Beginning Dialectical Behaviour Therapy

I started Dialectical Behaviour Therapy (DBT) properly this week, I say properly because I’ve already done what they call the foundation course. Tuesday was my first individual session and this coming Thursday will be my first group session - they started the individuals the week before the groups. Due to the commencement of DBT I thought I’d write a little about Borderline Personality Disorder (BPD) with which I am diagnosed but only just, enough to warrant treatment. I’ve had a look through my blog to see what I’ve already posted about BPD and DBT, finding that I posted a weighty article about BPD back in June 2013 and not much about DBT. Below is a little excerpt from Spectrum regarding BPD along with the diagnostic criteria. In bold and underlined are the ones I identify with, and just underlined are the ones I only sometimes or partially identify with.

According to the DSM-IV-TR (American Psychiatric Association, 2000), borderline personality disorder is diagnosed when there is a persistent pattern of unstable interpersonal relationships, mood and self-image, as well as distinct impulsive behaviour, beginning by early adulthood and present in a variety of contexts. These difficulties are indicated by five (or more) of the following:

1.      Frantic efforts to avoid real or imagined abandonment.

2.      A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealization and devaluation. 

3.      Identity disturbance: markedly and persistently unstable self-image or sense of self.

4.      Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating). This does not include suicidal or self-harming behaviour. 

5.      Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.

6.      Affective instability due to a marked reactivity of mood - intense feelings that can last from a few hours to a few days.

7.      Chronic feelings of emptiness.

8.      Inappropriate intense anger or difficulty controlling anger.

9.      Transient, stress-related paranoid ideas or severe dissociative symptoms.

Not all people diagnosed with BPD will present in the same way, as there are over 100 combinations of symptoms possible, if someone has five out of the nine criteria.

The diagnosis of BPD is only made when it is clear that these behaviours have been present over time (usually starting in early adulthood) and across a range of situations.

Reference:

http://www.spectrumbpd.com.au/pages/about-borderline-personality-disorder-bpd/formal-diagnostic-criteria-for-bpd.php

As you can see I identify strongly with three of the nine traits and partially with four of them, meaning I don’t quite fit the diagnosis. I should strongly identify with five of the traits. Because of this I’m unsure whether I should be pursuing DBT. I don’t know if there are people more deserving of my place, if I’m going to be sitting in the group not being able to identify with the topics because we’re talking about one of the traits I don’t suffer at all, or just sometimes or a little bit. I also have a lot of trouble with my memory and concentration. The group sessions go from 3:45 – 8:30, there are two breaks but that’s still a really long time it’s helped by being interactive but I get fidgety and restless and just don’t take anything in.

Below is the entire description of Dialectical Behaviour Therapy from the PsychCentral site. I don’t know how reputable that website is but having read through everything posted below I can tell you it’s right. I don’t have a good enough understanding of this to write it in my own words, but I know enough to be able to say this is right.

Dialectical behavior therapy (DBT) is a specific type of cognitive-behavioral psychotherapy developed in the late 1980s by psychologist Marsha M. Linehan to help better treat borderline personality disorder. Since its development, it has also been used for the treatment of other kinds of mental health disorders.

What is DBT?

Dialectical behaviour therapy (DBT) treatment is a cognitive-behavioural approach that emphasizes the psychosocial aspects of treatment. The theory behind the approach is that some people are prone to react in a more intense and out-of-the-ordinary manner toward certain emotional situations, primarily those found in romantic, family and friend relationships. DBT theory suggests that some people’s arousal levels in such situations can increase far more quickly than the average person’s, attain a higher level of emotional stimulation, and take a significant amount of time to return to baseline arousal levels.

People who are sometimes diagnosed with borderline personality disorder experience extreme swings in their emotions, see the world in black-and-white shades, and seem to always be jumping from one crisis to another. Because few people understand such reactions — most of all their own family and a childhood that emphasized invalidation — they don’t have any methods for coping with these sudden, intense surges of emotion. DBT is a method for teaching skills that will help in this task.

Characteristics of DBT

• Support-oriented: It helps a person identify their strengths and builds on them so that the person can feel better about him/herself and their life.
• Cognitive-based: DBT helps identify thoughts, beliefs, and assumptions that make life harder: “I have to be perfect at everything.” “If I get angry, I’m a terrible person” & helps people to learn different ways of thinking that will make life more bearable: “I don’t need to be perfect at things for people to care about me”, “Everyone gets angry, it’s a normal emotion.
• Collaborative: It requires constant attention to relationships between clients and staff. In DBT people are encouraged to work out problems in their relationships with their therapist and the therapists to do the same with them. DBT asks people to complete homework assignments, to role-play new ways of interacting with others, and to practice skills such as soothing yourself when upset. These skills, a crucial part of DBT, are taught in weekly lectures, reviewed in weekly homework groups, and referred to in nearly every group. The individual therapist helps the person to learn, apply and master the DBT skills.

