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A few months ago, my relationship of seven years broke down. For a long time, I had struggled to be the person my partner deserved me to be. Seven years is a long time. We were engaged to be married. We had wedding and house-buying plans. We argued good naturedly over names for the children we would have. I was confident that I knew what was ahead.
Last autumn, she chose to move to the other side of the world for work. I knew there were tough times ahead, but I believed we’d make it. I was due to fly out to see her just three weeks after she left. The day I was due to fly, it snowed. How simple. And random. It snowed, and no planes flew that day. If I had gone one day earlier. If it had snowed one day later. These are the thoughts I catch, and put away. Over and over again, some days. And other days, they come faster than I can notice or catch them. The days when I am surrounded by people with partners and children.
“We must be willing to let go of the life we have planned, so as to have the life that is waiting for us”
It’s not a DBT phrase. I don’t even remember where I saw it. But I think it captures the spirit of DBT perfectly. The magic word ‘willingness’. The concept of ‘letting go’. Radical acceptance. Flexibility.
The snow didn’t help. And it’s very possible that things would have gone badly even if we had seen each other at Christmas. But the truth is: my partner suffered and my relationship ended because I am broken. And although I work so very hard in therapy, I am not sure whether I can mend myself. I know that until I am mended, I cannot be in a relationship. So here I am, with the permanent lump of loss in the back of my throat, fighting to accept that the children whose names we so hotly debated will never exist. That my engagement ring sits in a box in my bathroom. That I will never again go to sleep beside her.
Letting go. But trying to hold on- to hope, that there might be a life which is waiting for me.
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.
These are some of the tricks I’m trying to use. Some I’ve had since I was 13. Others came to me recently via DBT. All of them help, none of them are enough.
1. Think only about the next 24 hours. Do NOT allow my brain to run ahead into the days and weeks and months and years of endless pain (it will not be endless, obviously, but it is easier just not to engage than to argue).
2. Make promises which I can keep to people who matter. “I promise I will still be here in 24 hours”.
3. Try to think differently. Remember that I have always felt better. Remember that I have never been sorry that I chose to stay.
4. Find a safe place. When I had health insurance, this was hospital. Until my greatest friend had a baby, it was her home. Now I have to be more creative. At the moment I’m at a religious retreat house by the sea.
5. Do not rehearse, either the practicalities or the reasons. Do not write the letters, even in your mind. Do not say, even to yourself, ‘It must be ok to stop now’, ‘Enough now’, ‘I tried my best’. Do not give yourself permission, or ask anyone else to.
6. Ask for help. Communicating suicidality is hard, because it takes hostages. I don’t do it much, except with my partner and my therapist. My partner delayed her holiday by three days to help me get to a safe place. My therapist is keeping pretty much continuous contact with me- when I make the 24 hour promise, which feels impossible and unimaginable, we break it down: ‘I will still be here at 9am when you text me, and then I will still be here at 11am, and by the time you text me at 2pm I will have done a distracting activity, and by 4.30 I will have done something soothing, and by tomorrow evening I will be in a better position to plan for the next 24 hours’.
5. Keep breathing. It sounds stupid, but it works when all else fails. If you’re still breathing, you’re still alive. You: 1; suicide: 0. ”From the point of view of mindfulness, as long as you are breathing there is more right with you than wrong with you”.
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.
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.
Is the name of an a capella group we saw in concert tonight. It’s one of the things we meant to do when we were at university here years ago. And since we moved back to the same city so my partner could work at the university, we thought we’d seize the second chance. But some days, this is a hard place to be, because it reminds me of how out of the blue this mental illness came.
This is the city I came to live in when I was discharged from a psychiatric hospital into foster care as a teenager. It’s the town I went to boarding school in when said foster placement was terminated without notice. It’s the town where I did my undergraduate studies. My experiences here cover a long stretch of my life, and are a very mixed bunch, but it’s the university years that are most salient.
It’s one of those old-school universities where students do exams in gowns and hats, wearing colour-coded carnations to show how close to the end they are. And right now the city centre is swarming with them. Four years ago (was it only four years ago? was it as long as four years ago?) that was me, and my life was golden. I finished top of my year in a degree that I loved. I had a place for a PhD I expected to love similarly. I spent the summer travelling with my partner, very much together and deeply happy. Funnily enough, I was unconsciously using DBT skills even then. A four page list of sentences beginning ‘I like…’ (pleasant events!) which I had stuck on my wall that year says ‘I like that I walked away relatively unscathed from my past’. Another sentence reads ‘I like that the problem is that I have too many dreams’. And: ‘I like knowing that I do anything and be anything I want to be’.
