Keeping it in the Here and Now

In this blog I've written about the 'time travel' problems caused by dwelling in the past or trying to guess the future.

Core Mindfulness skills are a set of skills designed to bring my thoughts and feelings into the here and now, in order to free me from the pain and distress of the past, and the anxieties and fears for the future. This challenge for the emotionally sensitive person is similar to that of 'mind reading'. I constantly make assumptions about what other people are thinking about me, mostly because I am mixing them up with people who hurt me in the past.

When I am feeling vulnerable I am at risk of slipping back into the past and reliving its hurts or of shifting myself into the future in anticipation of those hurts and injuries being repeated. Any thoughtful examination of our existence in terms of time and space tells me that the only time and space I am capable of occupying is the space around me right now and the present moment, as I am aware of it. When I dwell in the past or future in my thoughts, then I allow the present to slip past me unheeded and unlived. So, I need to use all of my senses to remind me of the good things in the here and now and, slowly, as I heal to begin to enjoy them for what they are.

This picture captures the essence of life in the moment. It was shared on Pinterest by Healing for BPD and I have found it helpful in reminding me to use my mindfulness exercises when memories from the past or fears about the future flood into my mind.

What on Earth is DBT?

I have found myself being asked this question a few times by people who follow my twitter feed or this blog. It's funny how easy it is to obscure your message by the use of jargon. I actually enjoy explaining what DBT is and what I have got out of it as a treatment - it has been a massive positive in my life. Unlike the question 'what does the borderline in BPD mean?' Not easily answered as frankly most people now don't actually agree with it as a descriptor of this condition - anyway that's another topic altogether and if my DBT has taught me anything it is not to be distracted by thoughts that are not relevant to the here and now.

Dialectical Behaviour Therapy (DBT) was developed by a clinical psychologist in America called Marsha Linehan (do google the name she has produced numerous videos and articles about her therapy) in the 1990s. It is a combination of mindfulness techniques and Cognitive Behavioural approaches to help those diagnosed with Borderline Personality Disorder learn to understand and control the extreme fluctuations in their emotions.

As a replacement for BPD as a label some have taken to referring to the condition as either Emotional Sensitivity Personality Disorder or Emotional Dysregulation. As a descriptor I find the latter preferable. Whatever term you choose to describe it, what it meant for me was a see sawing of moods which could cycle from being 'hyper', excitable, voluble and energetic to extreme feelings of depression with a high degree of suicidal feelings within the space of a few hours, several times a day.

As you can imagine such constant cycling of emotions can be extremely draining and distressing. A key hallmark of the condition is poor impulse control accompanied by strong urges towards self harm (or self destructive behaviours) and suicide. Throughout my life, until I really started to practice my DBT skills, the idea of killing myself or harming myself was an almost constant presence in my consciousness.

DBT is not offered as a cure for these issues, but seeks to offer the sufferer the means to interrupt and then control the emotional storms which are the moment by moment experience of BPD. One important point to make is that no treatment in Mental Health should be considered as one size fits all. This is why the individual sessions of DBT are so crucial for each person. I can only decide what skills I need to master in order to manage my emotional life. Because it is a skills based treatment it requires a major commitment, not only during the time in group and with your one to one therapist, but, more importantly, after discharge the treatment will only work long term if I commit myself on a regular basis to remind myself of the skills and to practice them.

I remember my GP expressing her frustration with patients who had been referred to the Physiotherapist to deal with one condition or another. She would make follow up appointments to see them after six weeks or so. 'How's it going?' She would ask on their return. 'No use whatsoever'. She would persevere 'Really?'. 'Oh yes, I went twice and to be honest the exercises were alright when I was there, but then the complaint returned in between visits.' Now, it seems to me that the GP shouldn't then have to explain that these exercises should be repeated daily in between 'visits'. If I think after discharge 'well that's that then' not practice or take seriously the skills I have worked so hard to develop, during my time in therapy, then I don't think I should be surprised if I start to lose control and become a prisoner of my emotions once more. I need to keep going with it.

So what are these skills?

