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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.
Today I felt my feelings. It was utterly exhausting and I desperately need to sleep. And I didn’t get much else done. But I did manage this, the hardest thing.
I observed my feelings and named them. I sat with them all day. I noticed when they morphed into secondary emotions. I experimented with expressing them- the not so nice ones too.
I didn’t act on the urges to escape them by cutting or drinking or eating and eating. I didn’t even slip with just ‘one drink’ or ‘just one bar of chocolate’.
I was skilful, using just enough self-soothing and just enough distraction to keep the situation manageable. I asked my partner for help when I needed it.
I wish I’d practised on a smaller situation before this one- the day that my therapist left for three weeks. But I wanted to acknowledge that I managed today.
Some days are “just hang on” days, and on those days I don’t get around to writing here. I think it’s partly that I want to keep this a ‘helpful’ place, for me and those who come here, and I’m afraid that I would rehearse all the things in my head that are so very unhelpful.
These days seem to be far more frequent at the moment, due to the LOSS LOSS LOSS all around me, which I’m aware I haven’t begun to process or address here.
A year and a day ago, I signed my DBT contract with my therapist. In it, I promised to stay in this world for a year and build a life I wanted. I kept my promise to stay. I built a life worth living. Other people’s decisions have torn much of that life down. And I no longer want to stay. This year has taken every ounce of commitment and energy and strength and I do not feel brave enough or strong enough to begin again from scratch. The year is up, and every extra day is a day too long.
This has happened to me before. Again and again, I have had everything taken away from me, and I have always risen up from the ashes and begun again. Each time I have not just survived but ‘achieved’. This has given me a strong self-concept as someone who is able to triumph over adversity, able to do anything I set my mind to. I keep telling myself that I am good at this, I have done it before after all.
But each time, it becomes harder and harder to do: harder to integrate the ‘new’ life in with all my former lives and come away with any coherent narrative of my life or who I am; harder to find the energy to do it; harder to fight the hopeless and despair that this will keep happening until I die.
I am on the fence. Not the helpful dialectical kind of fence, but the fence between staying and going. Emotionally, I am veering between believing I can stay and wanting desperately to go. Intellectually, I know that however I feel, I will probably end up staying; I always have before. But I have been waiting for more than two weeks now for the ’I will survive’ instincts to kick in, for the rising up from the ashes to begin.
I have tried all the things I know to kick start it: going to the sea to rest and regroup; going back to work to give me some purpose; getting back into the other activites in which I find meaning; making plans for the future; promising to stay.
But this time, nothing is happening. I am still here, but there is no overall shift in how I am feeling or dealing. Today the thread holding me here feels terribly thin. And that ^^ is why I don’t come here on the bad days.
I’m sorry I swore at you. I’m sorry I said that I hated you and your family. I’m sorry I said I wouldn’t be here when you came back. I would desperately like to explain away this last horror by saying that I said it out of fear that I would commit suicide, and indeed I was afraid that night, but I suspect that I said that out of sheer anger, because I wanted you to suffer just a fraction of what I was suffering, and honesty will not let me claim otherwise. This is a new low.
When I apologised, you told me to make a skilful plan about managing anger. My plan is not to feel anger, not to feel anything, anymore. One day I made a deal with the skills trainer. The topic was myths about emotions. Mine was ‘emotions are dangerous’, but I agreed to try them and see. For a few months my feelings towards you have been hard to manage and very painful, but I couldn’t fairly call them ‘dangerous’. Saturday was dangerous. Dangerous for my safety, because I became too dysregulated and my behaviour became risky. And dangerous for a peaceable collaborative relationship with you.
So I’m giving up all feelings towards you for Lent. Well, there’s still a long time to go before Lent, but that’s good, because it’s probably going to take a lot of practice to separate these feelings from me. Or maybe it won’t? At the moment, the prospect seems relatively simple, but that’s probably because at some point I consciously chose to detach from you. Sure, I still get the urge to randomly tell you I love you every hour or so, but I don’t actually feel very loving or attached. Mainly, I feel confused because although I do indeed feel remorse and I appear to be going to some lengths to repair (“I’ll do whatever you want and be however you want”), I think I’m actually still quite angry and upset with you (though I have no idea why) and I don’t especially want to feel closer to you again.
