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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 probably not the best person to explain radical acceptance, because I. Don’t. Get. It. I want to get it; it sounds promising. DBT claims that radical acceptance is the way to separate out pain from suffering- to make pain tolerable.
Suffering = pain + nonacceptance of the pain
where nonacceptance means clinging to what we want rather than what we have
The skills manual has a story about learning to ‘love’ what you have. It goes like this: a man moves to a new home and decides he will have a beautiful garden lawn. It’s full of dandelions but he mows it. The dandelions grow back. He weeds it. They grow back. He uses super-strength weed killer. They grow back. He consults gardening books and follows all the advice. The dandelions still grow back. He writes to a renowned gardening expert and waits eagerly for a reply. When it comes, he rips open the envelope. ‘I can help you’, it reads, and he sighs with relief. ‘My considered advice is that you learn to love the dandelions’.
I like this story, but I could never apply it to my situation. DBT emphasizes that ‘love’ in this context doesn’t mean you have to like it, but I think the story says otherwise. I imagine the man celebrating his dandelions, and I don’t want to celebrate the things I struggle with. Radical acceptance is still just ‘words’ to me. Sometimes I use them (e.g. ‘I can radically accept this’) but I’m not sure what they mean.
Which is why this story, from High Conflict Couple, made a lot more sense to me.
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…
