My Needs Are Not Important – Transference or Reality?

After reading a vulnerable post on my friend’s blog the other night, I decided that I wanted to share it with my therapist. It was all about intimacy and love in therapy, and the expression of that. 

I texted my therapist saying, “Hi I came across a blog post online that I’d like to talk about. I was wondering if you have time to read it before Tues (it’d take 10mins or so, it’s long). I don’t want to ask too much of you, I just want to work out the best way to talk about it together. Please can you let me know what would work best for you/ if you have any suggestions, so that I can plan for our session. Thank you!”

She replied a short while later, “Tue is your EMDR session, anything else will be read in session if you feel it is part of therapy, I don’t need to know what is written by someone else, it’s for you to discuss whatever you feel is relevant.”

I started spiraling immediately. Emotion mind took over and I couldn’t clamber out. The awareness of my reaction did nothing to stop me from sinking. I tried to rationalise using all the cognitive skills, but I can’t deny the visceral reaction it brought up in me. 

Regardless of reality, my interpretation of her message upset me massively. Even if she didn’t realise, I was asking for something that put me in a position of vulnerability (especially considering the content of the blog post I wanted to share with her!), and so her text felt like a huge rejection. I felt like my needs were ridiculous and unimportant (hurt, anger), and that I had no right to ask (shame, guilt) and spiraled into emotion mind.

This is what the interaction felt like to me:

Me: Hi, I have a need so I’m putting it out there even though I feel guilty and undeserving. I have something to discuss that feels vulnerable but I would like to be effective so I’m going to take the plunge and put myself out there! I think it would be valuable work for us and I love and trust you enough to ask how you can best meet this need of mine. 

Her: Hah, what a ridiculous need! What you think is valuable work doesn’t sound very valuable to me. Let’s shape your request around my needs instead. After all you don’t really deserve to have your voice heard and that shame you felt for asking was definitely justified. You are not important to me and I do not love you enough to give you what you are asking for, but nice try. 

I noticed jumping to thoughts like “fine I just won’t even bother telling her then” and “I’m never going to ask for anything ever again”. I know I was reading into the neutrality as her being angry or fed up with me but the traumatised parts of me couldn’t take in any other information. I really wanted reassurance from her and found it hard not to spiral. My mental state went down very fast and I found it very hard to get out. I know it’s probably related to Mum stuff but the traumatised parts of me can’t disentangle it all so it feels very much related to my therapist. 

I went from anger and shame to overwhelming sadness quicker than usual. I’m currently in bed cuddling my teddy bear with a stinking headache from having cried so hard and in severe attachment pain. I’m trying to self-soothe because as much as I’d like her to make this pain go away, that’s not going to happen.

Instead of processing around my friend’s blog post tomorrow in session, it looks like we will have to process this entire interaction (and everything it brought up for me) instead. 

My BPD Presentation

Last weekend I had the honour of speaking for 25 minutes in front of 250 people about BPD at a mental health conference. Although the months leading up to it were filled with panic and dread and I genuinely was not sure if I’d be able to go through with it, it actually went 100x better than I could ever have hoped for.

I have decided to share my presentation here (in a written as opposed to audio format to maintain anonymity). I trust that my readers won’t plagiarise or copyright the content, but I do want to put this out there as it is a rare achievement I felt proud of! (Some of the slides have come out in a squished format, but I think they’re clear enough).


BPD, ME AND ANXIETY

Hello everyone and thank you for introducing me. I am here to talk to you about what it’s like for me living with Borderline Personality Disorder and anxiety. I just want to say before I start that this is the first time I have done anything like this so if I appear really frikkin anxious, it’s because I am really frikkin anxious! Thank you for bearing with me and I hope you get something out of my talk today!

img_0271

So what exactly is Borderline Personality Disorder? BPD is basically a disorder of emotional dysregulation; people with BPD struggle to regulate their moods, feelings, behaviours, thoughts and relationships with others. However, it is pretty much impossible to sum up BPD in a single sentence, so I will be going into much more detail later in the talk. Just to give you some background information first, BPD affects about 1% of people and is more prevalent amongst women than men. In order to be diagnosed you have to meet criteria for at least 5 out of these 9 symptoms on this slides, and be at least 18 years old. However, because symptoms often start much younger and can appear to overlap with other disorders, many people might not be correctly diagnosed or treated for years. I was personally treated from the age of 12 to 19 for depression, anxiety, self harm, eating disorders, and later substance abuse. No one really understood what was “wrong” with me, and when I continued not to get better I was told that I was simply “treatment resistant”. Finally, at the age of 19, I was diagnosed with BPD. For me this was a huge relief because I finally had a diagnosis that I felt captured so much of what I had been through. It was also really important in helping me finally get access to the specialised support I needed, as well as understanding more about why I am the way I am.

img_0272
So what actually causes BPD? As with other mental illnesses, there is no simple answer, but it is understood that both nature and nurture have a role to play. Naturally, some children are born more sensitive than others and find it harder to deal with their emotions. If parents are able to meet their kids’ emotional needs, a child is more likely to develop a healthy emotional skill set. However, if a child is exposed to an environment that is unable to meet their needs, they might never learn these coping skills. People who develop BPD tend to be born as naturally sensitive kids into an environment that isn’t catered to nurture this sensitivity. People with BPD often grew up in environments that they experienced as invalidating. Invalidation happens when someone’s feelings or thoughts are ignored, ridiculed, dismissed, or judged by those around them. For example, teasing a child for crying, punishing a child for expressing anger, or telling a child that their feelings are silly or wrong or untrue. This invalidation can be especially damaging to children who are already sensitive, and when it happens a lot and over a long time, it can start having lasting impacts. The child might start to internalise the message that their thoughts and feelings are wrong, unimportant or unworthy of attention. They must try to shut their feelings down, judge themselves, and invalidate their experiences just like everyone around them has. As a result, they might never learn how to trust and manage their emotions appropriately – which leads to frequent emotional dysregulation. And it is this emotional dysregulation that underlies many of the difficulties seen in BPD.

img_0273
I’m now going to talk a bit about how BPD manifests. I personally find it helpful to split the symptoms into the surface ones vs the more hidden ones. This is because BPD is often associated with certain behaviours, such as self-harm, suicide and impulsivity, in the media, health care settings and in society. Society focuses on the external because it is easier to make sense of the things you can see, especially with something complex like mental illness. However because of this, these surface symptoms often become the face of BPD – and are what create a lot of the negative stigma that can be hard to shift. This is especially sad as people with BPD often feel massively misunderstood, and I admit it feels near impossible to explain what living with BPD is really like on the inside. My hope is that through talking to you about some of the more hidden aspects, I can make the invisible more visible – and help others understand.
img_0274
First I’m going to briefly address self harm though as it is one of the behavioural symptoms most frequently associated with BPD. Self harm can take a number of forms which I have outlined on this slide. Although self harm might be hard to understand from the outside, for people who struggle with it, it actually makes a lot of sense. Most people who self harm do so because they have no other coping mechanisms available to them. Maybe they were never taught how to deal with their emotions healthily or maybe their pain is so overwhelming that they see no other option. There are a lot of reasons why people self harm, but ultimately it is a dysfunctional coping mechanism for dealing with overwhelming emotional pain or distress.

img_0275
Personally, I have self harmed in an attempt to make things I’ve been experiencing inside into something more visible and tangible – in an attempt to make sense of a pain that often cannot be put into words. I have self harmed as a form of punishment. I have self harmed to try and purge myself of feelings that have been too unbearable to contain. I have self harmed to release feelings of anger that were not safe to express externally, and I have self harmed to suppress or appease intrusive thoughts I might be experiencing. There have been times when I have self harmed in an attempt to make myself feel alive, when I have been feeling particularly dissociated – which is something I will cover a little more later. Unfortunately for a long time self harm was a big crutch for me. When I didn’t know how else to manage, self harm seemed like the only way I could temporarily alleviate the pain. Now, I am more in control of these urges than I used to be.

However, not actively self harming does not mean I am cured of BPD. In fact, not using self harm as a crutch is challenging in itself – not just because there is no release for the pain in the way there used to be, but because without the physical ‘proof’ of this pain, people often start to take you less seriously. For example, a few years ago I had an assessment with a personality disorder team in which I expressed my desperate need for help. However, I was told by the psychiatrist that because I had not self-harmed for a whole month, I must be doing really well and he did not think their team could help me. I am pretty sure that if I had gone in with fresh wounds and stitches all over my body, I would have been taken more seriously, and given the support I needed. Instead, his response reiterated to me that using my words to express how I felt inside was not good enough. It backed up all the beliefs I have about my feelings not being important to anyone or worthy of support. A few days later, inevitably, I ended up relapsing; a communication of my pain, both to myself and the outside world.

