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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.
I hardly ever feel like this. Why would I? My old life was bad and sad and dangerous. My behaviours put me at risk of dying. They damaged me and those around me. But yesterday and today, I want them back. To be truthful, I miss the risk. I miss knowing that I still could die if I wanted to, that I might even die by accident. Risk seems more appealing than this quiet misery, the terrible struggle for every day with no outward manifestation of it- at least risk has the potential to change things, whereas at the moment it feels that nothing can change this day to day slog to get it ‘right’.
Yesterday was a bad day. I ended up by the train tracks, since they were next to my friend’s house. I wasn’t outright suicidal, though the thoughts are always there. The pre-DBT me would have got out of the car and played, would have flirted with risk. The one-year-into-DBT me locked myself in the car and resolutely did puzzle after puzzle in the sudoku book (distract with other activities). I suppose I should be proud but I feel sad.
After a near miss last October, where I was so out of my head on alcohol that I have no recollection even of being carried off an underground platform by an ambulance, I know that this is not how or why I want to die. In the days following that event, I saw clearly that the greatest tragedy of all wouldn’t be a suicide that I fully intended, it would be an accidental death that I didn’t even fully know was happening. I suppose I’m still reserving my right to ‘choose’, but I want it to be a choice I really do make, not a situation that spirals out of control.
DBT has saved my life and changed my life. But I’m not sure how I feel about that today.
I’m a convert! Whoever would have thought that saying a few positive sentences like you mean them could have such a strong effect? Not me. But they did. My interpersonal effectiveness cheerleading statements have enabled me to do several things differently this week, including dealing with the situation rather than fleeing the scene when the therapist expressed negative emotions about me, and being able to accept that I wouldn’t get what I wanted from my partner and deciding to meet my own needs.
So, I thought I’d try the same magic for my self-soothing difficulties. Here they are:
- It is not too late to learn
- It’s ok if it takes time to figure out what works
- I can tolerate not having my needs met by my partner
- I can tolerate not getting what I want from the therapist
- I am highly motivated to learn to self soothe
- Learning will give me power and strength and leave me less at the mercy of others
- Learning will give me more options in crises
- It’s ok if I sometimes fall back on old ‘soothing’ habits. These things aren’t ‘bad’, just ineffective
- Its ok to feel sad that noone helped me with this, but the effective thing is still to help myself now
Results of the self-soothing experiment so far:
Bingeing is not helpful; Vodka just plays tricks with your brain; Fairy lights are surprisingly and consistently effective.
I suspect that everyone else knew this already…
I feel desperately upset at the thought of soothing myself. Maybe because it’s like admitting that I am not getting what I need from other people. Which in turn suggests that I have a rigid belief that all my needs must be met by others.
Recently, I’ve been trying to turn this around. I’ve had fleeting flashes of insight into how the ability to self soothe would mean power for me, would give me more choices and control in a crisis, leave me less at the mercy of other people, diminish their power to hurt me. I don’t know how I never saw this before, but now that I do see, I am highly motivated to learn to do it.
But even with this new willingness to try, I’m still struggling with the details. I am still tending to fall back on using food and sex, both of which cause more problems than they solve as they’re very caught up in complicated patterns and histories. Beyond these things, I really don’t know what I find soothing. I stare at the lists in the skills training manual and feel quite blank. Many of the items in my crisis survival box are to do with self soothing, but I don’t actually know whether they work for me.
Yesterday, I consciously chose to soothe myself. I picked out a scented candle from my crisis survival box. My best friend gave it to me for Christmas. It had ‘Love’ written on the lid and interesting pink chunks sticking out of the top. I lit it. The smell gave me a sore throat. Maybe I’m not meant to self soothe! Or perhaps I should just ditch the candle and try something else…
Today was difficult from the moment I woke up. I struggled desperately, lost my skills, engaged in an old problematic behaviour and (more worryingly) a new one, and spent the rest of the day fighting urges to engage in all the others. I gave up on a big project I’d undertaken and ended up handing it over to someone else to do. I survived a very difficult therapy session only to argue with the therapist an hour later. I got home at 10pm hoping so much that my partner would see me, see the day I’d had. Hug me or commiserate with me, spend a bit of time being gentle with me. It didn’t happen.
I wanted my partner to acknowledge that today I fought against BPD, against suicide and terror and shame and I’m still here. But there are no prizes for these things. This world doesn’t give out stickers saying ‘I’m proud of you for not dying today’. It says ‘Why didn’t you do the washing up?’. My partner doesn’t say ‘I’m so sorry you had a bad day’, she says ‘I need a few months where everything is ok’. God, so do I. Tonight I feel that I would trade everything for one day where everything is ok.