Generally, dialectical behaviour therapy (DBT) may be seen as having two main components:

1. Individual weekly psychotherapy sessions that emphasize problem-solving behaviour for the past week’s issues and troubles that arose in the person’s life. Self-injurious and suicidal behaviours take first priority, followed by behaviours that may interfere with the therapy process. Quality of life issues and working toward improving life in general may also be discussed. Individual sessions in DBT also focus on decreasing and dealing with post-traumatic stress responses (from previous trauma in the person’s life) and helping enhance their own self-respect and self-image.

Both between and during sessions, the therapist actively teaches and reinforces adaptive behaviours, especially as they occur within the therapeutic relationship. . . The emphasis is on teaching patients how to manage emotional trauma rather than reducing or taking them out of crises. . . . Telephone contact with the individual therapist between sessions is part of DBT procedures.
(Linehan, 1993)

During individual therapy sessions, the therapist and client work toward learning and improving many basic social skills.

2. Weekly group therapy sessions, generally 2 1/2 hours a session and led by a trained DBT therapist, where people learn skills from one of four different modules: interpersonal effectiveness, distress tolerance/reality acceptance skills, emotion regulation, and mindfulness skills are taught.

The Four Modules of Dialectical Behaviour Therapy

1. Mindfulness

The essential part of all skills taught in skills group are the core mindfulness skills.

Observe, Describe, and Participate are the core mindfulness “what” skills. They answer the question, “What do I do to practice core mindfulness skills?”

Non-judgmentally, One-mindfully, and Effectively are the “how” skills and answer the question, “How do I practice core mindfulness skills?”

2. Interpersonal Effectiveness

Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict.

Borderline individuals frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioural sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioural sequence when analysing her own situation.

This module focuses on situations where the objective is to change something (e.g., requesting someone to do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a person’s goals in a specific situation will be met, while at the same time not damaging either the relationship or the person’s self-respect.

3. Distress Tolerance

Most approaches to mental health treatment focus on changing distressing events and circumstances. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by religious and spiritual communities and leaders. Dialectical behaviour therapy emphasizes learning to bear pain skilfully.

Distress tolerance skills constitute a natural development from mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Although the stance advocated here is a nonjudgmental one, this does not mean that it is one of approval: acceptance of reality is not approval of reality.

Distress tolerance behaviours are concerned with tolerating and surviving crises and with accepting life as it is in the moment. Four sets of crisis survival strategies are taught: distracting, self-soothing, improving the moment, and thinking of pros and cons. Acceptance skills include radical acceptance, turning the mind toward acceptance, and willingness versus wilfulness.

4. Emotion Regulation

Borderline and suicidal individuals are emotionally intense and labile – frequently angry, intensely frustrated, depressed, and anxious. This suggests that borderline clients might benefit from help in learning to regulate their emotions. Dialectical behaviour therapy skills for emotion regulation include:

• Identifying and labelling emotions
• Identifying obstacles to changing emotions
• Reducing vulnerability to “emotion mind”
• Increasing positive emotional events
• Increasing mindfulness to current emotions
• Taking opposite action
• Applying distress tolerance techniques

Reference:

http://psychcentral.com/lib/an-overview-of-dialectical-behavior-therapy/?all=1

I went through the assessments to do DBT a while ago, I think it’s been a couple of years now, but my doctor decided against having me do it because he worried I could be triggered by the struggles the others in the group are going through. I still worry about that because I am easily influenced by the suffering of others; I only have to see an ambulance to think of all the times I’ve been in them and what I could do to bring on one of those situations (that’s quite embarrassing to admit publicly).

I’ve become a bit lost in writing this. I don’t have a clear point to make, maybe just that I’m worried and reluctant about DBT starting this week. I don’t know how it’s going to fit in with my very frequent hospital admissions because you only have to miss two sessions to be kicked out and made to start that module from the beginning. Unless of course you elect to quit, something I’d probably choose over going over the same content from the start.

That’s this blog post done. Sorry it was long and didn’t really make a point.