I just want to highlight that for me, at the time, none of this was a conscious process. I have never planned the process of self harming in a reasonable state of mind with the awareness of what I am doing. In the actual moment, the urge to self harm is so high that it doesn’t feel like a choice, it feels like an instinct and a compulsion and the only way to survive. Fortunately, through my treatment, these behaviours have become more of a choice for me. Now, the parts of BPD that I struggle with the most remain invisible to the outside world. I am going to try and address these difficulties now.

img_0276
Like I said earlier, BPD is essentially a disorder of emotional regulation. This means that we can find it hard to control how we react emotionally to situations and can swing from one extreme state to another in very short periods of time. We can be managing fine one moment, but then in a total crisis the next, swinging multiple times in a single day. For some people with BPD these swings might be obvious from the outside, but for others we might try and hide them from the world, so you wouldn’t necessarily be aware of how controlled by our emotions we feel. It is not uncommon for me to experience feelings of both joy and suicidality at different times on the same day, just hours apart – and for no one around me to have any idea. As you can imagine, this is pretty discombobulating. BPD is pretty much a never-ending emotional roller coaster that you can never really get off and never know what’s coming next.

img_0277
However, it is not just our moods but also our relationships and perception of others that can be pretty unstable. People with BPD are very all or nothing in the way that we think. We think in black and white terms, and struggle to live in the grey. This means that we often see the world, including people, as one extreme or another. It is hard to integrate both the good and the bad into one at the same time and to hold all sides of a person or situation in mind. This means that small shifts in a relationship can feel very distressing and throw the entire relationship off balance. We might fluctuate from loving someone and wanting to be around them 24/7 one minute, to hating them and never wanting to see them again the next. For me, these changes are usually triggered by feelings related to rejection. For example, if someone close to me shows me a gesture of love, I might see them as the most important person in the world, who I love with all my heart and could never live without. However, if the next moment the same person did something that left me feeling rejected, hurt or misunderstood, I might switch to feeling like they are the most terrible person on the entire planet who has wronged me so badly that I never want to see them again.

img_0278
Of course, it is natural to an extent to be scared of rejection and abandonment, but with BPD this really takes on another quality. When these feelings are triggered, it can spiral us into a state of paranoia and anger, mistrust and distress, and even suicidality. Sometimes the feeling of rejection might in no way fit the reality of the situation, but even the possibility that someone might be leaving in some way can send us into a spin. These feelings can even triggered by everyday experiences that from the outside may seem menial. For example, someone cancelling an arrangement last minute or not replying to a text message can set off a complete meltdown. For someone without these difficulties, they might be able to rationalise that their friend is stressed out, forgetful, or sick, or accidentally messed up their dates – and look at the situation as a whole before moving on from it. For someone like me however, I might start to believe that my friend has ulterior motives, that she is trying to provoke a reaction in me, that she clearly doesn’t care about me, that I mean nothing to her, that I am boring, annoying, a handful, that she is choosing her boyfriend over me, that I am unworthy of having friends and that no one loves me anyway, that I am worthless and that I might as well kill myself. You can see how this irrational thinking quickly spirals out of control, and how overwhelming even small interactions or situations can become.
img_0279
The constant rejection sensitivity that we experience invariably leads to huge paranoia and hypervigilance within relationships. I often question what is real in relationships and what is in my head, as I know I have a tendency to read into situations too much. I might read over the same email fifty times convinced that my lecturer is having a dig at me. I might continually check someone’s ‘last online’ status to try and work out if they are avoiding me. I might seek constant reassurance from those close to me that I have not done something wrong convinced that they are angry with me. We look for clues everywhere and often create evidence that doesn’t even exist. Very often, the ability to distinguish between what is real and what is not can become overwhelming. It takes a lot of mental energy trying to filter out what is what in every single interaction, and sometimes it gets a bit too much. This is also something that absolutely feeds my anxiety.

img_0280
Sometimes when things get too much, I might start to shut down. This is not a conscious decision or process, but an automatic coping mechanism called dissociation. Dissociation is basically a state of disconnection from reality that many people with BPD struggle with. It is the brain’s way of saying ‘Okay, we are outside of what we can tolerate right now, reality is too much to manage, so we are going to check out for a while, cya’. It is hard to describe what dissociation feels like, but it’s sort of like being drugged with sedatives. It can either make you feel disconnected from yourself, or from the world around you, or both. It can make me feel like I am a robot or a ghost going through the motions, not really living, or like I am in a dream. It can feel like there is a fog shrouding everything around me, or an invisible shield blocking me off from the world. Sometimes things around me become trippy and hard to make sense of. It can make my senses go out of focus, especially my vision which often becomes blurry and distorted. It can make my body feel like it’s not my own or like my brain and body aren’t in sync. Sometimes time or distance feel shrunken or stretched, and it might even become hard to recognise myself or the people or places around me. The intensity of this feelings varies a lot, but are usually worse during times of greater stress or if triggered by distressing situations from the past.

img_0281
Somewhat related to this state of disconnection, is a feeling of emptiness that many people with BPD struggle with. This feeling is not just a typical emptiness, but the type of emptiness that goes on for ever and that nothing seems to ever fill. This emptiness can make me feel like I don’t exist or am nothing but an empty shell. It can also feel like I lack substance and even an identity. People with BPD often struggle with holding onto a clear idea of who we really are. I find it hard to know what I like or what my interests are, and I struggle to make decisions because I rarely know what it is I want. A lot of the time I look to others to confirm things about myself, because I find it hard to trust my own mind. As a result of this fragmented sense of self, I often feel like a fake person. I end up moulding myself, changing and adapting like a chameleon to the people and situations around me. Sometimes it feels like I am a different person in every situation, with no string of ‘me’ connecting all of those experiences together.

img_0282
With BPD, it can be hard to hold onto anything other than what feels real right now. When you are in one state of mind, it is almost impossible to consider that any other states of mind exist. When your mood drops, you can’t remember ever being happy. It’s seriously impossible, you can’t even imagine what happiness feels like. Even if you know in the back of your mind that it will pass, at that moment it feels like it will never end, like you’re stuck in that hopeless pit of darkness forever. And then the irony is that during the easier moments, when I feel okay again, I question my disorder entirely and convince myself I am ‘cured’. I stand here right now appearing perfectly functional (well, I hope). But if you had seen me yesterday, struggling to get out bed at 2 in the afternoon, agonising over a relationship difficulty with a friend, sinking into a cycle of self-destructive thoughts, you would have seen a very different version of me to who you see right now.

img_0283
I also think it’s important to point out that despite the internal chaos of BPD, many people with BPD are actually very good at hiding their distress from those around them. These individuals are often able to hold down careers, studies and other commitments, despite how much they are struggling inside. This might seem like a positive thing because it means that we are able to build lives for ourselves, and make it appear as though we are functioning. However it can also be hugely challenging, as how we feel on the inside and how we present on the outside can become hugely mismatched. Or, people might see one side of us, and assume that is how we always are, which can make it hard to seek support during the times things are not going so smoothly. For me BPD often feels like a real paradox. On the one hand I try desperately to keep up a façade of functionality to the world which I am terrified will shatter. On the other hand, I really do need people in my life to know when I am struggling and to support me within that. It’s often hard to strike a balance between the two though and I usually end up presenting as totally competent, or at the other extreme, as a massive emotional wreck.

img_0284
I think that one of the scariest parts of having BPD is the speed and unpredictability of the shifts we experience, never knowing what to expect from one moment to the next, or being aware of my reactions but still unable to change them. The most frustrating thing for me is when I know on one level that I am reacting to a situation or twisting reality in a way that makes no sense. I can often feel myself slipping into paranoia, but I can’t seem to stop it. I can rationalise and intellectualise and know that my brain is lying to me, but that still does little to stop the emotional take over. Usually having this insight makes it even harder as I just end up overthinking everything to another level, which definitely exacerbates the paranoia! It’s exhausting trying to change the way you think and feel when the organ responsible for thinking and feeling is not functioning very well in the first place! Sometimes BPD basically just feels like your brain has totally turned against you.

img_0285
So like I said at the start, I also struggle with anxiety, and often there are big overlaps between my anxiety and BPD. Although not everyone with BPD has an anxiety disorder, about 75% do. This makes sense, because having BPD is like having a faulty smoke detector inside of you. The fire alarm goes off not just when the building is burning, but every time even a harmful gust of wind brushes past. The slightest touch can trigger a huge emotional response, and this also applies to situations that might induce fear. People with BPD tend to live in a state of high alert; the world doesn’t really feel like a safe place but instead is something to watch out for. We therefore have heightened stress responses, we have learnt to look out for the next thing to go wrong, and so experience even neutral stimuli as threatening. Studies have even shown that people with BPD have much higher levels of cortisol in our blood than the average person, and this is the case for people with anxiety disorders as well.

Also, because of the hypervigilance that we experience, and because of how much we struggle in relationships, anxiety in social situations is a frequent occurrence for people with BPD. The interpersonal difficulties I described earlier on, such as rapidly changing perceptions of others, constantly reading into interactions with those around us, easily become paranoid about others’ intentions, and often finding ourselves out of touch with reality, are all experiences that might contribute to and overlap with anxiety. This might not always be experienced physically for people, but for me I do get a lot of physical anxiety. For example, a situation in which I have felt rejected by someone close to me might spiral me into a state of such high physical anxiety that I have a full blown panic attack. Usually I experience a lot of anxiety off the back on interpersonal conflicts and this might last hours or even days or until the conflict has been resolved and my system can finally relax again.

