Horses for Courses - One Therapy Cannot Fit All

This blog primarily shares my experiences of my practice of Dialectical Behaviour Therapy skills. After a lifetime of undiagnosed Borderline Personality Disorder symptoms, it was a huge relief to find a therapy that fitted with me and my needs. Having experienced as a Probation Officer the brick wall times of belief that BPD was 'untreatable', it seems that DBT has broken on Mental Health services as a sudden revelation, that 'something' can be done to offer a way forward for BPD sufferers. Great! A solution....except it's not that simple is it?

I know I bang on about how much I have benefited from DBT, but I am not so blinkered that I cannot conceived that this is not the whole or only therapy which can offer help for my condition. There is, nor can there be, one size fits all solutions for any Mental Illness - even if everyone engaged with Services had all of the same symptoms.

To advocate that DBT is the best and only way forward for everyone with a diagnosis of Borderline Personality Disorder, is to deny the complexities inherent in helping people to manage disorders and conditions which impact on every aspect of our beings. I was clear on discharge that completing the eighteenth months intensive therapy was only the first step in managing my BPD for the rest of my life. I have needed to address issues around my physical health following the impact of my emotional symptoms over the past 20 years.

Acquiring DBT skills also does not mean that I no longer suffer the symptoms of my condition. My discharge plan includes the continued prescribing of two medications to help me maintain my emotional stability. This is primarily to manage the accompanying Clinical Depression and Anxiety that I live with alongside the symptoms of BPD. I am only one person, I cannot hope to represent every person with the same or similar symptoms. Therefore, just because this combination of interventions is working for me at the moment, does not mean that it can be applied to all who may share my experiences of mental illness. Nor, does it mean that this combination will continue to maintain my stability forever. But for now, it is the right treatment path, for me.

A major problem faced by NHS Mental Health service providers is the pressure to 'justify' spending on intensive therapies. At this point numbers, rather than people, take priority and compete with what professionals know is best practice. Many NHS Trusts are hamstrung by funding issues which mean that they have to decide on one treatment pathway for individuals with the same diagnosis. Although research and practice indicates the complexities of helping human beings to manage complex conditions, funding issues seem to dictate basic, solutions. Or to put it simply, one size has to be made to fit all.

Reading other service users' experiences of what is on offer locally for BPD, I realise that in the UK there is a vast gulf between different parts of the country. In my area, I am lucky that there have been two evidence based therapy paths, both vastly different from one another, on offer via the local NHS Trust. Many other areas, are still grappling with managing people 'like me' without any specialised therapy on offer. I have gone through the trauma of 'failing' at one model, but thankfully there was another very different and more suitable model that has really helped me. How many people with various mental health conditions have that luxury?

Having said funding issues are the main reason for not considering a more integrated approach to Mental Health treatment, it is difficult to avoid the conclusion that such money saving approaches are short sighted. Certainly, if inpatient beds are perceived as being too expensive to continue to invest in, why is investment not then being made into developing a range of treatment options which can be adapted to individual needs? If you remove the 'place of safety' for people, where is there a safe place in the community if the one treatment on offer to some, is not effective.

I know I am looking at things rather simplistically, however, I am currently benefiting from the support of a physical fitness team run by the same Trust who run local Mental Health services. I get free gym and swim for three months along with an individual programme that is realistic and takes account of my emotional needs. I am in the process of dealing with my obesity in order to prevent long term illness and disease. A good investment? I think so, I feel so much better physically. In addition, taking care of my physical well being is one of the DBT skills for emotion regulation. Looking after my physical health is definitely supporting my ongoing practice of DBT and emotional stability.

We are all complex beings, unfortunately, the politics of funding seem to have swamped the instincts of best clinical practice and research. While the NHS is still in existence there is an opportunity for different teams to work together in co-operation with one another, rather than being made to compete for ever dwindling pots of money. If the focus can move away from numbers (referred to services, or successfully completing treatment compared with others) back to the whole person, there is maybe some hope that service users will be able to be treated more effectively.

Believe it or not, I actually recognise that just because DBT works for me in managing my BPD, does not mean that I expect it to work for everyone else with BPD. Although, I will keep sharing when I find something else that has worked for me in DBT...cos it excites me when I continue to be able to manage my emotions.

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.