Tuesday, 29 June 2021

A GUIDE TO DIALECTICAL BEHAVIOUR THERAPY


“If you plan on being anything less than what you are capable of being, you will probably be unhappy all the days of your life.”

Abraham Maslow

So, I was going to write a blog post about something and realised it would (as a few have recently) focus on Dialectical Behaviour Therapy (DBT) and with this I wondered whether I’ve ever published a post purely about DBT. Having created I’m NOT Disordered over eight years ago; I think it’s understandable that I can’t recall absolutely all of the content I’ve produced over the years; and this meant I had to scan through my post archives to determine whether I’d be repeating myself. It obviously turned out that the one post I’ve centred on DBT was published in 2016 (you can read it here) and I think it’s safe to say that I’ve had at least a ‘few’ new readers since then! Besides, I intended for this post to be more in depth than ‘ten things’ so here’s all you need to know about DBT…

In 2011, I moved down South to live with my Dad (I was born in Dorset) and when a few things went wrong, I found myself being sectioned under the 1983 Mental Health Act and admitted to a psychiatric hospital. Whilst in the hospital, a member of staff spoke with my Mum and mentioned DBT to her. When she asked for more information the staff were surprised that she and I weren’t aware of the Therapy which is arguably the most important treatment for someone with my diagnosis of Borderline Personality Disorder (BPD)!

It turned out, the mental health Trust back home (Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust – CNTW) was seriously lacking in the services they provided for helping and supporting someone with a Personality Disorder. This meant that at that time, the Trust only had a handful of psychiatric professionals trained in DBT. Not only did this reflect on the physical treatment available, but it also had an impact on the attitude and approach of many of the staff when speaking with or caring for someone with BPD. As though having a lack of training and understanding was an excuse to be rude, discriminatory, and dismissive. (Fortunately, CNTW are now in a much better position in terms of their Personality Disorder services and the knowledge their staff have of the helpful attitude and response to use with someone who has BPD.)

Being discharged from the hospital down South and moving back North to the CNTW locality, my Mum talked things through with my Community Mental Health Team and I began seeing the loveliest Psychologist. Unfortunately, that only stabilised me for a few months and after a suicide attempt left me on life support in Intensive Care, the decision was made to send me (once out of the coma, obviously!) to a psychiatric hospital which actually specialised in Personality Disorders and therefore provided intensive DBT group and one-to-one sessions.

Sometimes, I wonder whether if the support CNTW offered now was available when I was really poorly, would I have still gotten to the point of being so suicidal I had to be put on a machine that would breathe for me. But there’s really no productivity in considering that because the fact is, it didn’t exist, and I did have to get to that point where the professionals finally recognised that I needed more help and support than CNTW had to offer. However, in that hospital, going through DBT, a member of staff told me that had I lived in their locality, I would’ve been admitted after my first suicide attempt not until my second! So, with that in mind, I think it’s so important to recognise that the suicide attempt (and many other situations I experienced) which led to me being taken over 100 miles away for the specialist hospital, could have ‘worked’ and I might not have had the opportunity to be given that specialised help.

DBT MODULE ONE: MINDFULNESS

WHAT IS IT?

Mindfulness teaches us that we each have three different mindsets: emotional, reasonable, and wise.

Your emotional mind is when your thoughts and behaviours are mostly controlled by your emotions, which can mean that logical thinking is a challenge.

Your reasonable mind is the state where you’re approaching experiences with an intellectual perspective in logically thinking through your behaviour, planning your actions, and considering the facts of a situation.

 Wise mind is defined as being the product of your emotional and reasonable mind overlapping and is said to add a sense of intuition around the appropriate response for your thoughts and behaviour.

HOW DO YOU DO IT?

You are taught through the WHAT skills of mindfulness to observe an emotion, find the ability to describe it, and then allow yourself to participate in it with a level of self-consciousness.

Through the HOW skills, you are then taught three methods to approaching a ‘task.’ They are non-judgementally, one-mindfully, and effectively.

Non-judgementally is defined as resisting the urge to judge something ‘good or bad’ and instead, to consider the consequences of a thought or an action.

One-mindfully is seen as an opposite to multi-tasking in encouraging you to fully focus and put all of your thought and attention into one task or activity.