Fright

I know I said I wasn't posting anymore but I feel like I have no outlet without the blog. My parents now know about it thanks to a friend telling my mum, she had my best interests at heart though. So because my parents know about it you can expect me to be a little less candid, I've never been very open with them and I'm not about to start now.

I'm back in hospital having more ECT, this time I'll be having maintenance which means that once a week to once a fortnight I'll go to the hospital for one session, it will be done as an outpatient so I don't have to stay over once a week or anything.

I'm having a tough time at the moment, both of my housemates decided to move out, my overdose is at least partly responsible, I scared them off. No one wants to come home to a corpse and I think that's what concerns them. So basically I totally fucked up by taking that last overdose. I don't think I'll take another one for the purpose of being unconscious. There are other reasons to do it, but I don't feel that way at the moment. Because of this situation I'm pretty depressed and I have the classic borderline hollowness, it's like being filled with air with nails floating around inside you and occasionally one of those nails pierces an organ or bangs into the abdominal wall causing a sharp pain. There is not one positive emotion in me, I suppose I have to take ownership of the borderline label since I embody it. I can't get in to DBT until January so I'm stuck being a crazy borderline until then.

If you can please visit me, we can go down the street to a nice cafe, it doesn't need to be a boring hospital visit. I get pretty lonely, there's one girl who talks to me in passing and L is there but she wants some space. So visitors would be grand.

Shared Care

I made it through Monday night all by my self, but the same can't be said for yesterday. I cut my arm and took a reasonable sized overdose, sadly it wasn't enough for me to lose consciousness but it did sedate me and make the afternoon / night fly. I may have drifted off, but the nurses said nothing about it. I don't remember blood being taken, which apparently they did, so maybe I did drift off. Mum has forced me to stay with them for a couple of days until I'm back on my feet, probably a good idea since I'm not walking too straight or breathing very well.

I saw my psychiatrist this afternoon, he'd received a report from the hospital I went to detailing what I'd taken and my psych assessment; he's decided it's time for me to have a case manager, I'm not yet sure what this will involve, they were supposed to contact me this afternoon but haven't. But basically my psych wants my care to be shared between him, the case manager, my psychologist and my outreach worker, oh and he wants me to do DBT which I'm more than a little disappointed about, I thought we'd got past the borderline diagnosis. He's also decided to stop prescribing PRN medications (medications I take when I need them) since they're the ones I abuse, this will make life very tough when I do really need them and will in turn increase my self harm, not a wise move.

Not For You

I don’t have a new psychiatrist; shit! I cancelled my appointment with crazy psych today so I could comfort a friend – I've got nothing until 7^th June now. I came very close to a train line drive last night, managed to hold back and I’m glad I did, I wouldn't have been the only suicide last night to hurt my friend.

I still can’t sleep, my head hurts, I don’t have a psychologist, I don’t like my psychiatrist and DBT doesn’t start until October or January. I have a long wait and I can’t escape before then because it will destroy my friend. I wonder how long you can stay in an induced coma for, and where one can get hold of the necessary equipment to achieve this.

Toast

4:40am. I hurt from coughing. My body is exhausted but my mind won’t let it sleep, the sedatives don’t work and I can’t take more Seroquel (a definite sleep success) because it will ruin all the effort to get off it. 4:41. It has been a semi productive night, I read several Bible passages, I’m working my way through John – though I did start in the middle. 4:42. It’s been a long time since I’ve made any effort with the Bible, or even prayer; I’ve read it twice in a few days now. 4:43. Since I’ve been so out of the habit of reading it I just let it fall open to somewhere in John 4:44 (I think it’s my favourite gospel) and took it from there 4:45. I’m not a slow typist, I’m just tired and thinking slowly. 4:46. Small group was fantastic last night – it was just a dinner, but we all got chatting and it was just 4:47 lovely to have a very casual time to laugh, eat and exist together, no leaders present, I suspect that would have (4:48 and I didn’t just wake) changed the atmosphere. 4:49 I’m tired. 4:50, I’ve been writing ten minutes and have only a short paragraph which isn’t even complete. The other thing I did to make my sleepless night productive was 4:51 to fill out a more detailed character description for my original character – Francis. I made Nicola last week and she is complete and capable of living a 4:52 life out in the real world, Francis was lacking, I didn’t know her well enough. Now that they’re both complete I shouldn’t have trouble making them talk, just trouble 4:53 making myself open the file and start typing. It’s bizarre, I love creative writing, I’m good at it, but I can’t start. I don’t enjoy blogging 4:54 as much as I enjoy anything creative, but I find it very easy to do even in the worst of moods – or now in exhaustion, pain, boredom and resignation. 4:55. 4:56. 4:57 – Had to google a few things.

