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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’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…
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?..
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.