I think ultimately whilst I do see my BPD and anxiety as two separate difficulties, they are absolutely connected and definitely overlap and contribute to one another. My BPD certainly makes my anxiety a lot worse.

img_0286
To finish off, there are a few myths about BPD that I would like to address. Firstly, people with BPD are often thought of as manipulative. The word manipulative has such negative connotations and puts people with BPD in a really bad light, making us look like we intend to cause harm. The fact is that we do what we can to survive out of desperation and sometimes our intentions can be misunderstood and perceived as manipulative – for example behaviours such as self-harm. The thing is that manipulation implies a conscious and intentional process that needs planning, but people with BPD are far too impulsive to think things through when our emotions are so high.

People with BPD are also often accused of being attention seeking. The thing is that needing attention is a basic human need that most people with BPD were denied of growing up. Unfortunately many of us therefore learnt to get attention or get our needs met in dysfunctional ways, for example through behaviours that might seem attention-seeking, instead of words. Again, these gestures highlight a feeling of desperation more than anything else. And the fact that people with BPD often feel the need to go to such lengths to be seen or taken seriously, including hurting ourselves, is an indication of how much emotional pain we are in. The other thing to realise is that whilst many people with BPD do crave attention in certain contexts, in other situations attention is actually something we massively shy away from.

I have also read sources that say people with BPD lack empathy. I think that this might be because when we are in the middle of a crisis we can get so caught up in our own pain that it becomes impossible to think about the other person’s side. However, more generally, the truth is that the many people I know with BPD, are some of the most empathetic and intuitive people I know. We are not only sensitive when it comes to ourselves, but we are sensitive towards others as well. In fact, a lot of people with BPD empathise so strongly with others that it becomes painful in itself!

Finally people with BPD don’t choose to be this way. There is absolutely nothing glamourous about having BPD; it is no ‘Girl, Interrupted’ movie. If it were a choice there would be none of us around, because having BPD feels pretty much like a living hell. The thing that I want to leave you with is this: We are just doing the best that we can to survive in a world that we don’t always feel equipped to be a part of. And although we can be challenging at times, we also have huge hearts and a lot of love to give. Thank you.

I Will Hurt Me to Punish You

Something minor happened today which left me feeling like I wanted to cut myself. The event itself doesn’t feel important now; what I am more interested in is how quickly and automatically I jumped to self harming as a possible solution. 

(I feel like I am at a stage where I can manage the low/moderate urges pretty effectively, so it’s not like I wasn’t safe or anything. I was actually pretty effective in how I went about the next few hours, despite wanting to physically attack (either her or myself!) for a while.)

So, I was very mindful of the thoughts and urges I was experiencing, and was even able to start thinking about what was going on for me with curiosity and distance as opposed to impulsivity and willfulness. 

My thinking amounted to a realisation I have had before: that if someone hurts me, upsets me, shames me or angers me, I end up wanting to hurt myself in order to punish them for their wrongdoings. 

I think that generally I really struggle with anger and it’s much easier for me to turn it in on myself as opposed to onto other people – even the person who has provoked it. So one way of getting back at them is by attacking myself. Make total sense, right? 😉

These instances are absolutely not the number one trigger for me to want to harm myself, but when I do feel this way, it is a clear indirect mode of communication – to both myself and the other person. I think during these times, what I’m really meaning to say is something like this:

“Fuck you for hurting me. How dare you shame/ anger/ upset me. How dare you have that power over my world. If you think you can get to me, look how much worse I can get to myself. I can hurt myself (physically) far worse than you will ever be able to hurt me (emotionally). I will show you how much you hurt me and then you will suffer. Then you will see what you have done and why you should listen to my needs – so that I don’t have to show you so tangibly. I am the one in control here. And now it is your turn to feel the helplessness and powerlessness you inflicted upon me. And I on the other hand will feel liberated.”

Edit: ironically, this applies when the person has absolutely no idea that I have engaged in any behaviour, let alone that I am hurt or struggling because of them. The only people I ever told (and very indirectly at that, or they found out via other more dramatic means) were my therapists/ people on my treatment team. Then it really did apply. I will give an example later. 

(Insecure) Attachment

Today I have been studying Mary Ainsworth and her contributions to Attachment Theory. I am really interested in her work, probably because I can relate to it and understand aspects of myself better as a result.

Mary Ainsworth identified 3 main attachment styles (a further 4th one has been more recently added):

  1. Secure (type B)
  2. Insecure-avoidant (type A)
  3. Insecure-resistant (type C)
  4. Disorganised (type D)

In knowing myself and reading the literature, it is clear that according to Attachment Theory, my style is insecure-resistant.

The insecure-resistant style of attachment usually occurs as a result of mothering which is inconsistent; whereby the child is unsure whether or not they can rely on her for comfort during times of distress. The not-knowing-what-to-expect was something I related to hugely as a kid.

Insecure-resistant children tend to be needy and clingy even before the attachment system is activated. If and when the mother does leave them, they exhibit pronounced displays of distress; more so than children from any other attachment-style category.

Interestingly, their overly activated attachment systems mean that even when the mother returns, attempts to soothe the child are met with resistance, anger and confusion, even when it’s clear that comforting is what is needed. The child is confused and unable to trust the relationship or let themselves be soothed even though that’s all they may desire. Even if they approach the mother as they often do, it is likely they will also resist contact or even try and push her away.

Sometimes the child will be clingy and dependent towards the mother. Other times they will be resistant and rejecting. It’s possible to be both at the same time, as described above.
The “I love you, don’t leave me. I hate you, fuck off” pattern.

This is also exactly what I am like with my therapist now, despite being 21 years old. It also played out with my first love, in the exact same way. It is both fascinating and terrifying seeing the interactions playing out like this, again and again.

I wish I was securely attached. My life would be so much less painful. I’m guessing that most Borderlines are insecurely attached, considering BPD is seen as a disorder of attachment by so many clinicians now, and considering the main pain I’ve heard Borderlines talk about has come from struggles relating to interpersonal interactions and relationships – or a lack thereof.

DBT Interpersonal Effectiveness “FAST” Skill

This week in my DBT Skills Group we continued working through Interpersonal Effectiveness, looking specifically at the acronym FAST.

Where DEARMAN = Objectives Effectiveness, and GIVE = Relationship Effectiveness, the FAST skill is used to nurture Self-Respect Effectiveness. Although it can be helpful in a range of contents, generally it is used in conjunction with the DEARMAN skill. When used in this way, the aim is to achieve your objective within the relationship, whilst maintaining or boosting your self-respect both during and after the interaction at the same time.

FAST stands for:

  • (be) Fair – This applies to both the objective itself, as well as the way in which you go about communicating it. Regarding the former, ask yourself if the request you are making is realistic for the other person and to yourself practically and emotionally. Regarding the latter, ask yourself if the ways in which you are approaching the other person, as well as yourself, are in line with your values and long-term goals. It is possible to validate the other person’s feelings without minimising or dismissing your own; your own needs are no less important than anyone else’s.  
  • (no) Apologies – If you over-apologise (or even apologise at all) it can send the message – both to yourself and the other person – that you have done something wrong. If it is perceived that you have done something wrong or that you have no ‘right’ to ask for what is it you need, the other person may be less inclined to meet your request. Constantly apologising may even aggravate and push people away. And it isn’t particularly lifting for your own self-respect, self-efficacy or sense of self-mastery either!
  • Stick to values – If you are not sure what your values are, it may be helpful to brainstorm a few that fit into different domains of your life. For example, what are aspects you deem to be of value in the context of: family, friends, work, education, health, nature, leisure, creativity. Listing these enabled me to get a better feel for how to approach situations in a way that matched my morals and internal belief systems.
    Sticking to your values over time will help increase self-respect as you are acting in a way you deem to be ‘right’ – both for others and for yourself. On the other hand, acting in a way that contradicts these values will probably lead to you feeling shitty about yourself in the long run, even if in the short-term it enables you to get your objectives met.
  • (be) Truthful – Whilst white-lying is not discouraged in DBT (as long as it is effective, usually when the Relationship Effectiveness is the priority over Self-Respect Effectiveness), full-on dishonesty is unlikely to be very helpful in boosting the way you feel about yourself. (Unless of course one of your values is to lie or be a liar, in which case, this probably won’t be the most helpful skill for you to use!). This also means not acting helpless when you are not, or exaggerating in a potentially manipulative way. If you go about getting your objective met with honesty and integrity, you are more likely to feel good about yourself than if you approach it with dishonesty and immorality, no matter what the outcome.

IMPORTANT:
Be very careful in using the DEARMAN, GIVE and FAST skills in the context of any form of abusive relationship. These are not the skills to use in these sorts of situations as it is unlikely the other person will be able to respond to your needs at all, and you may find yourself in a situation of even greater risk. In these situations, the DBT pages on ‘Ending Destructive Relationships’ will probably be more helpful. In situations when destructive relationships cannot be ended, the focus will shift to Distress Tolerance and harm minimisation strategies.
This should all be discussed in great length with a therapist or other professional first. This is just my opinion from what I have learnt from the DBT therapists in my Skills Group.

DBT Interpersonal Effectiveness “GIVE” Skill

This week in the DBT Skills Group I attend, we continued working through the Interpersonal Effectiveness module. We looked primarily at the GIVE skill which I will outline below.

