Let's do Dialectical Behaviour Therapy (DBT)

@Phoenix_Rising @CheerBear I am not 'on the forum' at the moment however I am still going to try to participate here with both of you. This may infact also be too hard for me so please accept my apologies in advance if this is the case (which I suspect it will be). The last few weeks have been incredibly tough and that came to a head this morning on here as well as irl. I just can't cope with it all. The upcoming few weeks are going to be even tougher particularly with my present 'state of mind', hospital procedures and gradually changing meds. I do hope that in time I am able to come back and join in with both of you here as it has been something that I was really looking forward to doing (the intellectual interaction rather than the content). So please go ahead without me - I really do wish that it had not come to this for me - but sadly it has.

Thankyou both for including me in the first place - it meant alot.

"Flippers Up" Llittle Turtle and CB

Good evening @Zoe7 @Determined @Appleblossom @CheerBear @Faith-and-Hope, I am super excited to see you here sharing in the DBT adventure.

I seem to be flying all over Forum Land tonight, so this is just a quick check in. I super want to take the time to read through properly what people have written. I plan to do that tomorrow morning. I did some more reading today, but I probably won't be ready to post about it for a day or two. The next few pages of the introduction all kind of go together as one story - although I think I will follow @CheerBear's example of breaking it up into a few posts.

@Zoe7 it is absolutely totally ok to just drop by when you are feeling up to it. At the rate we are currently going, I think we will still be on the introduction until sometime in the year 2020!

@Determined it is super cool to have a carer venture over here. Has your darling done DBT???

@Faith-and-Hope I am excited to think that you might be able to explain the bits that any of us get stuck on. I did quickly read your post but I want to take the time to write a proper response.

@Appleblossom Friendly interested bystanders are definitely welcome.

Super big thank you everyone for taking an interest in this adventure.

Good morning fellow DBT adventurers,

I super love how @CheerBear has outlined her approach to this adventure. Like CheerBear, I was also a little overwhelmed when the manual arrived. I have had the original skills training manual for years and I figured the new one wouldn't be THAT different. Um..yeah, the first edition is 180 pages, which includes all the worksheets, whereas the new edition is 504 pages and you need to either download the worksheets from the website or buy them in a separate book, which is 422 pages long. So...since 1993, 180 pages has morphed into 926!!! Yay for progress. It is probably a good thing I didn't realise this before embarking on this adventure though!

I have decided that I'm going to purchase the book of worksheets rather than download them. This is the book I am talking about: https://www.bookdepository.com/DBT-Skills-Training-Handouts-and-Worksheets/9781572307810 I figure it isn't super expensive and it will help me to keep everything in one place.

While we are talking about books, this is the treatment manual (as opposed to the skills training manual, which is what we are working our way through): https://www.bookdepository.com/Cognitive-Behavioral-Treatment-of-Borderline-Personality-Disorder-Marsh-M-Linehan/9780898621839?ref=pd_detail_1_sims_b_p2p_1 The treatment manual goes into much more detail about the theory that underpins DBT, particularly as it relates to treating people with BPD. It is here that Linehan talks a lot about her conceptualization of BPD. I found it super validating when I read it. I love how she talks about the fact that people with BPD are NOT attention seeking or manipulative, we are simply trying to survive. This is all discussed a bit in the introduction to the skills manual, but if you want to know more, the treatment manual is the book to read.

Now is probably a good time to mention that perhaps the reason Linehan seems to understand people with BPD so well and why she has been such a trail blazer in the effective treatment of BPD is that she herself had (yes, I said "had" not "has" and yes, she is still alive ) BPD. You can read about that here: http://www.nytimes.com/2011/06/23/health/23lives.html?pagewanted=all&mcubz=3

Anyway, back to responding to CheerBear...

