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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.
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!..
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.
… realising, after I’ve written the suicide note, that it’s not quite true- I haven’t tried everything. Remembering the attachment the skills trainer sent me last week which suggested using ice to tolerate distress. And so turning back from my suicide drive to struggle into my swimsuit at 9pm on a cold August night ready to jump into the outdoor pool. Finding the pool closed so driving instead to the sea. Plunging into the freezing water, while others in their warm coats and even gloves stop to stare.
Love is holding the towel, like she did last night. Trusting that I am going in not to drown myself but to try one more thing that might work. Sobbing from the pain she cannot alleviate.
Desperation is clinging to each other, her in her waterproofs and me in my swimsuit, and asking her to remember this night, to remember- when it happens- that I had truly tried everything. And hoping she understands, and knowing that she can’t, really.
Irony is the jellyfish sting from those five minutes in the water that blew up my foot and caused me a night of acute pain when I needed a rest more than ever before.
It is hard to stay willing when everything I sincerely try brings more pain.
I know that this feeling will not last forever. I know that these obsessional self destructive urges will pass. I know these intrusive thoughts won’t torment me forever. But today, yesterday, probably tomorrow, I am up to my neck in misery, and pain is everywhere. These are the days when the world seems to be tuned wrong. Everything is too loud and too fast and too bright. Nothing that anyone says is right. I am so unhappy in my head that I would sign up for a full lobotomy if they were being offered. And so uncomfortable in my skin that I would like to rip it off.
All I have to defend me in battle are the DBT skills. I have pushing away, a form of thought blocking that feels pathetic and oh so very tiring against the constant heavy onslaught. I have observing and describing, but putting words on my reality is making me more desperate. I have letting go of judgements by putting them on leaves. I have used all the leaves in South West England, and I do not feel better; maybe I have clogged the river downstream. I have radical acceptance, but this doesn’t address the need to start to change my situation in some small way. I have distracting activities which today are not distracting. I have comparisons, which are dangerous because it’s so easy to fall into making the wrong ones. I have sharp physical sensations, and today these are the ones that can get through to me. Jumping into freezing swimming pools. Orgasms. Ru running and running. This is my first experience with a distress which prefers to be shocked than soothed away.
Today I am throwing every skill I can think of at this misery. Not just once but second by second from the moment I wake up until I finally fall asleep. Sometimes by 3pm I cave and have a drug induced rest. I feel so very small, and the skills so very inadequate, against the forces I’m battling. And to complicate matters, I am essentially fighting against myself, and I’m not always on the right side.
Somebody once told me that if you can wonder whether you’re going mad, you’re not going mad. I can’t picture their face, but I know it was a mental health professional, and I know they thought they were clever.
I disagreed then and I disagree now. I suspect that even on the descent into madness there are flashes of insight, moments when we observe ourselves and our behaviour as if catching a reflection in a mirror, and in that moment we ‘know’. This is certainly consistent with reports by people whose loved ones lose their minds to dementia or Alzheimer’s.
I have never wasted much time on the concept of madness. My thoughts and behaviours have always made sense to me, even when they seem seriously ‘disturbed’ by this world’s standards. My partner and I disagree almost daily over her insistence on asking whether I’m likely to ‘do something crazy’. I feel strongly that even if I had gone ahead with suicide on one of the hundreds of occasions I’ve considered it, it would have made sense.
But this time, I feel afraid. I see myself driving to find vodka in the middle of the night. I hear myself shrieking louder and louder, alone in the car, until the windows start to shake. I feel the force of raw emotions which have taken me over. I notice that things do not really make sense the way they always have before. And I wonder whether this time I really am losing it.
And then I wonder if maybe, actually, this is the closest to normal I have ever come: feeling my feelings, letting myself hurt. Screaming and crying and raging all fall within the range of ‘normal’ human experiences. Yet they are anything but normal to me, and I am terrified.