GIVE is used when the priority within an interpersonal interaction is on Relationship Effectiveness i.e. maintaining the relationship.

The GIVE Skill is usually used in conjunction with the DEARMAN skill when trying to be effective both in one’s Objectives Effectiveness and Relationship Effectiveness simultaneously. Here the combined skills may be referred to as DEARMAN-GIVE. In my opinion GIVE can be used on its own as well within any interpersonal interaction in which the relationship is important to you.

The acronym GIVE stands for:

  • (be) Gentle – quite simply, this reminds us to be gentle, kind and respectful in how we approach the other person. It consists of 4 main aspects:
    No attacks: try to stay away from blaming, shaming or accusing the other person. People are likely to become defensive if they feel they are being attacked, and this will get you further away from reaching your desired goals.
    No threats: do not ‘manipulate’ the other person or be passive aggressive in your tone. Even if you get your immediate needs met by threatening something like “If you don’t do X, I will hurt myself”, it is not going to helpful in maintaining the relationship healthily long-term.
    No judging: try to stay away from telling the other person what they ‘should’ be doing or what they have done ‘wrong’. Of course, don’t label them with words which are likely to hurt them. Try and stay descriptive.
    No disrespect: if you treat someone with respect, it is much more likely to be reciprocated. Be wary of urges such as eye-rolling, walking away, ignoring, belittling, etc. Treat the other person as you would like them to treat you.
  • (act) Interested – the skill here is that even if you don’t really care about what the other person is communicating to you, you have to act as though you do! This is why it is called a skill 😉
    People will think more highly of you if you give them the time and space they need, and will be likely to respond to your needs if they perceive that you are responding to theirs.
  • Validate – you can do this both with your expressions and your words, as well as in your actions. Mirror the other person; adjust your facial expressions to match what it is they are talking to you about. Look them in the eye and show that you are listening to them. This overlaps with the above skills – acting interested can be a form of validation.
    Try to find the valid amidst what is being said. Even if you don’t agree with the other person, validate with words that at least you understand why they feel the way that they do.
    The saying “Actions speak louder than words” is quite fitting here – if you validate in words (e.g. saying that you understand that the person is feeling sad) but continue acting in a way that is not helpful to the other person (e.g. continuing to behave in a way that leads them to feel sadness), it may negate your efforts.
  • Easy Manner – try to be light-hearted, flexible and approachable. If you are struggling with your own emotions or mood, try to leave them at the door and not let them infiltrate into the relationship. Try and make the interaction feel easier for the other person. Be smooth. Be soft. Be chill. (Of course, all only to an effective extent!)

We then moved on to expand on the in GIVE: Validation. We read through the Six Levels of Validation outlined in Marsha’s workbook; a topic which I have previously written about it more detail here which is a favourite topic of mine.

On Being Painfully Attached to My Therapist

It is a real pattern of mine to become attached to older women who are in a position of care or authority. Some of these attachments have brought great validation, comfort and healing; some have bred anger, upset and paranoia instead. One thing they all have in common however, is the emotional pain they carry with them. In fact, the pain I have experienced as a result of my difficulties with attachment is some of the most excruciating I have ever felt.

It may seem counter-intuitive to say that a relationship which provides holding and healing can also elicit such pain. But this is my experience, and it is exactly here that the problem lies. In fact, the more attached I feel to someone, the more pain the relationship causes me. It is a catch-22, a lose-lose situation, and I become stuck between a rock and a hard place.

Ultimately, I am in therapy because I want to make changes in my life and maintain them; because I want to reduce the intensity of the painful emotions I experience; and because I want to heal past traumas which affect me in my life today. Ironically however, the relationships with my therapists have often become so intense and complex that they take over everything else in therapy.

The depth of my attachment to these therapists has caused me to act in ways which haven’t been helpful to the relationship. I will use present examples of this with my current therapist. For instance, I will reach out to her in between sessions when I don’t need to, simply because I am feeling needy or alone. I will seek constant reassurance from her to the point that I am being paranoid and it will lead to a viscous cycle. I have tried to contact her outside of our agreed hours because I am so addicted to her support. I will send her abstract texts and she will not know if I am contacting her because I need to, or simply because I feel like I need her. Etc etc etc.

Because I am in DBT, this means that we end up talking about my Target 2 (therapy-interfering) behaviours in therapy, a lot, and it dominates the sessions. Of course we explore the issues on a deeper level, looking at my feelings, my motives, my past, my attachment history and the complex trauma related.

However, no matter how much we process things, no matter how much self-awareness I now have, it doesn’t make the pain go away, and there doesn’t seem to be a solution.

Having her in my life also means having to leave her (or her me, as it so often feels), and this means deficiency and emptiness once again. It is like her love is my drug and without her I am in the clutches of withdrawal. It is almost impossible to describe, but I will at least try.

Here is an excerpt of some writing I did a few years ago with another therapist, although the experience is pretty much the same:

“I have a gaping seeping wounded hole inside of me, centered in my core. Under the the illusion that this hole can be filled up with her love and affection, I seek as much of it as I can – although it never touches the sides for long. Sometimes it ends up becoming counter-productive; the more I get, the more I crave. The neediness does not go away.

I yearn for her love, affection, attention, validation and soothing. But no matter how much I get, I am always left wanting more. I feel like the neediest, greediest girl in the world (albeit 99% internally, which in itself is excruciating) and it is not a good look at all.

It has gotten to the point where if I don’t have contact with her at least once a day, it becomes pretty much all I can think about. I will debate with myself for hours about whether or not to contact her. If I do, I feel immense guilt and shame, or anger or hurt if she doesn’t respond how I want her to. If I don’t, I continue to ache, my immediate ‘solution’ ceases to exist and I get stuck knowing how to move on.

I want her to be there for me every single second of the day; to intuitively know what it is I need, even when she’s not physically present. I want her to pick me up and save me from all the painful emotions I feel inside, and to fix this chronic loneliness which does not want to budge. I want her to take me home with her, hold me and baby me and look after me for ever and ever, The End.

I do not know what happened to me as a child that could have led to this. It does not make sense. I must be inherently flawed.

I miss her every second I’m not with her, and it hurts so so so much.  I am constantly aching with the loneliness, yearning for something I cannot have – something which does not even exist. I am chronically aching, and I don’t know how to heal the wound. I am trapped within the confines of this emotional pain, and I don’t know how to escape it.”

DBT Interpersonal Effectiveness “DEARMAN” Skill

This week in my DBT Skills Group we looked at the DEARMAN skill in the Interpersonal Effectiveness module.

The IPE skills can be split into three subcategories which we looked at last week:
1) Objectives effectiveness
2) Relationship effectiveness and
3) Self-respect effectiveness.

When the goal is to get our objectives met, as outlined in the image below, the DEARMAN skill is the skill to use:

DEARMAN is split into two parts. The DEAR part describes what we do to try and get an objective met, and the MAN part describes how we do it.

When you are trying to get something you want or need from another person, because it involves somebody else – and because ultimately we cannot control other people – there is unfortunately no guarantee that the request will be successful. However, following this guideline will certainly maximise the chances. Furthermore, it will hopefully maintain the relationship as well as your self-respect as a natural consequence as well.

  • Describe – describe the situation exactly as it is; without judgement, blame or using emotive words (yet!). Just outline the facts in an objective and hence indisputable manner.
  • Express – express the way you feel about the facts of the situation. What emotions are you noticing have arisen? Be careful not to attach blame – avoid statement like “When you do X, you make me feel Y” and replace them with “When you do X, I feel/notice/experience Y”.
  • Assert – assert what you want or need with reference to the situation. Be clear what it is you are asking for, or what you are standing up against. Avoid words such as “should” and “must” and replace them with statements such as “Could you please…” or “What I need from you is…”
  • Reinforce – ‘reward’ the person ahead of time by letting them know how the request will benefit them/ the relationship. What would the positive outcome of getting your needs met be for them? Alternatively, what negative consequences could occur if your needs remain unmet?
    E.g “I would be so relieved and grateful to you, and a lot more pleasurable to be around if…”
  • Mindfully – stay focused on the objective, try not to sway from the goal of the conversation and bring the attention back if needs be. Ignore attacks from the other person to avoid getting into an argument (this is not easy!). Repeat yourself if necessary as if you are a broken record. At the same time, be aware of times when you may simply need to walk away if the person really is blocking you from being effective.
  • Appear confident – use a confident and competent manner including voice, facial expression and posture. Plan what you need to say ahead of time and speak clearly. Don’t apologise unnecessarily – if you do you will be sending yourself and the other person the message that you are undeserving of the request you are stating. Make sure you maintain eye contact, and try to sound as if you believe in what you are saying (even if you do not!).
  • Negotiate – be willing to compromise or reduce your request. If the other person deems your request unreasonable, ask them for their opinion on any alternative solutions. Query if there is something you can do to make them feel more inclined to give you what you want/ need.
    Tip: If you start out big, you may end up where you want to be, as in the Door-In-The-Face technique (see cartoon strip below)!

For a real life example of a DEARMAN, refer to this post here.