I really like what you said about working on accepting yourself CheerBear. I recognise that I am much more ok about being me than I used to be. For me, figuring out that I have ASD was a big part of that. It helped me make sense of so much of what I struggle with. In the legal report that Fred wrote for the court case, he described me as the most severe case of BPD he had encountered. However, I know now that what he was seeing wasn't a superly messed up "borderline," but an aspie with BPD. Since getting the ASD diagnosis I have felt much more ok about my oh-so-many quirks. I super hope that you can become more ok with being you too CheerBear. I think you are super wonderful, exactly as you are right now.

I super like what you said about how people need to solve their own problems even if they weren't of their making. Oh and as an aside, I super like that you jumped ahead in the book. I'm only planning to write at length about pages 1-12 in the introduction because otherwise we will still be in the first half of the book in the year 2050!!! Therefore please do add in bits that you think are important from later in the first half of the book.

Yep, I totally agree that it makes a world of difference to go from seeing yourself as the problem, to seeing yourself as someone who needs to figure out how to live more effectively with problematic life circumstances. I recognise that a massive part of my muddle is that I was very much seen as the problem when things went awry back in 1996/97. Although there is still far too much stigma around BPD, it is definitely better than it was back then!!!

@Zoe7 I definitely struggle a lot with the concept of being ok just as I am while also needing to change. Like you, I can't see how this makes sense - it is either one or the other. @Faith-and-Hope, I super like your response...but it doesn't totally compute in my brain. CheerBear's rug isn't complete until it is complete. While it remains incomplete she will keep working on it (i.e. changing it), when it is complete, she will stop working on it (i.e. she won't change it further).

What DOES make more sense to me, is the idea that I can be totally ok as I am right now and yet still be open to learning new things. To me, this is like my violin playing. Right now my playing sounds pretty much like you would expect it to sound given how long I've been learning for. And that's totally ok. But I practice every day because I want to get better at playing my violin. So...I'm totally fine with the way I play right now, and yet I work at playing better. I think this analogy fits better for me because it isn't that I need to CHANGE, it's that I can develop new skills. Thus the problem isn't ME as a being, it's simply that I'm not that good at some things yet. I'm not that good at playing my violin and I'm not that good at regulating my emotions...and that's ok. People who are good at those things aren't intrinsically better human beings than me, they just happen to have some skills that I don't have. Equally, I have skills that most other people don't have (like being able to stand on my head).

@Faith-and-Hope I super like the fact that you seem to be saying that it is just as ok to be a black-and-white thinker as it is to be a grey thinker. I super wish that view was held more widely. The reality is that in our society in this particular point in history, black-and-white thinking is regarded as somehow less-than grey thinking. At its worst, it is pathologised.

Ok, well I think that's all from me for today. I have now read up to page 12 in the introduction and I will post something about that over the weekend.

Thank you for sharing the adventure.

Thanks @Phoenix_Rising, appreciate the opportunity to gain insight from people who are experiencing similar emotions to my darling. I do my best to help and support her but often feel I miss the mark 😔

My darling was supposed to be starting DBT with a psychologist late last year but went to hospital before they got anywhere. Has been reluctant to go back and see him sincd then due to $$$ (I was and still am ok with the cost) but also the travel, 2 hr round trip each time. She has had a few admissions to hospital this year also making it difficult yo get a start. I dont know what exactly they do there but I dont believe DBT has been part of it.

My goal is to try and encourage her to go back to the psychologist to discuss dbt again when school resumes next year. A while away I know but it would be too much for her just now so jyst want to work on resuming some routines at home first. This thread will give me some insight to be able to support that process when we can get it started.

Thanks again for letting me join in.

Hi @Determined, I super know that you try your best to help and support your darling. You are doing your super best, and that is all you can ever do. Your darling is superly duperly lucky to have you. I am super glad that you are here to provide input from a carer's perspective. I imagine there is a pretty good chance that some of what you say may be tricky for me and others with BPD or other emotion dysregulation issues to hear, and vice versa. That's ok - I have the SANE helpline number on speed-dial (and...I just made whoever is moderating today shudder).

Hi @Neelix, it is super nice to see you here. Reading and pondering is warmly welcomed. Please feel free to ask what any words mean. If there's a word that you don't understand, chances are there are who-knows-how-many other people reading along who don't understand it either. There are no silly questions here. DBT is heavily grounded in Buddhist philosophy and to be honest, some of that philosophy isn't a good fit for my own spiritual beliefs. Thus I tend to take the bits that work and leave the bits that don't.