The core 'treatment' is a weekly skills group along with a weekly one to one session. In the group we are introduced to the skills and encouraged to start to use them to manage day to day issues as they arise. In the individual sessions there is an opportunity to discuss in more detail the skills that are most useful to me as an individual and the key parts of my emotion dysregulation I should be working on.

There are four main modules:

1. The Core Skill of Mindfulness runs throughout the length of both the group and individual sessions. (typically one year, although some centres are trying to offer 6 months which only allows one cycle of the skills modules).
2. Distress Tolerance - skills to help me manage when I am in distress without reverting to self destructive and self harming strategies that I may have used all my life. (here the importance of developing familiarity over a longer period of time becomes clear).
3. Emotion Regulation - longer term skills to enable me to recognise what feelings I am dealing with and to develop strategies to maintain a stability in those emotions. (these have become more regularly used by me since my discharge in seeking to maintain my progress with managing my emotions)
4. Interpersonal Effectiveness - anyone who has BPD or has lived with someone with BPD will tell you that the emotional maelstroms inherent in the condition wreak havoc in all sorts of important relationships. Reading other people is not a natural skill that I possess because of my invalidating upbringing. This is an area I need to consciously be aware of and that I need to practice constantly in order to counteract the natural urge to respond to my instinctive (often mistaken) feelings about the relationships around me.

I completed a one year programme, during this time, each module is introduced and after six months, and a review of progress, they are repeated and reinforced both in the skills group and in the one to one sessions.

This is a very sketchy outline of DBT, there will no doubt be many other questions.

Such as, what do I mean by Dialectics? Essentially, my understanding (which will be limited to my own experience) is that it seeks to bring stability and balance to my emotional life so that I can enjoy the parts of my life that are to be enjoyed, without expecting everything to be 'sorted' or 'perfect' (I've covered this in my blog on recovery and what it now means to me here: http://bpdlifeinthemoment.blogspot.co.uk/2014/06/putting-jigsaw-together-learning-to-fit.html

The following are links to helpful websites about BPD and DBT: http://www.dbtselfhelp.com/ has really useful exercises and videos for the practice of DBT skills and Mindfulness, www.my-borderline-personality-disorder.com (Healing for BPD) is an online version of DBT but there are also really helpful articles and examples of using DBT skills in recovery. There are many other websites that offer useful mindfulness videos or self soothe ideas etc. Just be selective and be aware nothing will bring about any miracle cure and any skill needs a lot of time and hard work to develop.

I think the best way to find out about Marsha Linehan who has an amazing story about coping with BPD herself, is to just google her name.

Access to DBT groups in the NHS seems to be very limited. I have been so lucky to live in Lancashire and to be able to access the Central Lancashire DBT Team for nearly 18 months. I am so grateful for a local NHS Trust (Lancashire Care Foundation Trust) which has seen fit to offer not only this, but also other therapies for BPD. Having not meshed with one previous therapy, I only had a waiting time of one year to access DBT. I am aware that not every area has so much to offer to what is a cinderella condition, but hopefully, if I can encourage others to ask about it and whether it is available in their area then, maybe, some 'up high' might begin to see the light.

For me, having my discharge report set down in black in white that I have not self harmed for over 18 months has helped me to see just how far I have come. My time in the group was an important part of my journey but I haven't arrived, I'm just moving on. I continue to work on my Emotion Regulation skills, occasionally I use my Distress Tolerance skills when an echo of my past takes me by surprise. Rather than creating dependence one of the best things DBT has given me is a developing confidence that I am ready for life without Mental Health Services, that I am capable of maintaining and building on the progress I have made so far and that even, if I may never have a life without my turbulent emotions, they will never have to overwhelm in the same way again.

I will be forever grateful for the visionaries behind this great innovation for BPD sufferers.

You mean, I have to keep going with all this Mindfulness business?

When I finished my main DBT skills group it took me some time to realise that all the benefits I had gained wouldn't magically remain without some effort on my part. It's a shocker, but no treatment for long term mental health problems will help without considerable effort from me. It's not as if I wasn't warned - we had 'homework' every week and we had one to one sessions every week to help us make the skills relevant to our real lives. So why did I think that magically, the symptoms I had suffered for over thirty years would just disappear, without some significant effort on my side?