Intro to DBT’s Interpersonal Effectiveness Skills

This week in my DBT Skills Group, we started the fourth and final (noooooooo!) module within DBT known as Interpersonal Effectiveness.

First of all we looked at what factors can get in the way of being able to be effective within relationships. We looked at this from three angles:

  1. Objectives Effectiveness: getting what you want or need from another person – knowing your limits, having your say, getting your opinion across, setting boundaries, resolving conflicts, etc.
  2. Relationship Effectiveness: keeping and improving relationships with other people – considering the other person’s needs, treating them with respect, working out what you want long-term from the relationship, maintaining meaningful connections, etc.
  3. Self-Respect Effectiveness: keeping or improving self-respect within relationships – respecting your own values and beliefs, acting in line with your morals and long-term goals, ending hopeless relationships, being effective, improving your sense of empowerment, etc.

We found that the main factors getting in the way of Interpersonal Effectiveness were:

  • Lacking the Interpersonal Effectiveness skills needed
  • Not knowing what you want or need from a relationship
  • The intensity of current emotions getting in the way of being able to act effectively in the moment
  • Impulsiveness and focusing on a short-term goal as opposed to considering what is most effective in the long-term
  • The other person making it more challenging to be effective within that specific relationship
  • Your thoughts and beliefs about yourself or others get in the way

Based on the last point above, our homework for the week is to look at some of the myths we tell ourselves which may get in the way of being Interpersonally Effective. Below are the worksheets we have to fill in. For each thought we relate to on the list, we have to come up with an alternative sentence to challenge the emotional myth.

For example, no. 1, “I don’t deserve to get what I want or need”, could be challenged with the counter-argument, “I deserve to get what I want or need just as much as everybody else does”.

See if you can go through the list, exploring myths that apply to you and challenging them as you go along:

They Are Not Just Cuddly Toys

From a young age I have had a large number of cuddly toys which I have collected and become very attached to over the years.

My mother has been trying to convince me to give the remainder of them away for months, if not years. Her rationale is that I am a 21 year old woman, not a 21 month old, and that it is ‘childish’ and ‘odd’ to have as many cuddly toys as I do, especially on display in my bedroom, and to feel so attached to them. My sister (age 19 and owner of all of one cuddly toy) is very much in agreement with her and often shames me on the topic.

I agree with them on one hand because comparing my bedroom to those of my friends, one would think I were about ten years younger. Additionally, it is common for me to take any reason I can to back up the core beliefs I have about myself; that I am a ‘freak’, ‘weird’ and ‘incapable of functioning normally’ (through the process of teleological thinking). Despite this however, I cannot seem to use their logic to budge my attachment and avoidance of approaching the issue.

Whilst part of me recognises that it may indeed be necessary to adapt my bedrooms to a more ‘age-appropriate’ environment, a stronger part of me is too attached to my toys to be able to even consider giving them away. A few years ago I gave away 6 black bags full to a children’s charity, and that was a huge step in letting go of my childhood. It honestly felt excruciating for me; the whole process took so much out of me and I just don’t want to go through that again right now. Especially when the lack of other people’s understanding made it so much harder to deal with.

Because I struggle with aspects of OCD, including hoarding, it made the situation even more challenging. This is something I continue to struggle with today.

I know that it sounds ridiculous (*ding* – judgement!) and I am almost ashamed to be blogging about this little big secret of mine. However I know that there are legitimate reasons for the way I feel and that the situation is not as clear-cut as it seems. I also know that I would never shame someone else approaching me with this struggle but instead attend to them from a place of compassion and curiosity.

My toys represent so much to me and letting go of them would represent even more. My Dad was away a lot when I was a kid, and every time he came back he would bring me a cuddly toy. When I was hurting as I child I would cuddle my toys and whisper to them.
“It’s okay. We’re okay”.
I would soothe and cheerlead them in an attempt to soothe myself.

I named each and every one of them and created rotas for who I would cuddle with that night to ensure a sense of ‘fairness’ regarding the amount of attention each of them received. I adopted them as my babies and endeavoured to make them feel cared about in the way I so desperately longed for. I would talk to them both out loud and in my head, convinced that they could read my thoughts and that they were as ‘there for me’ as I was for them.

In ‘looking after’ them it was as though I was actually attending to various parts of myself, ultimately ‘looking after’ myself – in the only way I knew how.

I was convinced that they could feel emotions and determined not to evoke feelings of abandonment or jealousy within them. I was gentle and loving with them as you would expect a mother to be with her child. I never wanted them to experience any of the hurt I felt, during times of distress or when I felt all alone in the world.

When I felt lonely I cuddled my toys in the same way I cuddle my dogs now – as though my life depended on it. I would literally curl up on my bed and self-soothe by holding onto my teddies and hiding from the rest of the world. My priority was to feel held, with the desire for safety and containment at the forefront of my psyche.

It reminds of the monkeys in Harry Harlow’s ‘Surrogate Mother’ experiment with rhesus monkeys which I urge you to take a look at.

I am now 21 and it is not seen as ‘acceptable’ to behave in this way. I have changed my behaviour in that I now have a few cuddly toys on my bed who that I sleep with, and the rest are kept in close proximity but not right with me at all times like they used to be. I do not have a rota and I no longer speak to them – unless I am talking to myself and they happen to be ‘listening’ 😉.
I also know that they don’t have a consciousness even though my inner child part cannot fully let go of that.

However, despite these changes, having my cuddly toys around me still evokes a sense of safety within me which I crave and I cannot bear to get rid of the few I have left for good. Old habits die hard and I still struggle to sleep without cuddling up to one or more of my childhood friends.

As is pretty clear from my writing, I have an immense fear of growing up and there is a lot more to this issue than what may appear on the surface.

Perhaps when I am able to practice taking care of myself more wholly (specifically on an emotional level), I will be able to detach from this desperate need to have my cuddly toys available to me for comfort. For now I have transferred most of them from my Mum’s house to my Dad’s house (see the photo below), essentially shifting – but not quite solving – the issue! However, this is something I am comfortable with for the moment whilst being open to changing when the time feels right at some point in the foreseeable future.

DBT Distress Tolerance – Reality Acceptance Skills

This week in DBT Skills Group, having finished going through the Crisis Survival skills, we were introduced to the Reality Acceptance skills that make up the second part of the Distress Tolerance module.

The first skill we looked at was Radical Acceptance. The clinicians voiced their collective opinion that this is probably the most difficult skill in all of DBT to master, and all the members of the skills group were in agreement with this notion too. Here is the handout outlining exactly what Radical Acceptance entails, and here is an example.

Now some of the reasons for practising Radical Acceptance may sound pretty horrific – and the chances are that they are. Radical Acceptance is not  easy. However, I can assure you that the alternative will most likely be even worse. Rejecting reality when there is absolutely nothing that can be done about a situation – or when trying to do so increases the likelihood of further complications – will only lead to more suffering.

In my DBT group we try to remember this using a simple equation:

Where Pain + Reality Rejection = Suffering,
            Pain + Radical Acceptance = Pain

Being willing to practice using Radical Acceptance does not mean that pain is avoided; however it does minimise the levels of suffering endured. Pain is a lot easier to manage because it a part of life, it is necessary, it is transient, it can be motivating, and is a valuable communicator that something is causing us to feel a certain way. Suffering, on the other hand, can be avoided.

Additionally, without fully accepting reality as it is, there is no option for change or growth. Sometimes the only way out of distress is through it, which means having to accept it for what is is instead of trying to avoid or push it away.

It reminds me of a quote from the children’s book ‘We’re Going On A Bear Hunt”, which I believe is rather apt –

“We can’t go over it, we can’t go under it…
Oh no! We’ve got to go through it!”


The next skill we were introduced to was Turning the Mind. Turning the Mind is in my opinion a precursor to Radical Acceptance, and it could possibly be helpful to be taught this skill first! Radical Acceptance doesn’t just happen – first you have to take the steps to willingly “turn your mind” towards the Acceptance path. The alternative to this path is the Path of Rejection.

Turning the Mind means making the choice and being willing to walk down the former road and away from the latter. It doesn’t equate to automatically being able to accept, but it does put you onto the path, which is closer to reality-acceptance than doing nothing at all.

With Turning the Mind, imagine visually a fork in the road or something similar with two outcomes. Imagine that one path leads to Acceptance and the other to Rejection. Mentally place yourself onto the Acceptance Path, and imagine yourself walking down this route. When you find yourself straying from the Acceptance Path, which invariably you will, notice the lack of acceptance seeping in, and intentionally re-position yourself onto the path. Commit to yourself that the path of Acceptance is the one you have chosen. Continue to do this, over and over again. Hopefully, Turning the Mind consistently in this way will eventually lead to Radical Acceptance of the situation – the benefits of which are outlined above.

Lastly we looked at the skills of Willing Hands and Half-Smiling, which involve accepting reality with your body in order to help accept reality in your mind. They both result in genuine physiological changes which in turn help lead to a more open and accepting stance mentally.

These two skills are outlined below on the handout where they are summed up beautifully!

Cute Cheesy Blog Post Alert!

When I left Boston, the clinical director – with whom I had developed a very close and meaningful relationship – made me a promise. She told me that she had a few trainings in London over 2015 and that she would be visiting four times over the next 9 months. Her promise was that she would see me when she came to the UK at some point during these visits – and I held onto these words with everything I had.