You didn’t seem very impressed by the new No Feelings plan. You had a better plan: I could continue to feel things, and just express them skilfully instead. I could say ‘I am angry with you because…’, or express action urges by saying ‘I want to send you an angry message’. Or I could act nice instead of angry. But I wanted to tell you: I’m new to this anger thing. Until you named it on Saturday I didn’t know what to make of the urge to attack you that ripped through me. I probably would have called it fear. If pushed, I might have gone for ‘feeling abandoned’. From the age of 11, I grew up in boarding schools, in hospitals, and in other people’s homes. All places where you’re on your best behaviour, or you’re out. If I ever felt angry (and I truly don’t remember this), I swallowed it. So this is my first time trying on anger for size, and what you’re taking to be wilfulness is actually a desperate lack of skill and practice.
You vetoed the No Feelings plan because you want our relationship to continue to be genuine. But I want out of this relationship altogether. If I tell you this, you will think it’s a reaction to you having set limits. Truly, it’s not; I’m actually quite relieved to have met a limit you set down clearly and in real time. So, no tantrum because you won’t let me treat you like dirt. Just horror at how out of control my feelings and behaviour became that night. I don’t want to be that person, so I can’t stay in this relationship.
You will say that the therapeutic relationship is grist for the mill- a good chance to practice what happens in all other (real) relationships. But to me, this relationship is nothing like my real relationships. For a start, I don’t feel like an adult with you, and I struggle to behave like one. In my real relationships I don’t repeatedly swear at people, I rationalise feelings of abandonment, I’m really very polite. With you I have the emotional control of a 2 year old. You told me not to say anything to you that I wouldn’t say to anyone else I respect, but often you are not ‘you’- you are all the people who hurt me and left me- at other times you are the ‘one’ who is different from everyone else that ever was. Whether I’m telling you I love you or swearing at you, I don’t think I’m really interacting with ‘you’, but with whatever I am making you into (perfect mother, cold abandoner). Acknowledging this makes me sad because I do want to believe that there was an element of something real about you and me and how we interacted.
You told me once that developmentally, it’s important for parents to be able to tolerate a child’s anger. I think you are trying to tell me that you can tolerate my anger, you just won’t tolerate the swearing. Another time, you said that there was nothing I could do which would make you stop caring about me, because you didn’t care about me based on my ‘good behaviour’. I think this might be what you are trying to show me now, telling me before you left on Saturday that you would still be there on Monday, saying that you’re glad I’m ok. But I do not understand what this means, cannot wrap my head around it. All I can see is that I tried being angry and it was awful and now I must promise to feel less and behave better. I feel very frightened and shocked by what happened and I’m not brave enough to try again.
I want to tell you I can’t come tomorrow, or next week, or any week. But again, I’m scared that it will look like a tantrum because you told me off, or seem like I want you to chase me. And besides, we both know I almost certainly will come, because I just can’t stay away from you. Which makes me hate myself so much I want to die.
You told me to tell you what I think. These are the things I think, but there is too much room for you to think the worst of me. And at the same time, there is too much capacity for you to really understand and for us to fix this properly, and truly I don’t want to because I can’t cope with the feelings of being attached to you. So instead I will tell you ‘Yes, whatever you think is best, it won’t happen again’, and I will tell the rest to the anonymous blogosphere.
When I started DBT my emotional illiteracy appalled me. I knew when my mood was low or high, but didn’t see this as an ‘emotional’ experience. I couldn’t remember when I’d last felt happy, and I swore blind that I never, ever felt angry. I still regularly struggle to identify two ‘emotions’ I’ve experienced in a whole week between therapy sessions, despite the assurances of the skills trainer that everyone experiences lots of emotions every day.
Happily, help is at hand. The DBT skills training manual has a breakdown of six of the most universal emotions: love, joy, anger, sadness, fear, shame. For each emotion, it lists possible prompting events, prompting interpretations, different aspects of experiencing the emotion, how we might express and act on the emotion, and the emotion’s after effects. You can jump in with any clues you may have (e.g. an urge to hide) and use the information to puzzle out what you’re actually feeling (e.g. shame).
Here’s where it gets tricky for emotion novices like me. Emotions do not come along singly. Not only can we experience ambivalence (more than one emotional reaction to the same event), but we also often have an emotional reaction to our emotions; we might love someone and then feel shame for having these loving feelings, or feel afraid and then feel angry with ourselves for being scared. When this happens, the focus tends to be on this secondary emotion, making it hard to identify or problem-solve around the primary emotion. I had dismissed this primary/secondary distinction as too advanced for a girl like me who’s still grappling with when she feels love and when she feels hate, but I mastered it by accident this weekend.