@Faith-and-Hope I kind-of get what you are saying in your rug analogy...but something still isn't quite fitting in my brain. Perhaps because in your analogy, the idea is that the tiny rug is complete, but can also be expanded upon, whereas the dialectic we are talking about is that the person is totally ok as they are and yet still NEEDS to work towards change. In your analogy, the tiny rug is totally acceptable with the potential to be more, but it doesn't NEED to be more, BECAUSE it is totally acceptable as it is. I think for me it still comes back to improving skills vs changing ME. To me it sounds fine to say "I am totally ok as I am, but I want to get better at coping with my big feelings" because this is saying I want to improve a skill that I DO, not that I want to change who I AM.

Super big thank you for engaging in the conversation everybody (although it is a bazillion percent ok for you to not engage and instead just read along).

Good afternoon DBT adventurers,
Welcome to part 2 of the introductory chapter of the DBT skills training manual. Once again I am trying to summarise...and once again I am finding it super difficult because it is ALL important. Oh well, here goes...

Understanding Emotion Dysregulation

Biosocial Theory: How Emotion Dysregulation Develops.
According to Linehan (2015), BPD is a severe mental disorder which results from serious emotion dysregulation. Linehan describes suicidal behaviour as being a response to unbearable emotional suffering (p. 5). I so very badly wish that more mental health professionals understood this. The stigma that continues to surround BPD is so crushing. I don't know how many times I have been told by mental health professionals that I am manipulative and attention seeking. I don't know how many times I have been told that I just need to grow up. How can we ever expect the broader community to understand BPD, when the mental health professionals hold such attitudes! I am so very VERY grateful for the wonderful people at SANE who truly "get" it.

The DBT Model of Emotions
According to Linehan (2015), emotions are brief, involuntary, full-system, patterned responses to internal and external stimuli (p. 6). Together, the following components make up an emotional response:

⦁ Emotional vulnerability to cues. The emotionally vulnerable individual is one who experiences a high level of negative emotions at baseline (i.e. when nothing at all is really going on), is super sensitive to emotional stimuli, experiences very intense responses to emotional stimuli, and takes a long time to return to baseline after being emotionally aroused.

⦁ Internal and external events that act as cues. Note that an event can only act as a cue if it is noticed. If you don't notice something, it won't elicit an emotion.

⦁ An appraisal and interpretation of the cue.

⦁ Response tendencies. These include neurochemical and physiological responses (i.e. things that happen in the brain and other parts of the body), experiential responses and action urges.

⦁ Nonverbal and verbal responses and actions.

⦁ The aftereffects of the initial emotion. This can include secondary emotions (e.g. feeling ashamed of having become so angry).

A core tenet of DBT is that by changing one component of this emotional system, you can change the entire system.

Emotion Dysregulation
According to Linehan (2015), emotion dysregulation is the inability, even when one's best efforts are applied, to change or regulate emotional cues, experiences, actions, verbal responses, and/or nonverbal expressions under normative conditions (p. 6). My favourite bit of this statement is even when one's best efforts are applied. Guess what? That means you can threaten me, shame me, and hand out aversive consequences as much as you like, it isn't going to help me to become better at regulating my big feelings. I am always doing the best I can - even if my best sometimes looks extremely chaotic to those around me.

Biological Vulnerabilities
Some people are born more impulsive, more sensitive to emotion cues, and more likely to experience negative emotions than other people. This is why it is unhelpful to compare people. If two people go through exactly the same experience, it is unfair to say that because one coped well with it, the other person should be able to cope well too. We are all born with different strengths and weaknesses...and that's ok.

The Caregiving Environment
As well as a person's natural disposition that we are each born with, the social environment also contributes to the development of emotion dysregulation. Linehan (2015) suggests that the family environment can contribute to the development of emotion dysregulation in three ways:

⦁ The child's emotions may be invalidated, and parents may not role-model how to appropriately express emotions.