Her first, second and third trips to London went by, and we hadn’t had the opportunity to reunite. I started dreading the possibility that we wouldn’t meet at all, and that she would break her promise. Promises mean a lot to me, and I was terrified that it would fall through. I convinced myself that she hadn’t meant what she had said, and that she was just being kind in the moment but had no intention to really see me.

As time went on, I would obsessively check my emails, including my junk folder, for any signs of movement on her end. I was on high alert for receipt of an offer or decision regarding our “reunion”. My fear was of feeling rejected and deceived by someone who hands down has helped me save my life. Even though I knew she wouldn’t do that – and that if she did she would certainly have a legitimate reason for doing so – the fear was still there. “What if, what if, what if”….. And time went on. I think I love too much.

It felt like days, weeks, months passing by… Until finally at the beginning of October we got in contact – and she confirmed the dates of her final trip to London and a desire (an ACTUAL DESIRE!) to see me.

We arranged to meet for a few hours in the day in a green area of London for coffee. She arrived a few minutes late and all I was thinking during that time was how terrified I was that she may not show up. I imagined what she would say to me in helping me target my unhelpful thoughts, and so used my mentalising skills. I realised pretty quickly that the possibility of a disruption to public transport would be far more likely than a last-minute cancellation on her part at this point! (And she was happy to hear this when I jokingly let her know upon her arrival!)

When she arrived and came through the barriers of the station looking like a cute lost tourist, I was shaking with nervous excitement. Even though she was right in front of me, I was flooded with memories, nostalgia and feelings of missing her – because suddenly there she was again, once of my favourite people in the entire world – and it was massively overwhelming. I had to fight with everything I had not to start crying. I wanted to have a conversation adult to adult, human to human, not patient to clinician; so this was important to me.

When I say overwhelming, I mean it only in the best of ways. Yes, I experienced anxiety and sadness and longing, and yes I dreaded having to say farewell again and was hit with a jolt of incredible sadness upon leaving. However, the joy that I felt being with her again, and the pride I was able to experience when sharing my current life and situation with her – especially compared to what it looked like this time was year – was immense.

We had coffee (I had tea!) and then walked for another unexpected hour (yay, another whole hour with her!) through the beautiful parks, taking in the view of London and chatting about a whole range of topics. I felt so safe and held and happy and at one the entire time I was with her. Despite the wind and the cold, I felt warm inside.

I had been waiting the entire year for the moment I could see her again, and finally it had arrived. I am so glad we waited because I was able to share with her all the progress I have made and the transitions that are continuing to happen within my life today. The two hours we spent together meant the world to me. I couldn’t stop smiling and that didn’t go unnoticed – especially because she has really seen me at my worst! It was also an incredible opportunity to look back and acknowledge the progress I have made. Sometimes it is hard to fathom… so it was helpful having her reflect her experiences back to me; I was really able to internalise what she was expressing to me.

She was hecticly busy, only here for a few days, had so many people to see and things to do, was pretty jetlagged and tired, and yet, she still made time to see me. She told me to remember just that during times I find myself doubting how much people care about me, or if I start thinking that I’m not worth spending time with or supporting.

“Don’t worry”, I told her. “I’ll remember that you came allll the way from America just to see me 😜!”

I know I would probably be discouraged from ‘putting her on a pedestal’ to this extent due to the typical Borderline trait of idealising vs devaluation – however, it has to be said: I do love her very much. She was like the Mummy of the unit in Boston and I was incredibly attached to her, always giving her cuddles and whatnot. Not just that, but she has a beautiful soul too and is simply great company. She radiates kindness and acceptance and I couldn’t ask for more than that from anyone. Lastly, without her, I may not even have ended up in treatment in Boston, and I most certainly would not be in the position I am in today.

DBT Distress Tolerance Self-Soothe and IMPROVE Skills

In my DBT Skills Group this week we focused on two more of the Crisis Survival skills within the Distress Tolerance module of DBT. The first was Self-Soothing and the second an acronym known as IMPROVE, or ‘Improve the Moment’.

Regarding the Self-Soothe skill, I have already written a post about it which can be found here. To add to this, below is a list of examples that I have found helpful to get me started when self-soothing is the last thing I feel like doing! 


The IMPROVE skill which we also talked about is broken down as follows, with examples included on the handout below:

  • Imagery – create a temporary alternate reality for yourself through visualisations and positive reappraisals; allow for some respite from the current situation that is causing you distress. Close your eyes, make yourself comfortable, and let your imagination flood your brain with more pleasant emotions and sensations than the ones you have been struggling to manage.
  • Meaning – ‘When life throws you lemons, make lemonade’ – Ask yourself if there is a way to make something good out of a not-so-good situation.
    As in the words of the WW2 survivor and psychiatrist Viktor Frankl,
    “In some ways suffering ceases to be suffering at the moment it finds a meaning…”

    (N.B. This will not take the pain away, however it may make it slightly more bearable.)
  • Prayer – this can be directed towards a supreme being if you believe in one, or alternatively to your own wise mind. Praying for guidance during times of distress may help you tolerate it more effectively, or help you in feeling less alone in it.
  • Relaxation – taking some time out of a stressful situation to relax and reduce the stress response is effective in reducing levels of distress. Especially with exercises focused on relaxing the body, it can have a direct impact on the mind as well. Often it is in accepting reality within the body, instead of trying to fight it or push it away, which enables us to work through it most effectively.
  • One thing in the momentSTOP! When overwhelmed with stressors, thoughts or emotions, intentionally focusing on a single thing for a set period of time can help calm the storm.
    This skill is linked with the One-Mindful aspect within the HOW skills of Mindfulness.
  • (mini) Vacation – take yourself away from the distressing situation for a temporary break from reality, until you are calm enough to attend to the situation effectively later. There is no point in trying to confront a problem when your emotional arousal is too high to be able to think straight. Take some time out for you, then reassess when your arousal has come down.
    (This is not permission to avoid coming back to the situation; it is simply taking some time out to attend to yourself, for the moment.)
  • Encouragement – during times of distress it is likely that judgements and negative intrusive thoughts will accompany you on your way. Reframing the way you talk to yourself can help change the messages your brain takes in about your ability to cope, even on a biological level. Try swapping “I can’t do anything right, I hate myself and deserve to die” to some kinder and more gentle words of encouragement such as “It’s okay, I’ve got this, one step at a time”.

Take a look at these examples below (as well as the Self-Soothe ones above) and try implementing them into your day to see what works best for you:

DBT Distress Tolerance TIPP and ACCEPTS

This week in my DBT Skills Group we looked at two of the Crisis Survival skills from the Distress Tolerance module.

The first was the TIP/ TIPP skill, which consists of perhaps the most ‘urgent’ skills in all of DBT. TIPP stands for –

  • Temperature
  • Intense Exercise
  • Paced Breathing
  • Progressive/ Paired Muscle Relaxation

These skills should be used when you are too deep within a crisis to use any other skills to regulate yourself. When the building is burning, it’s not going to be possible to access cognitive skills in a way that will put out the fire. During these times, skills need to be about keeping yourself safe and as contained as possible. This is where the TIPP skills come in. They act to regulate your body chemistry immediately so that you can stay safe and not make a situation worse. 


My favourite of the TIPP skills is the T – which stands for Tipping your Temperature – because it is so notably and quickly effective. It has helped me get through many near crises; from high urges and distressingly high emotions , to helping me move out of highly dissociative states. It is a number one go-to skill during moments of uncontainable distress.

The way I find the T in TIPP to be most effective is by Ice Diving. This involves filling up a large bowl or basin of cold water and putting ice cubes in it, before submerging your face into it for between 30-60 seconds at a time. Having a cold bath or shower will work in much the same way. Holding ice cubes to the space on your cheeks just beneath the eyes may be helpful too.

The mechanism behind this skill is based on biology. When parts of the face which contain the vagus nerve are exposed to freezing cold water, it activates a response of the parasympathetic nervous system, called the Dive Response. After 15-30 seconds, the body goes into a state of mild shock in which the heart rate is massively slowed down and blood flow becomes restricted to the vital organs (brain, heart).

Try doing this skill during a time you are not feeling dysregulated just to give it a go, and see whether it feels possible to think about anything else…

In my experience, the shock of the cold water is intense enough that my attention becomes completely redirected from whatever thoughts, feelings and urges I am experiencing. This skill almost ‘resets’ your system and brings you back closer to a baseline level so that you become more able to implement other skills which will help to get through the crisis in the longer-term.

I also find the T in TIPP highly effective when I am feeling dissociated. It is remarkable how it can both increase and decrease arousal in this way, depending on what state I am in before engaging in the skill.

Just remember the TIPP skills are effective in the short-term (around 20 minutes) so need to be followed up with other skills, for example Self-Soothe or IMPROVE.

The second skill we learnt about was the ACCEPTS skill. It stands for –

  • Activities
  • Contributing
  • Comparisons
  • (opposite) Emotions
  • Pushing Away
  • (other) Thoughts
  • Sensations

This is a Distraction-based skill which is helpful in reducing a negative or harmful thought, feeling or urge, and replacing it with a more effective and healthy alternative. For example, if I am feeling extremely sad and tearful, I may consciously choose to engage in an Activity such as going out for a walk with my dogs or meeting a friend for lunch, instead of going with the Emotion Urge to stay in bed and cry for hours on end.