I live in a constant state of fear that the therapist will leave me. I know I’m feeling scared, and what I’m scared of. So far so good. But then, inexplicably, I send her horrible text messages telling her to stop wasting her time with me, and to f*ck off and leave me (or one of a large number of variations on this theme). A few hours later I come to my senses, apologise for swearing at her, and then spend a few more hours in severely heightened fear that she will indeed leave me because of the way I just behaved and, um, because I asked her to! Even after she says it’s ok and reassures me that she’s not going to leave me, I have to carry the shame of what I said for the rest of the day.
This is not fun (for either of us, I suspect) and these outbursts have been getting more frequent. So I asked her to help me stop ‘being horrible’ to her. According to her, it’s not called ‘being horrible’, it’s called ‘expressing anger’. Who knew? I genuinely didn’t- I couldn’t have picked anger out at an emotion identity parade. Furthermore (here’s where the whole primary/secondary thing kicks in), anger isn’t the actual feeling, she tells me. First I feel scared, then I get angry in response to my own fear. And the anger causes me more problems and bad feeling than the primary emotion would have done if I’d just experienced it.
So, we have a new plan (her idea, not mine, as with most brilliant ideas so far). Instead of sending her angry texts, I write, ‘I’m having urges to send you an angry text, but I’m actually feeling… because…’. Filling in the blanks is hard, and if I don’t know, I have to give my best guess. But so far, it’s working (though please note that this is only day 1!). And the unexpected bonus is that when I’m paying more attention and being more accepting of the primary emotions, I don’t seem to get to anger.
I’m still emotionally illiterate. But I’m learning, and at least I’m not swearing at my therapist 
It’s probably tough in most forms of therapy when the therapist goes away on holiday. My experience is that in DBT it feels tougher; because the therapist is usually available for contact up to seven days a week, a therapy break doesn’t feel like ‘1 missed session’ but rather like ‘10 days apart’. When someone is ‘on call’ for day to day consultation about whatever life throws up, it can feel very daunting to be suddenly left to deal with things entirely on your own. DBT, typically(!), says that therapy breaks are grist for the mill. That is, the therapist should not go to great lengths to ‘protect’ the client from situations which occur anyway in normal life, and they should be used as opportunities to practice skills.
When my therapist recently went on holiday, I didn’t handle it particularly skilfully. I spent about a week working myself into a frenzy of anxiety about it. What if another volcano eruption meant that she couldn’t get back for a while? What if the plane crashed and she couldn’t come back ever? What if she didn’t want to come back once she realized how peaceful it was being away from me? What if she got pregnant and came back only to go off on months of maternity leave? I do believe that the BPD criteria call this a frantic fear of abandonment. I got it! In fact, I’ve got it so bad that I started to develop abandonment anxiety on behalf of her small child- what if she went holiday without said child and a volcano erupted and she was separated from her child for ages and ages? And so on and on and on… (with a bizarre number of the scenarios featuring volcanoes, which a month ago would have sounded like science fiction!). We discussed all this, addressed my anxieties, made a skilful plan for the difficult situations which we could forsee, and off she went.
But once she was actually gone, something strange happened: everything felt better. This is probably because a lot of my issues play out in the therapeutic relationship. In short, I love her, I wish she was my mother, I may well want to sleep with her too though I feel confused about that (hi Freud!) and the whole thing hurts like hell. This has been happening to me since the beginning of time, so I can’t even fairly blame it on her. So, my therapy-break fears were less about needing her help, and more about missing her and not being able to manage my thoughts and feelings about her. Actually, the intensity of the thoughts and feelings became far more manageable- it felt like a real ‘break’ from the craziness which I struggle so much with day to day. So much so that by the end of the 10 days, I felt that only a true masochist would voluntarily return to such a relationship.
Fortunately, we had one up on the situation, as exactly the same thing happened when the therapist went away over Christmas. This time we pre-empted my I’m-dropping-out-of-therapy-brainwave by each writing a letter before the break summarizing the progress I’d made in DBT and all the ways it was helping me. I confess, I still texted her last night to say I was never coming back. But this time we contained it to a couple of text messages rather than letting it take over a whole week. And even though the feelings are already flooding out of the freshly opened box, I’m glad I went back today. The benefits of DBT definitely make it worth tolerating the parts that hurt. I didn’t handle the run up to the holiday very skilfully; and although I handled its ending better than I did last time, it still wasn’t great. But fortunately (at least as Marsha Linehan would see it!) there will be many more therapy breaks to practise on…