I guess DBT says that self-validation is the ‘prize’. So here I am to say: I had a bad day and I controlled my behaviour. I dealt directly with conflict and made attempts to repair. I was mindful of how my rigid expectations of how she should behave would influence our interaction. I radically accepted that I was not going to get what I wanted from her. I used a cheerleading statement to motivate me to soothe myself. I identified a crisis, and I opened my butterfly box. I lit the candle. I can do this, and I choose to keep doing it.
I am struggling to manage my feelings in both my real relationship with my partner and my defies-all-labeling-therapeutic relationship. Time to break out the pom poms. I am not a natural cheerleader. In fact, I’m rather averse to the whole concept- the rhyming and leaping around and shrieking.
But I must admit that when things feel impossible, I hear myself say ‘good girl, just put one foot on the floor. Well done. Now the other foot. And now you’re standing up, that’s great, you can definitely manage this…’. I’ve been doing this for years, but now I’m doing DBT it’s an official skill- Encouraging yourself is a distress tolerance skill, the ‘E” in IMPROVE the moment.
I’m hoping that some self encouragement will help with the interpersonal issues, and I’ve dreamt up some meaningful cheerleading statements:
- I can tolerate not getting what I want or need (I often feel it is the end of the world when someone says no to me)
- I am able to tolerate conflict and I can choose to engage with it (I am massively conflict avoidant and am still learning to stay in the room/house when conflict arises)
- Conflict, arguments and anger do not mean relationships must end. I can choose to stay (I tend to have a lot of hopeless thoughts and give up as soon as there is conflict or anger)
- I can make small changes in how I respond and these do count (I sometimes feel that I have failed because I have not been as skilful as I would have liked and I still see the same old patterns and behaviour in my interactions. Also, I feel that my partner expects Total Change Right Now and discounts the small changes which I have made, so I need to validate for myself that these are real and important)
- Even people who are skilful don’t get what they want all the time (I find it helpful to remember that I am motivated to be skilful not just for objective effectiveness (getting what I want) but also for relationship and self-respect effectiveness)
They’re not exactly catchy but they might just work.
Now where to put them so that I’ll see them but others won’t?..
After many months of meaning to (and then another two weeks deliberating between a cupcake box and a butterfly box!) I’ve finally put together my skilful toolbox for surviving a crisis.
This is what’s in it:
- Glow sticks (they glow for 4-6 hours, so when I first open the box I snap one and set myself the task of managing well for as long as it glows)
- Manicure/pedicure set (soothing touch, distracting activity)
- Peel off face mask (distracting sensation and activity)
- Bath oil (soothing scent and touch)
- Colours and colouring book (soothing and distracting activity)
- Bubble wand (soothing sight)
- Legally Blonde the musical CD (create opposite emotions)
- Book of wedding cakes (soothing/beautiful sight)
- Fruit tea bags (soothing taste and one-mindful activity)
- Scented candles (soothing scent and sight)
- Sudoku (distract with other thoughts/activity)
- Extra strong mints (distract with other sensation)
- Joke book (create opposite emotions)
- Photo album of ‘Times I have been blissfully happy’ (remember when you’ve felt differently)
- Hot chocolate and marshmallows (soothing taste)
- Silly putty (distraction)
- Spinning magnets (distraction)
- Stress ball (distraction)
- Lavender essential oil (soothing scent)
- Mindfulness CD (variety of mindfulness and relaxation exercises
I’ve also got a wordle of emotion names inside the lid of the box, so I can have a go at picking the one which best matches how I’m feeling, and I’ve got some emotion identification forms stashed in the box. I’ve also put a ‘today’ form, something I invented when I came out of hospital pre-DBT, which helps me focus on taking it one day at a time by identifying what I’ve noticed and done well and enjoyed in the day.
Other things I want to add, but need to hunt down, are: sherbert dip dab (distract with other sensation), small chocolate bar (soothing taste, but I ate the one I originally bought for the box), and origami papers and instructions (distracting activity), and a list of fun and distracting websites (need to get some ideas from people for this). Also, the liquid in my bubble wand is running a bit low… well, I had to try it out extensively in the park to check it would work in an emergency!
Each item has a fun coloured label on it describing what skills it’s relevant for. This may sound strange but it helps me to focus on the meaning of what I’m doing- otherwise I just open the box and think ‘how the hell is a tea bag going to help in this life or death crisis?’.
The other thing that’s important to me is that each item is complete in itself- the candles have matches, the sudoku book has a pencil stuck to it, the tea bag has a mug. In a crisis, the smallest challenge feels overwhelming, and if I had to go hunting for these things, I’d give up.
So, that’s my crisis survival box. What’s in yours?