On hearing that my partner is moving to Australia (more on that when I can think about it without my head exploding…), one of my stranger acquaintances suggested that I should accompany her as a ‘professional surfer’. We all had a good laugh because I can barely lug my body around a 10k course, let alone repeatedly raise it up to balance on a board which itself is balancing on water. Of the possible ways I could keep myself gainfully occupied in Australia, surfing is most definitely not one.
But today, I’d like to call him back. And tell him I am fast becoming a professional surfer.
But the ‘waves’ I ride are urges to cut up my arms and drink litres of vodka and eat all the food in the world and bang my head against the wall and tear my hair out and die and die and die. Too much detail, I suspect. Both for random real life acquaintances (who glance tactfully at my scars but don’t ask- I love being British!) and for online readers (cardinal rule of mental health sites seems to be ’don’t trigger others’). But when I try to describe the battle of today, ‘target behaviours’ doesn’t cut it.
I don’t know when ’urge surfing’ crept into DBT, or where it came from. It’s not in the ’official’ skills. But my therapist likes it, and I’ve been trying it. The idea is that urges to engage in destructive behaviour will come and go, like waves. If you can ‘ride out’ the urge it will naturally peak and subside. Only engaging in the behaviour will prevent the urge from subsiding.
To me, this is similar to ‘remember when you have felt differently’- a component of mindfulnes of emotion. Which itself is similar to ’This too shall pass’. On the notepad in my car, I have pages and pages where I have written that sentence again and again, trying to hold off from harming myself. Knowing this won’t last forever is helpful and believable to me. How I feel can change considerably over a short period of time, and I am very aware of this.
Being able to categorise the compulsions as ‘urges which must be surfed’ does also help me to get some distance. It separates them out from me, rather than them consuming me as something I must do right now. Rather like the ‘you are not your emotion’ stuff.
To make full use of the skill, I think I’m going to have to find out a bit more about surfing. There’s something about the analogy that doesn’t quite sit right with me. I think it’s that surfers aren’t just there to endure the wave- they don’t go out hoping that they’ll survive each wave. They are actually there for the exhiliration of riding, to harness the power of the waves to raise themselves up and propel them forward.
With some work, I feel hopeful that I can somehow make the analogy fit. But today, I feel like ‘keeping my head above the waves’ would be a more accurate description. And now, exhausted at the end of the day, I still have to swim back to shore.
If only I had a surfboard, and the waters were calm enough that I could rest on it until the morning.
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.
Before DBT attempts any kind of emotion regulation, it gets you to examine the myths you believe about emotions. Mine was:
“EMOTIONS ARE DANGEROUS”
It was sort of true; two years of being continually immersed in grief and all the other feelings associated with my past had left driven me to a whole variety of maladaptive coping mechanisms and left me suicidal. However, by the time I came to DBT, I had to admit that the methods I was using to manage my feelings were even more dangerous, and if I was going to die anyway I may as well give emotions a second chance.
Over this year of DBT I would say I’ve got better at identifying what it is I’m feeling, but not significantly braver about actually feeling it. I still feel my brain reaching out for suicide as a comfort blanket and wrapping it around me when my feelings start to hurt too much. And in this last episode, the trigger was so significant that I didn’t even experience that as a conscious choice or action- I just skipped straight to suicide. And once there, it was to dangerous to try to engage with the triggers. I had to try to manage, to distract and soothe, to live from moment to moment.
Those strategies worked, and suicide retreated. I realised yesterday that I hadn’t yet engaged with the triggers themselves and that I had a limited time in which to do so. So I sat down with a pen and paper and tried to work out what the real thoughts and feelings were underneath suicide. Within minutes, suicide was back.
Here is the dilemma:
1. I must manage my distress without committing suicide, because the distress will pass.
2. Managing my distress does nothing to deal with the trigger, which is not going to just ‘pass’.
3. Attempting to deal with the trigger makes me so suicidal that I have to revert back to the strategy of managing my distress.
What to do?