Effectively, is defined as acting in accordance with a goal for the situation rather than acting upon judgments.

MY THOUGHTS ON IT:

Initially, Mindfulness was my absolute least favourite skill in DBT because I was so completely terrified of being ‘in the moment’ at fear that it would actually make me feel even more suicidal. I mean I had spent so many years determinedly not in the ‘moment’ because I believed that doing the opposite would leave me overwhelmed with memories of the abuse and deafened by the auditory hallucinations; so why would that suddenly not be a possibility?!

In the end, the hospital staff realised they really weren’t going to get anywhere in bombarding me with information and desperate attempts to encourage me to get on board with mindfulness. I think an aid in the stopping of their nagging was when they saw that I was totally willing to learn and try out the other coping skills DBT teaches and that I wasn’t just being difficult in my reluctance to try Mindfulness. And ironically – and typically – it was at this point when I had a few realisations around mindfulness and began to see it in a whole new light…

The biggest game-changer was in discovering that being ‘in the moment’ didn’t have to mean letting myself experience something negative; it could also mean allowing myself to really enjoy a happy moment. I’m so thankful I learnt this because it meant that at the party I hosted to celebrate reaching over 100,000 readers (which you can read about here), I can remember one particular moment – because I used mindfulness – so well and so clear that even years later, it was the best night of my entire life!

MY TOP TIPS FOR MINDFULNESS:

ü  Go into this module of DBT with an open mind and a willingness to learn!

ü  Don’t write it off immediately!

ü  Know that it isn’t about meditation!

ü  If the ‘exercises’ don’t ‘work’ for you, change and adapt them!

DBT MODULE TWO: DISTRESS TOLERANCE

WHAT IS IT?

Distress tolerance is all about learning to cope with distress with the belief that it is something which cannot always be avoided in life. In this module, you’re taught that finding the ability to do this, will ensure an absence of impulsive actions that could – in the long run – lead to increased pain and suffering.

HOW DO YOU DO IT?

One key component of this module is around distraction with suggestions for the distracting methods being inspired by the acronym ‘ACCEPTS.’ With ‘A’ being for activities such as a hobby, going for a walk, or doing something for a friend. The first ‘C’ is for contributing which is referring to doing volunteer work or some other kind of task which benefits another person. The second ‘C’ is about comparisons in putting a lot of consideration into the thought of exactly how your life has changed – how it has improved and how you have come so far. Then the ‘E’ is for emotions and is about watching an emotion movie or listening to a song which makes you feel a certain way. The ‘P’ is about pushing away by mentally leaving a situation you’re distressed by. The ‘T’ is for thoughts and it’s about distracting your thoughts with various exercises such as counting to ten or reading. The ‘S’ is for sensations and it’s about doing something which encourages different sensations such as auditory and tactile, like having a bath or cuddling a pet, in a bid to distract from distressing situations.

 The second component of this module is about using self-soothing tasks/activities as a means for tolerating a distressing situation, thought, or feeling. The ways to self-soothe can be identified by selecting one (or more) of your five senses; vision, hearing, smell, taste, and touch; and doing something which you find pleasing for them.

Finally, a part of Distress Tolerance is ‘pros and cons.’ Doing this component of the module involves creating a list of the benefits you would receive if you were to tolerate distress, and the negative consequences you’d experience if you do something which illustrates you are unable to tolerate the distress.

MY THOUGHTS ON IT:

I really think that this part of DBT was/is my favourite module! This is probably because a huge part of my mental illness was my inability to tolerate distress of any level and any nature.

I think that a huge reason for this has been that I didn’t report the abuse for so long (over two years) and that meant an enormous part of my head – and life – felt consumed by this distressing part of my life for years. As though there was no real relief. And refusing to talk about that – allowing all the reasons why I shouldn’t report it, win; just meant that I didn’t learn how to tolerate things. Because I ran away from them. I hid. I hid rather than face up to the horrible truth and reality. And this meant that I spent years believing that blocking things out, was the only – and best – way to cope.

That absence of knowledge and support in developing coping skills for tolerating distress meant that when terrible, distressing things happened to me, it almost naturally came to me to ignore it and to push it away. This automatic response led to my self-harming increasing because I was so desperate to turn the mental pain of the distress into something physical. Because – mostly – people can get rid of physical pain in a much more simple and reliable way. This meant that this module of DBT became one of the most essential aspects for my recovery.