Alternatively, I may choose the in ACCEPTS – eliciting different Emotions (e.g. to sadness) – by watching funny videos of cats on youtube to try evoke an alternative emotional response that would help me remain effective for longer.

I could also use Sensations which I find soothing to calm myself down, such as lighting and smelling a lavender scented candle and taking a soak in a warm bath whilst listening to relaxing music.

Here are some more examples:

Hi Ho, Hi Ho, It’s Back to Uni I Go…

Tomorrow marks the first week of lectures starting at university, and my first day back into full-time student mode after almost a whole year out.

I have transferred to another university since taking an Interruption of Studies due to my mental ill health last year, so it really is a brand new start for me. Luckily, because I have already completed my first year, I am going straight into year two.

I will be continuing to study Psychology, and the modules include:

  • Social Psychology
  • Developmental Psychology
  • Research Methods and Statistics
  • Cognitive Psychology
  • Personality and Individual Differences
  • Brain and Behaviour

I am thinking of using my blog space to document any relevant or interesting concepts and research I come across as I am studying. I am excited (despite being scared) to be going back into an educational institution where I can exercise my brain in a healthy and productive way, have structure, purpose and (hopefully!) a sense of achievement. Thank goodness I am passionate about what I am studying. I can not imagine taking a course in which I have absolutely zero interest!

Although I feel anxious about going back to university, I recognise that it will probably be very helpful for me. I haven’t had the most typical or enjoyable experience of educational institutions – having moved schools a lot, taken a lot of time out, and struggling socially for years, it has not been easy for me. However, I have also realised over the years not just how important structure is for my sanity, but also how much I genuinely enjoy learning, and so being back studying full-time for my degree will provide me with lots to keep myself preoccupied.

I am also applying for some volunteering positions and hope to participate in at least a few hours of this per week whilst studying. Some options include working in research collecting and analysing data, volunteering at a charity for people with learning disabilities, co-facilitating a support group for vulnerable students at my university, joining a crisis-line team, etc. I am waiting to hear back from a lot of the organisations I have emailed, and have my fingers crossed; I know how hard it is to find and gain experience in the field of mental health these days!

Overall, since Thursday 24th September (see this post here), I have been feeling infinitely better than I had been before that date. It is scary how clearly I can pin-point the moment things started to feel more manageable again; I literally remember waking up on that Thursday morning feeling as though a large bulk of the black fog had lifted and like I could see the light again.

Over the last ten days, I have of course still had my ups and downs, but overall I am in much less emotional and mental pain, experiencing far fewer urges, feeling mostly non-suicidal, and even my anxiety has greatly reduced. I have been doing pretty much nothing differently, which is the ironic thing! It is scary to think that these changes in longer-term mood may be largely physiological in origin for me. Heck, having BPD or any psychiatric diagnosis is scary as f*ck. Specifically for me, it’s the not knowing what to expect from one day to another; the waiting in fear for the fog to descend upon me once again…

STOP!

I am trying to take things one day at a time for now, treading slowly, allowing myself to be okay in each moment of okay-ness, and trying to perpetuate this relative state of calm whilst I am in a position to do so.

DBT Distress Tolerance Crisis Survival & STOP Skills

Last Saturday my DBT Skills Group started up again, so I am back posting regular updates about what we are covering on the program! It was the first week of the Distress Tolerance module – the 3rd module out of the 4 we have covered so far.

There were 8 people in the group, a big difference to the mere 2-3 of us who regularly attended the Emotional Regulation module back in August. My anxiety was high due to the new(ish) situation and people, however it was surprisingly more manageable than I had expected it to be – considering that on my first ever week I had a near panic-attack in the bathroom before we had even started. I guess that’s progress right there, and proof that exposure and Opposite Action really can lead to lasting change. (Damn, maybe the therapists really were right all along about that one 😜.)

Because there were many new members to the group, we started with a brief introduction to the Core Mindfulness skill of Wise Mind, as well as a briefing of the WHAT and HOW skills; because it is the Mindfulness aspect of DBT which underpins so much of what we learn over the whole.

We were then introduced to Distress Tolerance which I will outline here:

What are the goals of Distress Tolerance?

  • Crisis Survival – ensuring not to make an already challenging situation worse.
  • Reality Acceptance – how pain does not have to lead to suffering, and how to move forward from a place of “stuckness”.
  • Becoming Free – escaping from the confines and control of urges, desires and intense emotions.

We started off by looking at the Crisis Survival aspect. A crisis is a situation that is highly stressful, short-term and where there is pressure to resolve the crisis now – to avoid otherwise worsening the situation.

When do you need to use Crisis Survival skills?

  • If you have intense pain that cannot be helped quickly.
  • If you want to act on your emotions, but it will only make the situation worse.
  • If you are experiencing high urges for harmful or destructive behaviours – either to yourself or others.
  • If you are struggling within a highly stressful or emotionally overwhelming situation, but where demands must be met.
  • If Emotion Mind threatens to take over, and being able to access skills is essential.
  • If you are highly aroused or dysregulated, but the problem cannot be solved effectively, straight away.

What are the Crisis Survival skills?

  • STOP skill
  • Pros and Cons 
  • TIPP (tip body chemistry)
  • Distract with ACCEPTS
  • Self-soothe with the senses
  • IMPROVE the moment

We then read through the STOP skill handout and discussed situations in which it would be helpful to implement it:


Examples could be anything from receiving an email from a colleague evoking anger and the desire to respond aggressively and disrespectfully, to experiencing feelings of intense shame of fear after a triggering interaction to the point of emotional overload.

It is important to remember that the STOP skill, alongside the other Distress Tolerance skills, always need to be followed up with other skills too. This is because they are only short-term and targeted at not worsening the problem, however they will not solve things long-term; this is where the other skills will come in.

Peace Amidst The Storm

Recently I have been struggling a lot with the return of low mood, high anxiety and intrusive thoughts and urges. Just last night I was crying my eyes out, doubled over in (emotional) pain, alone on the floor of the hallway; trying to find the strength to simply carry on existing. 

This morning however, as I got up, my first thought was “Wow, that was easier than expected“, because whilst recently getting out of bed early (or at all) has been such a struggle for me, today it was not! I showered and dressed and got ready to go to work (a one-off morning school run) with a lightness and ease I had not felt in days. I did not feel like I was living in slow-motion trying to catch up with the world. I did not experience the usual internal dialogue regarding my inner turmoil or the feeling of dread at having to face yet another day. I did not feel the need to go through the usual Pros and Cons of showing up for life vs. avoiding reality. 

Not turning up didn’t even cross my mind. I felt like I could function and do life . I felt like a “human” again.

In fact, my only thoughts at the time were ones of surprise, relief (and doubt and guilt chucked in there), for the fact I was finally able to experience a sense of peace within myself again. After many days of being convinced I would never feel okay again, the moment had arrived. 

Thoughts like, “When is the pain going to return?“, “Is the universe mocking me?” and “Can I trust this?” seeped in to my consciousness. 

Of course the stark contrast between such different states of mind is going to be confusing, hard to trust, and thus scary in itself. But I was acutely aware of where these thoughts – and fears – were trying to take me, and unwilling to give in to them and risk sabotaging the moment. I felt motivated and energised enough to put my Mindfulness skills into practice instead; letting myself experience feeling A-Okay (shock, horror!) for what it was, without narrative or judgement.

The fact is, I know realistically that these moments will not last because I know how my disorder manifests. I still want to acknowledge them however – because they are what provide even the tiniest fraction of hope that things can be okay again when it feels impossible to believe they ever could be. 

Welcome to Borderline Personality Disorder. 

Thank goodness for those moments of peace amidst the storm.

Marsha Linehan’s DBT Workshop in London    

Earlier this week, I was fortunate enough to be given the opportunity to attend Marsha Linehan’s two day DBT Workshop in London. As the only non-clinician in an entire lecture theatre of over 250 people, I was worried I would feel out of place or unable to keep up with the content. However, I could not have felt more at home there; as soon as I arrived I was greeted with a beaming smile and warm hug from the organiser, and made to feel like one of the family by each and every clinician I met over the two days.

My anxiety was painfully high, due to the fact that my therapist was there – and I was feeling incredibly hyper-vigilant around this. Also, a crowd of 250 is rather a big feat in itself for someone like me in a situation like that! However, I was so skilful throughout, using a ton of Opposite Action, Paced Breathing and making sure I looked after my PLEASE skills to reduce my vulnerability to Emotion Mind.

Although the anxiety was physically nauseating, with respect to the workshop itself I was 100% in my zone. I didn’t feel bored or lose concentration for a single minute, which is an absolute miracle for me. I was engaged throughout, able to laugh at Marsha’s jokes, relate to a lot of the examples she expressed as well as her own experiences, and even help out a few DBT novices sitting by me when they were having difficulties understanding the content!
This of course I was chuffed about 😉

The workshop was originally meant to be based on the Emotion Regulation module of DBT, and we spent most of the first day being briefed on this. However we also dipped into Distress Tolerance, DBT and Spirituality, and other aspects as dictated by Marsha’s passion and flow.

