behaviours down under control. When Marsha Linehan talks about ‘quiet desperation’, she is acknowledging up front that bringing dangerous behaviours under control is not enough- it just traps us in a life of quiet despair. Stage 2 of DBT addresses the underlying trauma which got us so stuck in the first place. Stages 3 and 4 address ordinary problems of living and developing the capacity for joy.

*DBT incorporates a huge range of skills. These include: various ways to be interpersonally effective so you get what you want, maintain the relationship, or retain your self respect; a wide variety of ways to help you manage your distress; many different ways to regulate your emotions; various strategies to build mindfulness into your life. I don’t believe for a second that every skill will work for everyone. There are some skills which don’t do it for me, and a couple which make me worse. However, I also find it very hard to accept that there are any people for whom none of the skills are effective. The skills are not bizarre or crazy or even particularly unusual. Many of the skills are explicitly teaching us what ‘normal’ people learnt naturally to do as they grew up, because their environments gave them a chance.  

*Not even the best treatments work for everyone. I’m training to be a psychologist. We use an evidence base to decide what is likely to work. DBT has such an evidence base. However, the evidence (yes, more evidence!) suggests even the most ‘effective’ treatments- the ones with the best evidence- do not work for up to 1/3 of clients. When this happens, it doesn’t matter how ’effective’ the intervention was in theory, it’s back to the drawing board as far as that particular client is concerned.  

*I wanted and needed DBT to work. I chose to do DBT, and went to great lengths to track down a therapist. I was invested. I guess DBT might call this ‘willingness’. I am absolutely *not* saying that DBT doesn’t work for others because they are not trying hard enough or don’t want to get better. Even DBT itself refuses to say this, as one of its core beliefs is that the client cannot fail- only the therapy and the therapist can fail. However, I am saying that I wasn’t sectioned and thrown into a DBT programme against my will, or told that DBT was all that was on offer when I actually wanted a different kind of treatment. And I’m sure that makes a big difference. However, I certainly do not think that I- my attitude, investedness or any other characteristic of mine- was the only or even the main factor which made DBT work for me. I think a lot of it was down to the therapist I had. Over and over again, in so many different kinds of therapy, the quality of the therapeutic relationship has been shown to be the main predictor of success, and I got very very lucky with my therapist. I’ll talk about this more in my next post on how DBT is experienced by clients…

*DBT only works if you use the skills. And I’m talking about me here, not ‘you’. I know that many of the DBT skills work well for me. That doesn’t mean that I always use them. Sometimes I forget, slipping automatically back into old habits. Sometimes it feels too hard, perhaps because there’s a new situation I haven’t had any practice applying them to. And yes, sometimes I just plain choose not to. Some days, I choose to wallow in pain rather than help myself. I don’t always realise that’s what I’m doing, but the next day, when I pick myself up and try again, I can see that’s what I did. I think this says more about my less than perfect willingness than about DBT’s effectiveness.  

*Building a life worth living. That’s what my blog’s called, and that’s what I’m doing. It is not yet built. I will be building it each day for the rest of my life. Sounds tiring? It is. But there is so much satisfaction and even some joy in the building. Every time I succeed in soothing instead of escalating my distress, every time I get out of bed and make it into work, every time I see my friends instead of cancelling, that’s building a life and living a life all at once.

What are the choices?

March 7, 2011 in Uncategorized | Tags: , , , , , , , | Leave a comment

Recently, I’ve been struggling to see the choices in the situation. I know that the suggestion that we have choices at all can feel very invalidating, even insulting. But I keep looking for choices, because the reality of having choices is utterly liberating.

I looked through an old folder tonight for some diary cards. I have fallen hard off the DBT wagon, so hard that I’m being dragged along the ground behind the wretched wagon, and the skills diary card is my first step back on. In the folder, I found this:

there are five choices:

1. Change the trigger (= solve the problem)

2. Change your feelings (= your response)

3. Use radical acceptance

4. Keep suffering

5. Make things worse (= engage in target behaviour)

I’m not sure where I saw this and scribbled it down from. But I’m so very glad I did. I can see I have made progress; I rarely choose number 5 any more. But I am choosing number 4 all too often. These wise words will be written on my phone and stuck on my mirror. I couldn’t see any choices, and now I have five. Well, three, hopefully!..

A song still in me?

February 8, 2011 in Uncategorized | 4 comments

Things are very bad. This is suffering, not just pain.

Somewhere, I don’t remember where, there was this:

“Don’t die with your song still in you”

 

When I first came across it, about a month ago, I was struggling but not suicidal. And it resonated- I felt strongly that I had so much song still left in me.