The two parts I found the most helpful were around using distracting and self-soothing activities as a coping skill in distressing situations. I think that I favoured these because – in my eyes – they were a healthy, agreeable, and safe version of my incredibly harmful and life-threatening avoidance techniques.

The one challenge in utilising self-soothe activities was that I very quickly developed the notion that I was undeserving of any level of relief in my distress. Especially, where that relief was achieved through something pleasant and rewarding. And learning how to recognise that I should be happy and that what had happened to me was definitely not my fault and therefore I didn’t deserve punishment, was such a long process. But it was a process that was completely worth all the time and hard work that went into it! It’s also a process which I can’t really put a finger on as to how it came about and what I did to make it happen…  

MY TOP TIPS FOR DISTRESS TOLERANCE:

ü  Don’t feel guilty for doing something which benefits yourself.

ü  You deserve to feel happier and less distressed!

ü  If a distracting activity suggestion feels dismissive or trivial, recognise it won’t for all.

ü  Don’t use the C in ACCEPTS to minimise your own distress in comparison to another!

DBT MODULE THREE: EMOTION REGULATION

WHAT IS IT?

This module isn’t just about its title – it’s not all about regulating your emotions. The module teaches you that to do this, you need to learn more about emotions – find the ability to name what emotion you’re experiencing, learn how to describe it, and also figure out what purpose it serves (whether that be negative or positive).

HOW DO YOU DO IT?

The emotion regulation module teaches you a six-step process when experiencing an emotion:

1.     A prompting event – which initiates the process

2.     Your interpretation of the event – which influences the emotion you experience

3.     Bodily changes – and recognising them to understand the impact the emotion has

4.     Action urges – which allows you the opportunity to be aware of dangerous behaviours

5.     Expression and communication – which teaches you how to describe your emotion which will enable you to receive help and support where necessary/required

6.     After effects – which is the moment when you establish the consequences of the emotion

This module also teaches you about the three possible functions an emotion can have:

1.     The ability to communicate and influence others

2.     The influence to organise and motivate an action

3.     Self-validation

You are then taught a method to reduce your vulnerability to negative emotions in the acronym ‘PLEASE.’ The ‘P’ and ‘L’ come from ‘physical illness’ and are about recognising that being poorly physically in any way can impact your mental health. The ‘E’ is for ‘eating’ and illustrates how your diet can strengthen you to cope with emotions safely. The ‘A’ is then for ‘mood altering drugs’ which sheds light on the fact that using drugs (particularly illegal and unprescribed drugs) can alter your vulnerability to coping with negative emotions. The ‘S’ is about ‘sleeping’ and this teaches you that having a healthy sleep regime – especially getting a decent number of hours sleep – can enable you to be a lot more balanced in experiencing emotions. Finally, the ‘E’ is for ‘exercise’ and centres around the fact that having a healthy exercise pattern can help your vulnerability too.

Finally, you are taught three methods to encourage and increase positive emotions:

1.     Paying attention to positive emotions – a means of replacing the negative experiences

2.     Letting go of painful emotions – through recognising they are there without allowing them the opportunity to impact your safety

3.     Opposite to emotion action – which is about concentrating on setting an action into motion which is helpful rather than harmful

MY THOUGHTS ON IT:

A lack of regulation on my emotions was another huge reason for my mental illness, and I think it began with the abuse because I spent six months stuffing my emotions way deep into me so that no one could realise what was happening. Now, I recognise that six months isn’t a huge amount of time, but it felt like forever while it was happening. And I think that was long enough to leave an enormous imprint on my life.

Those six months of pushing things down and working so hard to not show any emotions, was amplified when I made the decision not to report the abuse to anyone for the following two years. This meant that when I began hearing voices toward the end of those two years, I seemed to almost naturally have the impulse to keep it a secret.

Of course, hiding emotions, experiences, and thoughts doesn’t get you far, and so I guess I shouldn’t have been surprised when everything became so overwhelming and powerful that I was left feeling as though I had no choice but to attempt suicide.