Despite knowing a large bulk of the surface content, what I found fascinating was the empirical evidence underlying each of the skills Marsha talked about, how these skills came about, and all her witty and entertaining anecdotes – many of which were personal to her own or her clients’ experiences.

I met many interesting people from different backgrounds, and with varying degrees of DBT training, who had flown in from all over the world (e.g. Copenhagen, France, Dubai, Jordan); and all of whom I was totally honest with about my diagnosis and reason for being there.

Every single person I came into contact with expressed an interest in me (probably due to the fact I was clearly the youngest one there), my history and most significantly, my recovery – which was the most valuable form of reinforcement I could have been given. In fact, I even received a response to a thank-you email from the president of the Society for DBT saying that she would be “honoured to have me as a colleague one day”, as a final farewell!


During the conference I did of course have all the interpersonal sh*t going on with my therapist. I saw her a bunch of times within the crowd; and felt like a meerkat on high alert, or a spy, watching her every move. Our relational difficulties recently have been overwhelming to say the least! I actually took the opportunity to speak to some of the DBT experts about my current situation with her and get some advice on how to proceed with or without her as my therapist…

The general consensus was that the situation sounded extraordinarily complicated, and that my feelings around it were totally understandable and appropriate. At the same time, they challenged my methods of communication and urged me to give our relationship just one last chance, and advised me on how to go about doing so. They could see my love for DBT very clearly, and were keen for me to continue with my program, especially considering the lack of other full-program DBT options available to me.

In fact I saw my therapist today for our session which I had originally cancelled, and I cannot express the difference in how it went. I truly believe that this has happened at this time for a reason; and that the workshop provided us both with much necessary food for thought. She genuinely listened to me today, validated my experiences, agreed on much of what I was saying, and finally took some ownership for earlier ineffectiveness on her part! I could not be more pleased with how the bulk of the session went, and believe me, I am surprised at this in and of itself.

I feel like perhaps this was most of what I have needed all along; simply for her to acknowledge where she has messed up, apologise for the distress it has (inadvertently) caused me, and take the necessary steps towards repairing the ruptures.

All in all, it is a relieving ending to a hectic and emotional week!

Navigating The Termination of a Therapeutic Relationship

As outlined in this post here, on Friday I decided it was necessary to finally terminate with my therapist J. Last night, at some ridiculous hour, I thought it would be a wise idea to go through every single text interaction we have ever had since April.

Obviously, it was not so wise…

I am now even more confused by the whole experience, as well as my perception of the relationship. The sadness and loss I feel does not seem to be compatible with the anger and conviction I have that this break-up is for the best. Internally, I am so conflicted, especially now having realised that there were indeed times I felt incredibly held and supported by her, and many moments she genuinely did help me through.

I thought it had been “all bad”, but now I have been through the evidence that this is not the case; perhaps I had simply forgotten these positive times because I am so stuck in Emotion Mind around the whole palaver. No doubt there is a ton of Teleological Thinking going on, on my end, too. It is so easy to pinpoint absolutely everything around me that acts to back up a strong (especially emotional) belief, dismissing any evidence to the contrary – especially whilst in this state and regarding something so painful and complex.

At the same time, my way of thinking in relation to her is reminiscent of the push-pull often seen in abusive relationships. I am NOT saying she is abusive (she is not), although I have felt emotionally and mentally flung around by her somewhat frequently. It is just that I recognise a pattern within myself; similar to the way I thought about my first love, L, for example. Like I did with him, with my therapist, I always seem to “bounce back” to a place of forgiveness, giving her the benefit of the doubt, questioning my own judgement and sanity, and letting her “off the hook” per se. Because the attachment I have to her is stronger than the anger, perhaps, and a huge part of me does not want to lose her. So, I blame myself, and everything she has done wrong somehow becomes my own doing. I convince myself that “It will be different next time“. The cycle then restarts, until we have another similarly painful interaction, when I again query the competence and inconsistency being shown.

I cannot count the number of times this has happened; the number of times I have swung from loving her to hating her; the number of times I have considered terminating our relationship. On one hand, this is typically Borderline, on the other hand, my Wise Mind reasoning is totally valid.

It is such a paradox. Ultimately, I do not feel that I am progressing with our relationship issues being such a large factor for me in the work we have done. I do not feel she has handled certain situations professionally, even if in other circumstances this has not been the case. There has definitely been inconsistency shown, as well as a lack of responsibility being taken for this.

Whilst the intensity and impact some of our interactions have had may be more subjective (essentially, “in my head”), there is no denying that the overall effectiveness of the relationship has not been particularly high. For me, it has been more damaging than healing. I know in my core that it’s the right decision to terminate.

Right?

Yes, my expectations are very high, and then again – there is no reason they should not be, especially considering some very different experiences of therapists I have had in the past. I am too fragile within my BPD to settle for second-best, and the importance of the right therapist for someone like me is essential.

So why do I feel so pushed and pulled within myself with this decision?

I feel guilty, because a part of me recognises that she really does care, and has been trying her best; which simply hasn’t been working for me. Is it my fault for being such a difficult (albeit typical) Borderline? Are my expectations too high? Am I misinterpreting and putting my own shit on to her, unwarranted?

I feel sad, because there have been times I have truly felt supported by her, and which do mean so much to me. Letting go of the relationship to say goodbye to the negatives, also means bidding farewell to the positive aspects. It is a loss, and one that I will need to grieve.

I feel scared because DBT is so hard to come by here, and because I do not know what the future holds for me now. I will be without a DBT Skills Group, have no access to crisis coaching and no individual therapy under a DBT team. For the moment, I have no therapist, full stop. I have not not had a therapist for years.

There are so many reasons for staying with her, and there are so many for not.

I just do not know.

Terminating With My Therapist

In light of ongoing difficulties with my DBT therapist, and after an especially difficult week with her last week, I decided on Friday (after months of deliberating, to be honest) to finally terminate our work together.

I’m not going to delve into what has happened right now, because I’m aware that I am deep in Emotion Mind about this and that it could skew my judgments regarding both the situation, and her as a person. Also, there is so much to say, it would probably take me hours to explain, and my brain just can’t be dealing with that right now. I genuinely do not want to write about her or act from a place of malice, however I recognise that at some point I will need to decide if this is something that needs to be taken further, or not. For the time being, I need my space from her, so that I can cool down and be effective in finding a new therapeutic support network ASAP.

Unfortunately this means that I won’t be able to attend my weekly DBT Skills Group any longer, as she is one of the facilitators; I know what I am like and that if I continue to go it is likely to be extremely dysregulating for me due to her presence there.

Even though I know that terminating with her is 1000% the right decision for me, I feel infinitely confused, hurt, angered and unsettled by a vast amount of her behaviours and the interactions we have shared. I am subsequently feeling a lot of emotional (anger, sadness, fear) and mental (confusion, concern, disbelief) pain.

I am not going to lie and say I’m managing this ‘break-up’ well; I’m not. I am struggling to stay present; spending hours each day focusing on what went wrong in our relationship; questioning my judgement and ability to accurately perceive the situation; swinging between every imaginable painful emotion there is relating to what has happened; and spending an unhealthy amount of time in bed, crying, and avoiding the outside world. This is on top of and partially related to having sunk mood-wise over the last few weeks, anyway, (which I am finding hard to admit).

I have never felt the need to terminate therapy so strongly before. If this was a common pattern for me, I, and others around me, would feel more inclined to question the accuracy of my judgement regarding the situation and relationship. However, as my psychiatrist reminded me, I have a long history of therapeutic relationships of varying kinds; I know what to be wary of and what is effective, or what is damaging; I know what works for me and what does not; I can recognise limitations and faults within a therapist; and ultimately I am intelligent and intuitive, at least emotionally. If my psychiatrist is telling me that this is not all in my head, I take his word for it, right? I am not being manipulative, or altering the situation to suit my agenda, am I?

There has been a lot going on recently in my life. The last few weeks have been the most challenging for me mood-wise since Boston, and ironically I am now getting the least support at a time I am needing it the most. I feel incredibly alone and lost. I miss my friends who have gone back to university in other cities and it just adds to the aloneness. I have been feeling rather depressed. The situation with my therapist has, of course, not helped.

What I find most upsetting about how things ended between us is her seeming lack of willingness to help me achieve the closure I was after – especially having directly communicated that need to her on Friday. I know more than anyone the importance of having an effective ending when a therapeutic relationship terminates, especially after a great many messy and somewhat traumatising ones over the years! However, I felt as though I was unfortunately met with resistance and dismissal instead of compassion and professionalism when asking for guidance on how we could make the ending as smooth as possible. Perhaps she did not realise I was so serious about my decision, although this is no excuse. Closure is vitally important to me, and I fear not being able to move on without at least the acknowledgement and apology I feel I am owed.

What I really need is a professional – ideally DBT and BPD specialist – with whom I can discuss the above. Until then, I will continue with everything I have learnt and everything I do know about myself, DBT and BPD; and prove how effective I can be, regardless of her place in my life, or the lack of it…