Today, I am clinging to these words in case they can keep me alive. My slow poorly out of control brain is trying to work out: is there any song left in me? how do I sing it today, tonight, tomorrow? what are the tiny things I can change so that I am closer to singing instead of suffering?

Lighting a candle

December 19, 2010 in Uncategorized | 2 comments

My partner moved to Australia in November. At some point in October, my raging and terror and suicidality burned itself out, and I began to act skilfully. I moved to London, found a home, made it a place I’m happy to live in. I showed up to my course and work and participated fully. I made plans with my friends, and stuck to them. Next to my bed in my new home, in this new life I have built, is this:

I painted the canvas white, ordered the letters, measured them carefully and stuck them on straight. I have been using this sign to figure out what to do, how to live, each day. It expresses the choice I have more clearly than anything I have ever come across. To me it covers a whole bunch of DBT skills: radical acceptance that it is dark; acting opposite to the emotions which make us want to curse the darkness; doing what’s effective by lighting a candle; working out which ‘candle’ to light- a distress tolerance activity from ACCEPTS? A pleasant event from emotion regulation? It means that each day I do one small thing to make my life better… and some days, simply getting out of bed definitely counts!

Today is a particularly dark day. I should be in Australia right now, in my partner’s arms. Instead, I am alone in London, and here I will stay for the holidays because the Snow Gods intervened and closed the airport. There have been times today when I have turned my back to the sign and cried. But I keep turning back to it, and I know that I have a choice about how I respond. And I know that I will choose a skilful holiday. I will light all the candles I can get hold of, because I am tired of living in the dark.  

For today, I’m tired and ill and the best I can manage is a list of possible candles. Tomorrow, I will make a plan. And I’ll post here each day about my Skillful Christmas. Three more days than the original 12 days of Christmas, and involving far fewer gold rings and livestock (I always thought all the turtle doves, partridges etc. were a bit odd). Just me and the DBT skills. We’ll do ok.

Tonight’s candle comes courtesy of my therapist, who randomly gave me a lovely candle a few months ago, knowing nothing about my new approach. And particularly fortunately, she gave me three refills for Christmas on Friday. It’s looking like I’ll need them. This is enough for tonight:

      

My DBT (new and improved) life

December 19, 2010 in Uncategorized | Tags: , , , , , | 1 comment

At some point, I seem to have stopped writing about the skills and started living them. Sometimes I don’t even notice that I’m doing it. My training course involves techniques from brief solution-focused therapy. As part of this, we ask clients we consult with what their best hopes are for our work together. DBT did not start like this, probably because I couldn’t have felt or articulated any hope at that point. My goal was not to die by suicide, and some days I wasn’t even totally committed to that. Yet eighteen months in, I realise that DBT has changed my life beyond my best hopes. I’m finding  that I want to preach the skills to everyone I talk to, because they work. And the result is that there are more and more days when I do not have to fight the noise in my head to get up and go out and live. The noise of suicide and self destruction and suffering. There is still pain, but I am not suffering in the same way. Until I met radical acceptance, I didn’t even know that pain and suffering were different. Mostly, these days, it is quiet enough in my head for me to be able to hear life. I never expected this; I realise now that my best hope was to find a way to live over the noise.

Hospital

October 25, 2010 in Uncategorized | Tags: , , , | 7 comments

In the months before I began DBT, my dangerous behaviour was escalating. I was ending up in hospital with increasing frequency. My relationship with hospital was complicated. It was a safe place, to an extent. But as soon as I was there I was desperate to leave again. The environment was nice (it was a private hospital) but the nursing staff were so unskilled and unempathetic that I wouldn’t have trusted them with my dog. I’d go in for the night and then skilfully talk my way out of there the next morning, determined to try harder and do better.

There have been times in the last year when I have had urges to go to hospital so strongly they felt like physical cravings. There have been other times (notably this summer) when I was acutely suicidal and actually quite unsafe, when it might actually have been helpful to be able to spend a few days there, getting back on my feet. Because it hasn’t been willpower or skilfulness alone that has kept me out of hospital. In January, my insurance company cut me off. I have some (limited) money for treatment, but have never been able to justify to myself spending £1000 for 24 hours in hospital, when this would pay for 8+ weeks with my fantastic therapist who gives me far more help.

I still get the odd hospital related pang, mostly at random. An ambulance drives past me and I wish I was in it. I walk past a medical hospital after work and look up at those huge lit windows and imagine the warmth. I think a lot of this comes from spending a whole year in hospital aged 13. Although it was a terrible, desperate year, it was a large chunk of my life at a formative age and I think the feeling is akin almost to ‘homesickness’. But even as I feel it, I know I don’t really want to be there. I know I can help myself better than they can help me. That wasn’t true before DBT.