And yet, I have found myself surprised when my negative soundtrack reawakens inside my head and I lose the balance of 'wise mind' as 'emotion mind' rears its ugly head. With a start I realise, hey 'you haven't been using your mindfulness to keep on track.' Now if I weren't being mindful, that statement would be accompanied by a hefty dose of judgement. However, just because I have lapsed a bit, doesn't mean I haven't made progress or that I should even consider giving up. Life is full of ups and downs, trial and error, failure and success. The most important thing is that I have NOTICED that I'm slipping back. Falling down is not the end of the story, I can get up again and get back on the DBT horse. It would be a waste of all the effort, all the learning to live with difficult emotions, all the pleasure I have learned to find again in life, if I just give up on the things which have helped me recover so far.

So, yes, I do have to keep going with all the DBT skills. They do help me, I know this because it is obvious when I'm not using them to manage my BPD symptoms. Full recovery will take time and effort, and practice, practice, practice. After all, I had over 30 years to hone those unhelpful emotional and cognitive habits.

Who to Tell? What to Tell?

I believe firmly in the importance of the 'Time to Change', 'Time to Talk' campaigns run by Mind, Sane and other mental health charities. I know that the best challenge to Mental Health stigma is for people like me to be open about my diagnosis. But there is a caveat -

sometimes discretion and self preservation are needed

simply because even those closest to us, just don't get it.

I have found it easier to tell those who are distanced from me - the 'strangers' in my life, if you like, that I have Borderline Personality Disorder. a) Because I was not invested emotionally in their reactions to me and b) because they were not invested in keeping me in roles that didn't help me.

I have encountered a number of reactions:

1) The first person I told was my Line Manager immediately following the second or third assessment when Mental Health staff started to discuss my BPD symptoms. Despite her lack of knowledge (and, indeed my own!) she was consistently supportive and was keen to listen and learn with me about what my condition would mean for my remaining in post as a Probation Officer. In the end I took voluntary redundancy due to the realisation that my challenging caseload was not helpful to me in seeking manage my emotion dysregulation. She even supported me when a Senior Manager insisted on expensive assessments by privately funded Psychiatrists whose sole aim was to assess my risk of physical harm to my cases - the vast majority of whom were violent and dangerous male offenders! Three times the response came back 'no, the highest risk of BPD is of suicide and self harm'!! and still Senior Management sought to prove that I was suddenly a risk to others, having worked successfully in that office for seven years! However, my own instability meant that I knew it was best for me and my cases if I moved on. On leaving my career behind my Manager left me with a positive professional regard which I am slowly able to take on board and use to move into a future career - just don't know what it is yet.

2) Telling my family is problematic - I can never tell my parents. Growing up even physical illness was dismissed - certainly no room for compassion for mental illness. Ask my brother who suffers from chronic severe Asthma and who was told that his attacks were just due to him being 'highly strung'. Instead of opening myself up to reinforcing negative statements and parental rejection, I have been living a lie with my parents since I was diagnosed. They know I have a condition which requires me to have given up my job and to attend therapy twice a week for the past year (Dialectical Behaviour Therapy - DBT), but beyond that I cannot share with them. Sometimes accepting that I will never change them or their views stops me from suffering further at their hands.

3) The rest of my family - I have received nothing but support and love from my brother and his wife. They have read up on the websites and books I have recommended and have recently supported me in speaking publicly about my experiences to small groups. Their children have now grown up with me as their auntie who gets very down at times but will always be the person they have known and loved since they were little.

4) Speaking in public about my experiences has shown me that there are so many people hungry to hear that they are not alone.

I hope that as I articulate my own experiences they will resonate with others - I know I really appreciate the Twitter community of those who have BPD and who have been helped by DBT - it reminds me every day that they have come through and are leading stable rewarding lives. (esp @HealingFromBPD and @DBTPath - thanks guys)