⦁ The way family members interact may reinforce emotional arousal. That is, a child may learn that they need to express very intense emotions in order to get their needs met.

⦁ The child's natural disposition and the caregivers' parenting style may be a poor match.

The Role of the Invalidating Environment
From an evolutionary perspective, the purpose of emotions is to convey information. If someone expresses an emotion and it is invalidated (e.g. ignored, not heard, or labelled as somehow "wrong"), then it makes sense that the person will express the emotion more strongly in order to be heard. If the other person doesn't "get" what the person expressing the emotion is trying to convey, they will tend to try and shut the person down with further invalidation (e.g. ignoring, telling the person they are over-reacting, telling the person they shouldn't be feeling that way or to stop feeling that way). This becomes a vicious cycle; the person trying to be heard escalates their expression of emotion in order to be heard, and the more it is escalated, the more the other person responds in an invalidating way to shut it down, which escalates it more etc. etc. etc.

This very much sums up my entire life, and yes, it was tricky reading this because it raises a whole lot of painful "if only's..." in my mind, which in turn make my tummy ache. I very much hold core beliefs of "no one hears me," "no one believes me," "I do not matter." Therefore, some of the most comforting words for me are "I hear you" and "I believe you." One of the things I find so super amazing here in Forum Land is the way in which I can use my calm voice to ask for support, and support appears. You have no idea how novel this experience is for me, and I'm not sure if I will ever grow tired of experiencing it here. I think I probably need to experience it about a bazillion times in order to negate the bazillion experiences I have had of not being heard.

Anyway, back to the story...
So...biological vulnerability (nature) and social environment (nurture) can interact in one of four ways:

⦁ Someone who is biologically predisposed towards developing emotion dysregulation and who also then experiences an invalidating environment, is at super high risk of developing emotion dysregulation.

⦁ Someone who is NOT biologically predisposed towards developing emotion dysregulation, but who experiences a particularly invalidating environment (e.g. where there is severe abuse or neglect), is also likely to develop emotion dysregulation.

⦁ In contrast, if someone was born biologically predisposed to emotion dysregulation but was raised in a very supportive and validating environment, then they are likely to become a well adjusted albeit sensitive adult. This demonstrates that biology (or innate nature) is certainly not destiny.

⦁ The ideal of course is to be born without the biological predisposition towards developing emotion dysregulation AND be fortunate enough to grow up in a nurturing and validating environment. Such a combination tends to lead people towards becoming emotionally healthy well-adjusted adults.

I recognise that I fall very much into the first of these categories. Being Aspie, I am naturally superly duperly sensitive. I can see that if my family dynamic hadn't been so complex and unhealthy, and if the icky abuse stuff hadn't happened, I would have become a successful albeit socially awkward and quirky adult. Again, the "if only's" are weighing heavily in my thoughts right now.

Reading this conceptualisation of how emotion dysregulation develops caused me to reflect again on the fact that people try to differentiate between BPD and complex PTSD. I am yet to find anyone who can explain to me how one would do a differential diagnosis between these two labels. People try to argue that not everyone with BPD has a history of trauma. This is quite correct. According to Linehan (p. 9) it is estimated that 60-75% of people with BPD have a history of childhood trauma. However, it is entirely possible for someone to be naturally superly duperly sensitive such that even a relatively healthy environment is experienced as invalidating, leading to emotion dysregulation. Equally, as described above, it is possible to be born with a naturally resilient disposition, but experience such severe invalidation (through abuse or neglect), that emotion dysregulation develops. The end result is the same. Therefore I genuinely have no idea how any clinician can ever label someone as having both BPD and complex PTSD. I am super open to anyone trying to explain this to me because right now I view this very much as an example of using two labels when one would be perfectly sufficient

Ok, well I think that is probably more than enough for today. All comments, thoughts, reflections and questions are warmly welcomed (not that I am going to guarantee I will have any answers for you ). The next installment will be about the consequences of emotion dysregulation. Stay tuned.