I keep trying to remind myself that those years weren’t as golden as nostalgia and memory make them seem. I had struggles, which I put down to personal quirks. The urges to cancel plans and commitments, the inability to manage my feelings, the intermittent bouts of suicidality, the not being able to get out of bed, the extreme social awkwardness- these are the seeds of the things which later became overwhelming. But because overall I managed and did well, I tend to think in terms of suddenly falling from on high, rather than of problems which I kept a lid on for years until they finally burst through.
It is very hard to re-frame my life in the detached, heart-breaking terms of mental illness, even without the ‘BPD question’ which I can’t even face today . It is hard to admit that then I truly believed I’d walked away for good. And it’s hard to concede now that there were signs, that perhaps I should have been more honest about my own vulnerability, even acted pre-emptively, and this might have stopped me from falling quite so far.
We don’t get to do the past again (good old radical acceptance) and even if we could, I don’t think I would change those years. As with everything, the trick is in how I think of them. So when I walk past the joyful students finishing their finals, I try to mindfully let go of comparisons. I let myself remember for a moment the joy and the strength and the certainty of that summer. And then I ground myself in my life now- which isn’t so bad after all.
“There are sad things and they do happen, but these are not all, and this is not the end”
- Stella Duffy, Room of Lost Things
“Though much was taken, much abides”
- Tennyson, Ulysses
This isn’t scraping the bottom of the barrel. It’s not a forced attempt to count my blessings. I’m not Pollyanna and I’ll never fake it. These are words which have seemed deeply real to me, when my brain was hurting too much to live, and they are no less real tonight.
The trouble with skills, I’ve decided, is that there’s only so much you can plan in advance. Actually, now that I’ve written that, I suspect that this is the general problem with life, and skills planning is just a victim of this general phenomenon. Because doing the skilful thing still doesn’t come very naturally to me, I try to work it out beforehand. This means knowing what will be happening, identifying the likely triggers, working out a skilful response and then rehearsing it. It sounds pretty foolproof. Except that it’s turning out that there are a lot of triggers we can’t forsee or plan for.
Today I visited a friend and her small daughter. The friend lives in a town where I had a particularly disastrous hospitalization, and the town has become synonymous with great pain for me. Ah ha! Trigger 1 identified. I therefore premptively planned not to hang around in the town, to stick to my route, and committed to absolutely definitely under no circumstances not popping over to site of said hospital, where I have planned my suicide numerous times.
So, as I said in my last post, my thoughts are toturing me. They tell me I need to die, or at least Stop This Therapy Right Now. I know that these thoughts happen because of a lot of complicated stuff which happened a long time ago. DBT will not address this stuff until I am firmly in control of my life-threatening behaviours. Rather than feeling frustrated about this, I actually feel safe; I’ve had intensive therapy before which addressed the past, and I would leave sessions feeling totally unable to manage, which only worsened the struggle with life-threatening behaviours.
So here I am, needing to reduce the control these thoughts have over me without wrestling with the content of the thoughts. DBT says I should be Mindfully non-judgemental: notice the thought, but don’t engage with it. Recognise it as a judgement, give it a label e.g. ‘worry thought about therapy’, and put it in a box for worry thoughts. I get stuck at the first hurdle. These thoughts are so familiar and so gripping that they suck me in before I’ve even noticed. And that’s it. Recognize it as a ‘judgement’? But these thoughts reflect Absolute Reality. These thoughts (e.g. ‘I must die to stop it all from happening again) are essential to protect me and others.
At the moment, the conflict is between what I consider FACTS and the therapist calls judgements. She argues that such thoughts are ‘unhelpful’ and ‘ineffective’ and I should let them go. I say that it’s not about the utility of the thoughts but about the truth, and I can’t ignore the truth. Of course, our approaches have very different outcomes. My way, I’m dead pretty soon. Her way, I let myself stay in DBT, use it effectively, and have a chance at building the life I want. She asked me to try her way; to see what my life could be like if I wasn’t constantly sentencing myself to death in my head. While I’m scared that ignoring thoughts like ‘I’m a dangerous person’ could lead to dangeous outcomes, I’ve had such a horribly wretched week that I’m prepared to give it a go.
Where do I start? This is so new to me that I think the first thing I need to do is try to recognize when I’m making a judgement. For seven days, I’m going to keep a list of any thought which might be a judgement about myself or the past. I’m not going to worry too much right now about whether I’m then able to put them in boxes or float them on leaves down riverbanks (another Mindfulness exercise). I’m just going to try to start to recognise which thoughts I should be boxing up or floating away.
I’ll report back on this challenge next Sunday. For now, I’m off to find a very thick notepad for my list- think I’ll need it with my volume of judgements!