My stomach has 4:58 just alerted me to the fact that it is empty, I dare not eat now and provide myself energy, I want to sleep, maybe it will be easier if not 4:59 in pain, but maybe food will wake me more. Conundrum. I forgot to mention, I don’t have whooping cough, just a virus which has stuck around 5:00 for five weeks and seems to be getting worse; surely there is a point when my body has to start being nice to me 5:01. 5:02. My mind isn’t coping well 5:03 with the added burden of physical illness, but I’ve still not succumbed to the blade, as tempting as it is 5:04 it really achieves nothing. Mum drove me to my appointments today so I didn’t have to make everyone on the tram sick, the DBT assessment 5:05 went well and provided I’m still interested in two months time when I go back for my second chat it’ll be go. The next term starts in September and the following in January 5:06, I may not get in the September one, but that’s the one we’re hoping for. The epic assessment was followed by coffee with mother whilst I almost 5:07 fell asleep and then a very short session with my psychiatrist; I can see his brilliance, but I’m not convinced he’s for me, maybe I’m scared that 5:08 he might actually help. There’s a weird fear attached to recovery from mental illness, I want it greatly, but it is unfamiliar territory and if achieved 5:09 it will be different from anything I’ve ever known, even in childhood. 5:10.

I would appreciate it if my friends could make an effort to contact me this week and coerce me out of the house. I feel a hermetic period approaching 5:11 and it’s hard to bring oneself out of that.

There is a 5:12 possibility I’m a little more sleepy now, so I will end here and make attempt four at sleep. Good morning. 5:18 post proof read and publishing.

A Setback

You all know by now that I’m pinning my hopes on DBT; since January I’ve been told that I’m likely to start in May – wrong! The very earliest is September, but that doesn’t look too promising because that’s the next one and I’m not even on the waiting list yet. I wonder sometimes if my whole life is just one big punishment for “the sins of my fathers”, there’s not much devotedness in my bloodline and plenty of outright rebellion. Things never go smoothly for me, this isn’t just woe is me thinking, but well observed fact; good things don’t happen, but on the occasions they do they don’t last. I knew M and I wouldn’t get married because that was something that was happening to everyone around me, and I don’t get the same things as them; you may call it self-fulfilling prophecy, I call it my curse. I try not to dwell on it because that just makes it more likely to continue, it just confuses me so much. I am a good friend, very loyal and honest (maybe a little too honest), I’m a good girlfriend, loving, caring, fun and sensible, I’d like to say Godly, but not so much at the moment; but the things that make me good are overshadowed by my expectation to have the same in return, and the need to be loved enough to make up for a mostly loveless life. When I am feeling suicidal it is not because of how I feel about that very moment, but rather what I feel in that moment about the future. Some days I can hold a little hope and imagine a life that isn’t completely worthless, other days all I can see is a lifetime of loneliness and mediocrity. I want to be loved, or I want to excel in my field, both would be grand; at the moment I’m just a thing.

One Week

Last night marked one week since I last hurt myself, I was going to do it just before bed but had no energy and no dressings so I just went to sleep; aren’t I a good girl. I’m feeling a lot better re overdose now, my brain is working again and I don’t constantly feel nauseous. As awful as it was, the temptation to do it again is high, because it worked. When I woke up I only felt physically awful, mentally I was fine, and I know now that I don’t fear death. The things holding me back are; two friends who have said they would end the friendship if I did it again, the fact that it would make me fall behind at uni – I’m already behind but the work is very easy and I should still be able to wrangle HD’s (cocky eh) – and that I’d have to use over the counter meds in massive doses and I have no idea what they’d do to me. I don’t fear death, but I do fear being physically or mentally impaired to the point where I am unable to end my life, I need to have that control.

L is still in hospital, I miss her and I hate knowing she’s not well; this illness stinks. I’d like to be better or dead, better takes a very long time and dead makes people sad. I know L wants the same, I don’t want her dead, but I know better takes so long and it is hard to achieve, DBT had better work for me and someone better find something to work for L, because the world needs her in it.

I’m writing a big post based off this Croakey article and all the others it references, plus a few others. It’s been a while since I did a nice researched, informative post; I’m not full of energy and need to work on uni when I am, so it might take a week or so, but there’s something for you to look forward to if you like that kind of thing.