Today marks a year survived without resorting to going to hospital. It’s a mixed anniversary- a year since I almost accidentally died, having been failed by the aforementioned nursing staff. But that story’s for another day. Today it is cold but sunny. I spent a perfect Sunday with my girl (and whoever’s thinking that ‘perfect’ is a judgement… I know, but I’m using it anyway!). And I have skilfully kept myself alive and well for a year. Here’s to the next…

Wobbling away

October 3, 2010 in Uncategorized | 3 comments

I’m out of practice at this skills thing, as it turns out. Today’s small successes:

  • Apologising when I did something wrong (interpersonal effectiveness)
  • Taking time out to have a hot chocolate and read a good book (self soothing, pleasant event)
  • Pushing myself to go swimming when I was distressed (distracting with an activity, reducing physical vulnerability)

Ok, maybe medium successes :)

Getting back on the bike

October 1, 2010 in Uncategorized | Tags: , | 2 comments

I’m not sure quite how I spent September, but it wasn’t doing DBT. And I’m not sure either how I got so far away.

When I began DBT in June 2009 , I genuinely felt that I had everything I wanted in my life, in terms of external/environmental factors. The problem was me/my head/my feelings, and I felt very willing to change myself and believed that I could. My experience was that the skills worked, and by using them I was able to build a life that I wanted. Towards the end of that first year I began to feel like ‘it’ was done. I was successfully riding the bike, but actually I was riding with stabilisers across a totally flat soft surface. 

Then the bottom fell out of the life I had built because of someone else’s decision, and this time there was nothing I could do about it. It wasn’t a case of trying harder or being more willing. It took me a while to realise how far and fast I was falling, but when I did realise I clung to the skills. The ground fell away and the bike wobbled uncontrollably. I had to come to terms with the fact that I don’t really know how to ride.

And then the actual format of my life changed when I began a full-time training course at the beginning of September, and I went from too much time to not enough. I had been using the skills to manage my time, and now I have no time, the skills are squeezed out. Suddenly all my attention was focused on learning to juggle while somehow still riding the wobbling bike with no ground underneath me, and I fell back on my old cycling methods- do whatever it takes in each moment, but without any systematic method or support.    

This is where I acknowledge that I have fallen off the bike. I have thrown it down and I’m sitting wilfully on the ground. I have felt so very tired from the years of work it took to get me this far. I have felt that there is no point working to build a life when others can knock it away in a second. I have not felt able to sign a contract because the thought of being here in a year is impossible. I have felt like a stranger to skills, as if I never had or used them. For the first time I feel that DBT is telling me to shut up and put up. I have felt constant despair- that my life is unbearable and that nobody can help me anymore. 

This has been the situation for over a month now, but yesterday out of nowhere I made some decisions.

Spending too much time dwelling on pain does not work for me- I end up drowning in it. The DBT stance and skills do work for me. I know this because I saw it happen. I can do it again.

I do not like that this is my life, but it is. I can keep kicking and screaming, or I can try to do as well as possible within the circumstances as they are set. Whatever I choose, life will keep going and I will have to live it, so it is less painful to choose to accept and change. Bad things are going to happen to everyone in time. If it hadn’t been my partner choosing to move to Australia, it would have been something else further down the line. Being able to ride the bike only on one terrain was never going to carry me through. This is a chance to properly learn, in all seasons and all terrains.  

For at least a month now I have been surviving the ‘old’ way- making it up as I went along- no wonder I’m tired. Why am I putting myself through this when there’s already a tried and tested way which works? Going back to DBT will make me less tired, not more. 

I have mixed up committing to DBT with committing to life. I have told myself that I can’t sign another year long contract because I haven’t decided. But I already am committing to life every day by how hard I’m trying. It is not one big existential decision, it is about how I live each day. The decision is already made.

I cannot wait any longer to feel ‘ready’. The waiting is making things worse, not better. I’m as ready as I’ll ever be. Today is the day I get back on the bike.

Welcome

This is my attempt to use dialectical behaviour therapy to finally overcome chronic suicide ideation and depression. I write about getting started in DBT, and about putting the skills into practice in everyday life- however well or badly I manage this. I write about the process of individual therapy, and about my experiences of wrestling with suicide day to day. I write about DBT and me. I do this because despite the several years I spent studying and working at a psychiatric research institute, I'd never heard of DBT, and I wish I had. "There is every reason to hope"

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