I live in my head more than I live in my body or in the world. It’s exhausting, like a full-time soap opera, one of those really over the top tele-novellas, which I’d really like to switch off, only I lost the remote control years ago. Every thought and judgement and memory demands my complete attention, and they’re all utterly real.
The only alternative has been total detachment, where nothing seems real. This sounds fun, but it’s dangerous because when my feet aren’t touching the earth nothing matters, and so my suicide wouldn’t matter. It also feels very distressing.
Tentatively, over the last couple of weeks, I’ve been trying a third way. I don’t know why I hadn’t tried it before, or why I suddenly gave it a go, but it does seem to be helpful.
Mindful observing and describing means first noticing and then using words to label your internal and external experiences. The idea is to not get too caught up in the experience but to let everything naturally come and go.
I have found that the most effective ‘describing’ is the most simple- saying to myself ‘I notice I’m thinking a lot about suicide’/'I notice I’m feeling really agitated and I want to escape’/'I notice I’m having lots of urges to drink’.
Until very recently, I would get so caught up in the suicidal thoughts that I often wouldn’t even notice what was happening until I was standing right on the edge, ready to jump. Or if I did notice, my internal dialogue said ’oh my god, I’m thinking about suicide, this is terrible, I’m going to die I’m going to die’ which massively escalated my distress.
There is something peaceful in simply acknowledging what is, without judgement, and this enables me to stay with how things are rather than needing to act impulsively to change them. And in letting myself experience the discomfort, the negative feelings, the destructive urges, I’m finding that they’re not as awful as I thought, and I can survive them. Maybe the escaping has been making things worse all along.
It feels like a beautiful secret- something I’ve been struggling to understand for months, which has finally clicked. It’s hard to describe what it’s like, or how I got here.
It’s not all peace and serenity. There are still a lot of thoughts and feelings which frighten me too much to be able to use words for them. And in those cases, old patterns and behaviours still reign supreme. But I’ll keep trying to step back.
So yesterday I got a job. It sounds like a good thing, and it was certainly a nice confidence booster. But it’s just another job on the pile of jobs I can’t start yet because it requires yet another Criminal Records check. My criminal record is actually squeaky clean, and I hold numerous CRBs to prove it. But most organizations will only accept CRBs that they themselves have applied for, so here I am at home, papering the walls with worthless CRBs.
A month ago I gave up my previous job to move from London to a sleepy market town with my partner. Because of the aforementioned CRB problem, I’ve been staying at home while she’s gone to work, and I did well. I unpacked the boxes and cooked and tidied and walked the dog and exercised and started learning the harp. At the height of my domestic goddess phase, I even made a clothes-peg bag out of a tea towel. But really, I should have said that I did well for about three and a half weeks. Read the rest of this entry »
I try to keep this blog fairly positive and constructive. This doesn’t mean that I force these things, it just means that I’m less likely to post if I’ve nothing positive to say. I tend to write about difficult situations once they’re over and I have a more skilful perspective of them. I deliberately chose to do it this way, because my own experience is of being easily overwhelmed by other people’s problems and pain when I’m reading blogs looking for stuff about DBT, and I wanted this blog to be helpful to others.
This has been a hard week, hence the lack of posts. I have struggled to be skilful, but my success has been very limited. A lack of external structure and now physical illness have left me vulnerable. My head is rioting with therapy-related (but non-DBT) stuff. There have been several days of lying in bed sobbing that I can’t do this anymore. I think part of the problem is cumulative tiredness- I’d struggled for several years before coming to DBT, and I was already so very tired when I started. In the context of things getting steadily better, it feels very frightening to be ‘right back there’, where I was for so long. It’s easy to believe that the progress wasn’t real, and that I really will feel like this forever. And the pain feels sharper when there’s recent okay-ness to compare it with- it’s almost like when I felt like this all the time, at least I didn’t know any better.
To put it in perspective, I haven’t engaged in any target behaviour, neither have I even particularly wanted to. I haven’t felt suicidal. Although I’m miserable, I do genuinely seem to have found other ways to cope, and I couldn’t have imagined being able to control my feelings this well a year ago (this is a distress tolerance skill called ‘Compare’). And even though it hurts and it’s scary, this is a good chance to practise the skills; I need to know I can use them not just when things are going well, but when things are really hard (come to think of it, this is another distress tolerance skill called ‘find Meaning’… maybe I’m being more skilful than I thought!). So I’ll keep plodding along with distress tolerance and crisis survival skills. I’ll keep trying to radically accept that this is a difficult time, and I can tolerate how I feel without having to change it.
One thing that has made me feel really hopeful this week is a fab book called High Conflict Couple, which sets out how to use DBT skills in your relationship. I’ll post tomorrow about the book and the ideas I’m going to try…