This became a pattern for the following three years – me feeling overruled and instructed by my emotions to self-harm or to try to take my own life in a bid to escape the mental pain and swap it from some actual, pain which I could more easily control and get help for. So learning this module and discovering all these methods to regulate my emotions and find positives in them, really helped my safety.

MY TOP TIPS FOR EMOTION REGULATION:

ü  Don’t perceive any of these skills as ways to dismiss or invalidate your emotions

ü  If you don’t usually exercise, don’t think that completely rules out using ‘PLEASE’

ü  Know that you might initially think a ‘helpful’ action is to hurt yourself

ü  If you’re struggling to stop using mood altering drugs, reach out for specialist help

ü  Getting help for your emotions is much healthier than stamping them down

DBT MODULE FOUR: INTERPERSONAL EFFECTIVENESS

WHAT IS IT?

This final module in Dialectical Behaviour Therapy is all about building and maintaining healthy and safe relationships, with friends, family, yourself… It’s also an opportunity for all of your other DBT skills coming together to be used for one primary reason.

HOW DO YOU DO IT?

The first acronym discussed in this module is ‘DEAR MAN’ which centres around a scenario where you’re asking for something you’d like. The ‘D’ is for ‘describe’ and the ‘E’ is for ‘express’ which are both about putting effort and consideration into the way in which you are requesting what you’d like. The ‘A’ is for ‘assert’ which focuses on the importance of finding the ability, determination, and courage to really advocate what you’re asking for. Next, is the ‘R’ which is for ‘reinforce’ and this puts concentration onto the power behind putting more of your strength and support into your own request. The ‘M’ is ‘mindful’ which is all about being conscious of what you’re asking for, concentrating on it, and really centring your time and effort on it. The ‘A’ is to ‘appear confident’ which is something that would really aid the aspect about ‘asserting’ yourself. The rationale behind this recommended quality for making a request, is all about it being a big way to enhance the persuasive nature of it. Finally, the ‘N’ is for ‘negotiate’ which puts attention on the possibility that it might be important for you to take into consideration the thoughts and feelings another person has over your request.

The next acronym – ‘GIVE’ – is the ideal methods for maintaining a relationship. Firstly, the ‘G’ is to ‘be gentle’ and it’s all about showing care, thought, and consideration for the other person in the relationship. The ‘I’ is for ‘acting interested’ and this is all about respecting and sharing a regard for something the other person does. The ‘V’ is for ‘validate’ and it’s a focus on how important and powerful it can be to encourage someone and provide reassurance that they are understood and therefore not alone. Finally, the ‘E’ is for ‘easy manner’ and this concentrates on having a friendly, kind attitude toward the other person.

The final acronym is ‘FAST’ and this is all about having respect and appreciation for yourself. The ‘F’ is for ‘be fair’ and this sheds light on the importance of treating yourself, your thoughts, and your feelings fairly and without harsh judgement and invalidation. The ‘A’ is for making ‘no apologies’ which is probably one of my favourite parts of this… I’m very supportive of having the mindset that whilst you need to take responsibility for your actions, you shouldn’t apologise for who you are and the passions you have. And this leads on to the ‘S’ which stands for ‘stick to your values’ and I think this part really stresses the importance of being undeniably yourself and if that means difficult discussions then it’s worth it. Finally, the ‘T’ is for ‘truthful’ and this about avoiding lies, exaggerations, and excuses by being honest, open, and authentic.

MY THOUGHTS ON IT:

 I honestly found this module one of the most boring if I’m honest! I think it was about all the acronyms and in group sessions we very often had highlighters to pick out words in each letter. In some ways it felt like being back at school!

One part I did really enjoy and find helpful though, were the pieces about maintaining or forming stable and healthy relationships with others. One huge symptom of my diagnosis of BPD is around having volatile, intense, and unstable relationships, and it was definitely something I experienced with a whole host of people in my life.

MY TOP TIPS FOR INTERPERSONAL EFFECTIVENESS:

ü  A lot of this is about treating others how you’d like to be treat

ü  Validating can be The Most Important tool in a relationship

ü  Using DEAR MAN doesn’t make you manipulative

ü  Being truthful can go a long way in relationships with others and not just yourself

WEBSITES USED IN THIS PIECE:

https://www.dbtselfhelp.com

https://www.goodtherapy.org/

https://nourishyourmind.com/

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